IV hydralazine

[cbrons]

For asymptoamtic AAA, not urgent. For ruptured AAA, type A, intramural hematoma, penetrating ulcer, an acute type B or a symptomatic aneurysm it is urgent and these people should be in an ICU (which opens up your options for management). It depends on the hospital location as to who manages these patients prior to the OR (anesthesia, vascular/CTS or cardiology). It does seem counter-intuitive that people who aren't used to managing hypertension are acutely managing antihypertensives. At my shop, the surgeons found that cardiology was better at acutely managing these patients so so we manage them until the OR is ready. It makes sense as we are also able to evaluate the aortic valve and pericardium by echo acutely prior to the OR.

Management of acute aortic syndromes is the following:
Beta blockers to start. Goal to give as much as you need to bring the HR down to ~60. As above I said we use metoprolol but most would say that esmolol and even labetolol are ok. You push it quick and hard (that's what she said) because with the degree of catecholamine surge, it is exceptionally rare to run into problems. For instance, the other day, in an hour I gave a total of 400mg IV metoprolol in 10-20mg IV pushes (start slow, and then rapidly go up)

Once your HR is at goal, then you use your other agents. We use Clevidipine because NTP is now exceptionally expensive and with nicardipine we were having problems with hypotension from overzealous titration. I would not use hydralazine

Why not use Esmolol? It would seem way easier and safer to titrate. And also, clevidipine from what I understand is also through the roof expensive.

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[Instatewaiter]

Why not use Esmolol? It would seem way easier and safer to titrate. And also, clevidipine from what I understand is also through the roof expensive.

Esmolol is very reasonable. It is institutional dependent but nationally esmolol is more common. Esmolol is exceptionally expensive as well. Clevidipine is cheaper than NTP.

 

[TooMuchResearch]

Esmolol is very reasonable. It is institutional dependent but nationally esmolol is more common. Esmolol is exceptionally expensive as well. Clevidipine is cheaper than NTP.

My N is low, but I titrate up esmolol and then add nicardipine. I don't have good numbers in my head for starting labetalol, and I know our pharmacy can get me esmolol very quickly.

For the students, cyanide toxicity can happen pretty quick when running nitroprusside.

They'll switch to nicardipine as soon as the patient hits the ICU from our ED, and I'm more comfortable titrating nicardipine anyway.

 

[Instatewaiter]

My N is low, but I titrate up esmolol and then add nicardipine. I don't have good numbers in my head for starting labetalol, and I know our pharmacy can get me esmolol very quickly.

For the students, cyanide toxicity can happen pretty quick when running nitroprusside.

They'll switch to nicardipine as soon as the patient hits the ICU from our ED, and I'm more comfortable titrating nicardipine anyway.

While I agree that cyanide toxicity, its diagnosis and treatment should be understood by anyone using it, It is a lot rarer than people make it out to be (and this is coming from the center that uses the most NTP in the country).

 

[bannie22]

This was a good learning thread

I do think that sometimes patients get IV prn because the hypertension is transient and is likely limited to the acute hospitalization phase and there is the desire for a quick fix

 

[Psai]

This was a good learning thread

I do think that sometimes patients get IV prn because the hypertension is transient and is likely limited to the acute hospitalization phase and there is the desire for a quick fix

wtf are u talking about?

 

[cbrons]

Severe asymptomatic hypertension;

Date Released: Jan 25 2017