1. HYPERTENSION IN ICU Common causes include: pain agitation
cold, shivering
hypoxia, hypercarbia
increased ICP
transducer height etc.
Urinary retension
Positional discomfort
Omission of pre_admission anti hypertensives (esp.B blockers)
withdrawal

2. Hypertension in the ICU
Dr Danie Babypaul
Worthing Anaesthetic Department

3. HYPERTENSION IN ICU Underlying hypertension Essential or primary
Secondary Phaechromocytoma
Aortic stenosis
Renal artery stenosis
Cushing’s syndrome
PIH

4. Pain Adequate analgesia Opioid analgesics Simple analgesics NSAIDS
Dexmeditomedine &tramadol – novel agents
Local anaesthetic agents
Volatiles
Ketamine
Supplemental – acupuncture,acupressure,massage,TENS

5. Sedation Primarily in ventilated patients
Benzodiazepines –midazolam,diazepam
Anaesthetic agents- propofol,thiopentone
Butyrophenones- haloperidol
Phenothiazines- chlorpromazine
Volatiles
Opioids
Dexmeditomedine

6. Cold , Shivering Passive –warm environment,warm blanket
Active ,external- warmed pads,blankets,Bair Hugger
Active, core-
humidified inspired gases
warm intravenous fluids
Body cavity lavage-gastric,pleural,peritoneal
Extra corporeal methods-hemodialysis, Bypass

7. Other therapies Hypoxia- oxygen therapy(masks,cpap,bipap,ventilator)
Hypercarbia- bronchodilators,steroids,CPT,NIV,ventilator
Maneuvers to reduce ICP- medications,ventilator
Adjust transducer height
Urinary retension-catheterize,definitive treatment
Comfortable position for the patients
Reintroduction of pre admission antihypertensives
Psychological support- trust with staff
Look for possible secondary causes-eg:renal artery stenosis

8. Antihypertensives &vasodilators
Mechanisms
Diuretics – bendrofluothiazide, frusemide
α antagonists-labetalol,phentolamine,phenoxybenzamine,prazosin, carvedilol,haloperidol,chlorpromazine
β antagonists-propranolol,metoprolol,atenolol,esmolol
CCB- nifedipine,nimodepine,verapamil,diltiazem,magnesium
Direct vasodilators-SNP,GTN,isosorbide,hydralazine,diazoxide
ACE inhibitors-captopril,enalapril,lisinopril
Angiotensin receptor blockers- losartan,irbesartan,eprosartan
Centrally acting-clonidine,methyl dopa,trimetaphan

9. α antagonists Act by alpha adrenergic blockade
Phentolamine-nonselective-1-10mg I.v. boluses,5-30mg/hr
Phenoxybenzamine-nonselective-1mg/kg/day
Labetolol-α1, α2,β mg I.v boluses,0.5-4mg/min infusion
Prazosin- α1—2-10mg/day,8th hourly
Carvedilol –oral preparation
Side effects
Can cause tachycardia, idiosyncratic hypotension

10. CCBs Acts by blocking voltage gated calcium channels
Nifedipine– 5-10mg po/sl
Nimodepine- mostly used in SAH
Amlodepine- 5-10mgpo b.d.
Magnesium- physiological calcium antagonist
40-60mg/kg loading, 2-4 gm/hr infusion
Side effects: hypotension, tachycardia,peripheral oedema

11. β blockers Widely used now,acts by β blockade,
inhibit release of renin from juxtaglomerular cells
Prejunctional inhibition of nor epinephrine
Atenolol mg iv boluses,25-100mg pob.d
Metoprolol-same doses
Esmolol-loading 0.5mg/kg,50-200mic/min
Side effects :
Bradycardia
Bronchospasm
Hyperkalemia,masking response to hypoglycemia

12. Dirct vasodilators Sodium Nitro Prusside
44% cyanide by weight- cyanide toxicity
Nonselective vasodilator
50mg/250ml 5%D ml/hr
Glyceryl trinitrate
30mg/100ml5%D ml/hr
Hydralazine
10-20mg I.v. bolus, mg 6-8 hrly
Diazoxide
50-100mg I.v. boluses, 15-30mg/min infusion

13. ACE inhibitors
Captopril mg QDS ,in acute hypertension sl
Enalapril-5-20mg QDS
Enalaprilat – mg boluses(parenteral)
Caution in renal impairment, hypotension
Losartan – mg daily
Caution in renal failure

14. Diuretics Salt &water excretion Inhibition of aldosterone
Direct vasodilatory effects
Eg: frusemide, thiazides
Caution in hypovolemia,renal dysfunction

15. Acute treatment In hypertensive encephalopathy Heart failure Eclampsia
Acute dissecting aortic aneurysm
In c/c hypertension or a/c neurological events
A precipitate reduction- worsens CPP-further deterioration
Target CPP>70mm Hg

16. Hypertensive crisis Symptomatic
Increased drowsiness,seizures,papilloedema,retinopathy
In presence of elevated systemic pressures
Diastolic BP> mm Hg
Mean BP> mm Hg
Encephalopathy can occur at lower pressures

17. Principles of management
Adequate monitoring-invasive BP,ECG,CVP,CO,U/O
Consider pain,hypovolemia,hypothermia,agitation
Consider specific treatment-phaeo,thyroid crisis,dissection
Slow iv infusion-GTN,SNP,others
Aim to reduce to mildly hypertensive levels
Longer term treatment –started at low doses

18. Drug doses GTN 0.5-20mg/hr SNP 0.5-1.5mic/kg/min0.5-8mic/kg/min
Labetolol mg iv over 1 min repeated every min to max 200mg
Esmolol mic/min
Hydralazine mg slow I.v. followed by mic/min

19. Thank you