Cardiovascular Critical Care II
| (6) | Eclampsia: new-onset tonic-clonic, focal, or multifocal seizures in the absence of |
|---|
other causative conditions often associated (but not required) with hypertension in
pregnancy
| (b) | Preeclampsia with severe features can only be managed by delivery of the baby. |
|---|---|
| (c) | Magnesium can be considered as an adjunctive therapy to decrease seizure risk or if |
seizures develop.
| (d) | Intravenous medications should only be considered for (1) severe-range hypertension, (2) |
|---|
preeclampsia/eclampsia, and/or (3) hypertensive emergency (signs of target organ damage)
in a pregnant patient.
| (e) | Hydralazine and labetalol are feasible first-line options, and labetalol may have fewer |
|---|
dependent on provider familarity and local practices and protocols (Cochrane Database
Syst Rev 2013;2013:CD001449).
| (f) | BP target goal for severely elevated BPs, preeclampsia/eclampsia, and hypertensive |
|---|
emergency in a pregnant patient is 160/110 mm Hg or less with avoidance of abrupt
decreases in BP, which can lead to potentially harmful fetal effects. Because of this
caution, the MAP should be decreased by ~20%-25% over the first few minutes to hours,
and the BP should then be further decreased to the target of 160/110 mm Hg or less over
the subsequent hours.
ii.
Catecholamine-induced hypertensive emergency
| (a) | Phentolamine is the drug of choice because it competitively inhibits Ξ±-adrenergic receptors. |
|---|---|
| (b) | Ξ²-Selective antagonists are contraindicated unless the patient is fully Ξ±-blocked. |
iii.
2007;131:1949-62)
| (a) | Benzodiazepines are used to target the central effects of cocaine as first-line therapy and |
|---|
often will result in control of tachycardia and hypertension. Can consider diazepam 5β10
mg intravenously or lorazepam 2β4 mg intravenously titrated to effect.
| (b) | If central control of cocaine-induced hypertension fails, consider direct Ξ±-antagonism with |
|---|
phentolamine.
| (1) | Phentolamine 1 mg intravenously; repeat every 5 minutes as needed. |
|---|---|
| (2) | If direct Ξ±-antagonism does not gain control or is unavailable, consider additional |
antihypertensives:
| (A) | Nitroglycerin, nicardipine, nitroprusside, or fenoldopam titrated to effect are |
|---|
viable options (see Tables 9 and 10 for dosing and considerations).
| (B) | Verapamil and diltiazem decrease coronary vasospasm associated with acute |
|---|
| (C) | Controversy exists regarding the use of Ξ²-blockers. |
|---|---|
| β’ | Labetalol has shown conflicting results regarding ability to control MAP but |
does not alleviate cocaine-induced coronary vasoconstriction.
| β’ | Consensus opinion recommends Ξ²-selective antagonists only if full |
|---|
Ξ±-antagonism is used first.
iv.
Blood pressure variability (BPV)
| (a) | Concept of BPV emerging as a key therapeutic target in various populations (Stroke |
|---|
2014;45:2275-9; Eur J Neurol 2013;20:1277-83; J Cardiothorac Vasc Anesth 2014;28:579-
85).
| (b) | BPV is often expressed as the standard deviation of SBP, MAP, DBP, or the area under the |
|---|
curve of time spent outside of blood pressure target.