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Krisis Hipertensi

Salli Roseffi Nasution

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Krisis Hipertensi

Krisis hipertensi mewakili 27% dari kegawat-daruratan medis yang ditemui sepanjang tahun) (Sekitar 1- 2 % dari seluruh penderita hipertensi akan mengalami krisis hipertensi dalam hidupnya)

Definisi :Suatu keadaan peningkatan tekanan darah mendadak

SBP > 179 mmHg atau DBP > 109 mmHg pada penderita hipertensi yang memerlukan penanganan segera

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Lebih sering ditemui pada orang tua dan angka kejadian pada pria 2 kali lebih sering dibanding wanita.

Dalan suatu penelitian

Lebih dari 50 % penderita adalah mereka yang tidak menggunakan obat antihipertensi seminggu sebelumnya.

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HYPERTENSIVE CRISIS

Severe elevation in blood pressure, generally a SBP > 179 mmHg and/or DBP > 109 mmHg

HYPERTENSIVE

URGENCY

HYPERTENSIVE

EMERGENCY

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Hypertensive Urgencies

A situation with markedly elevated BP but without severe symptoms or progressive target organ damage, wherein the BP should be reduced within hours, often with oral agents

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Hypertensive Emergencies

A situation that requires immediate reduction in BP with parenteral agents because of acute or progressing target organ damage

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Hypertensive Emergencies

• Accelerated-malignant hypertension with papilledema• Cerebrovascular conditions• Hypertensives encephalopathy• Intracerebral hemorrhage• Subarachnoid hemorrhage• Cardiac conditions• Acute aortic dissection• Acute left Ventricular failure• After coronary bypass surgery• Renal conditions• Acute glomerulonephritis• Renovascular hypertension• Severe hypertension after kidney transpl

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Hypertensives emergencies (cont )

• Surgical conditions• Postoperative hypertension• Postoperative bleeding from vascular suture lines• Severe hypertension in patients requiring • immediate surgery• Excess circulating catecholamines• Pheocrocytoma crisis• Sympathomimetic drug use ( Cocaine )• Severe epistaxis• Severe body burns

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Differences

The distinction between an emergency and an urgency is often ambiguous

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Breakthrough Vasodilatation

• Changes in BP – Cerebral vessels dilate or constrict to maintain of cerebral blood flow ( Autoregulation )

• Progressive vasodilation as pressure are lowered and progressive vasoconstriction as pressure rise

• When arterial pressure reach a critical level Approximately 180 mmHg, the previously constricted

vessel, unable to withstand such high pressures, The vessels are streched and dilated hyperperfuses

the brain – cerebral edema

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AutoregulationC

ereb

ral B

loo

d F

low

(m

l/100

gm

/min

)

150

15010050

50

100

200

Normotensi

Hipertensi

Mean arterial pressure (mmHg)

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Pathophysiology

Adapted from Wu MM. Hypertension. In: Tintinalli J. Emergency Medicine:A Comprehensive Study Guide. 5th ed. McGraw-Hill; 2000:403.

Circulating vasoconstrictors

Abrupt BP

Arteriolar fibrinoid necrosis

Endothelial damage

Loss of autoregulatory function

End-organ ischemia

Abrupt SVR

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Clinical presentation

• Most patients have persistent BP elevation for years before they manifest a hypertensive emergency

• Directly related to the particular end-organ dysfunction that occurred

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Clinical manifestation of hypertensive emergencies

• Hypertensive encephalopathy• Acute aortic dissection• Acute myocardial infarction• Acute coronary syndrome• Pulmonary edema with respiratory failure• Severe pre-eclampsia, eclampsia• Acute renal failure

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Signs and symptoms

• Chest pain 27 %

• Dyspnea 22 %

• Neurologic defisits 21 %

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Diagnosis Krisis Hipertensi

Anamnesis Riwayat hipertensi, gangguan organ

Pemeriksaan fisik Sesuai kecurigaan organ target yang terkena

Pemeriksaan laboratorium Urinalisis, Hb, Ht, ureum, kreatinin, gula

darah, elektrolit

Pemeriksaan Penunjang: EKG, Foto toraks Ct Scan, Echo, USG

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Tatalaksana Hipertensi Emergensi

Penanggulangan hipertensi emergensi harus dilakukan di RS dengan monitoring yang memadai (ICU)Pengobatan parenteral diberikan secara bolus atau infus sesegera mungkinTekanan darah harus diturunkan dalam hitungan menit sampai jam dengan langkah sebagai berikut:

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Tatalaksana Hipertensi Emergensi

5 menit sampai 2 jam pertama tekanan darah rata-rata diturunkan 20-25%2-6 jam kemudian tekanan darah diturunkan sampai 160/100 mmHg6-24 jam berikutnya diturunkan sampai < 140/90 mmHg bila tidak ada gejala iskemia organ

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Hal-hal yang harus diperhatikan

Segera memberikan obat yang tepat dan sudah tersedia walaupun diagnosis belum tegak benar tetapi sudah terdapat kecurigaan.Pastikan bahwa tim ICU sudah terbiasa mengetahui dosis obat yang diperlukan, tehnik pemberian infus, monitor ketat, dan efek samping dari obat yang digunakan.Prinsip “do not harm” harus selalu dipegang dan diperhatikan.

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MANAGEMENT OF HYPERTENSIVE EMERGENCIES

Reduce Mean Arterial BP no More than 25 % over 2 hours then Reduce to 160 / 100 mm Hg within 2-6 hours.

Avoid excessive falls in Blood Pressure

Titrate with Intravenous antihypertensives

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The ideal properties of IV agents for Hypertensive emergencies

Have ability to regulate easily blood pressure Have ability to regulate easily blood pressure Allow to control of blood pressure reductionAllow to control of blood pressure reductionMinimize the risk of hypotensionMinimize the risk of hypotensionTreatment preparation should be rapid and Treatment preparation should be rapid and predictable to reduce BPpredictable to reduce BPThe agent should have minimal side The agent should have minimal side effects/few adverse effecteffects/few adverse effect

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Parenteral Drugs for Treatment of Hypertensive EmergenciesParenteral Drugs for Treatment of Hypertensive EmergenciesVasodilatorVasodilator

Drugs Onset of action Duration of action

Nicardipine * 5 min 1 hr

Sodium Nitropruside immediate 1-2 min

Fenoldopam < 5 min 30 min

Nitroglycerin * 2-5 min 5-10 min

Enalaprilat 15-30 min 6 hr

Hydralazine 10-20 min 4-6 hr

Diltiazem * 5 min 30 min

Trimetaphan 5-10 min 10 min

* Available in Indonesia

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Dosage and adverse effects of commonly used Parenteral antihypertensive medications

Agents Dosage Adverse effectsEnalaprilat

Esmolol

Labetalol

Nicardipin

Nitroglycerin

Nitroprusside

1.25 mg over 5 min every 4 – 6 h,titrate by 1.25 mg increments at 12-24 h intervals to max of 5 mg q6h

500 mg/kg loading dose over 1 min, infusion at 25-50 ug/kg/min, increased by 25 ug/kg/min every 10-20 min to max of 300 ug/kg/min

20 mg initial bolus, 20 to 80 mg repeat boluses or start infusion at 2 mg/min with max 24 h dose of 300 mg.

5 mg/h, increase at 2.5 mg/h increments every 5 min to max of 15 mg/h.

5 ug/min, titrated by 5 ug/min every 5 to 10 min to max of 60 ug/min

0.5 ug/kg/min, increase to max 0f 2 ug/kg/min to avoid toxicity

Variable response, potential hypotension in high renin states, headache, dizziness.

Nausea, flushing, first degree heart block, infusion site pain.

Hypotension, dizziness, nausea, paresthesia, scalp tingling, bronchospasm.

Headache, dizziness, flushing, nausea, edema, tachycardia.

Headache, dizziness, tachycardia.

Thyocyanate and cyanide toxicity, headache, nausea, muscle spasm, flushing.

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Parenteral Drugs for Treatment of Hypertensive Emergencies

Sodium nitroprussideNitroglycerinClonidinDiltiazem Nicardipine

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OBAT-OBATAN YANG DIGUNAKAN PADA HIPERTENSI EMERGENSI MENURUT KONSENSUS INASH 2008

Obat Sediaan Perhatian

Clonidine 150 mcg/ampul Tidak boleh dihentikan mendadak karena bahaya rebound

Diltiazem 10 mg dan 50 mg/ampul Hati-hati pada penderita gangguan konduksi jantung dan gagal jantung

Nicardipine 2 mg dan 10 mg/ amp -

Labetalol Belum beredar di Indonesia

-

Nitroprusside Belum beredar di Indonesia

-

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Nitrogliserin

Merupakan venodilator yang poten dan hanya pada dosis yang tinggi memiliki efek pada arteri. Nitrogliserin dapat menyebabkan hipotensi dan reflex takikardi yang dieksaserbasi deplesi volume.

Nitrogliserin menurunkan tekanan darah dengan mengurangi preload dan cardiac output, dan memiliki efek yang tidak diinginkan pada pasien dengan gangguan perfusi ginjal dan otak

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Nicardipine vs Clonidin

Nicardipine Clonidin (*)

Target organ Arteriole CNS(Ca channel) (2-agonist)

Clinical effect Vasodilatation Vasoconstriction BP decreased increased BP

then soon followed by decreasing of BP (caused by stimulation of central adrenoceptor

in CNS lower part)

Heart Rate Increasing reflex Decreasing HR stimulate central

parasympathetic

Rebound Effects No effect ++

Nicardipine Clonidin (*)

Target organ Arteriole CNS(Ca channel) (2-agonist)

Clinical effect Vasodilatation Vasoconstriction BP decreased increased BP

then soon followed by decreasing of BP (caused by stimulation of central adrenoceptor

in CNS lower part)

Heart Rate Increasing reflex Decreasing HR stimulate central

parasympathetic

Rebound Effects No effect ++

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Nicardipine vs Diltiazem

Nicardipine Diltiazem

Target organ Arteriole Arteriole

(Ca channel) (Ca channel)

Clinical effect Vasodilatation Vasodilatation BP decreased BP decreased

Heart Rate

Nicardipine Diltiazem

Target organ Arteriole Arteriole

(Ca channel) (Ca channel)

Clinical effect Vasodilatation Vasodilatation BP decreased BP decreased

Heart Rate

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Recommended antihypertensive agent for hypertensive crises

Conditions Preferred Antihypertensive agentsAcut pulmonary edema/systolic dysfunction

Acut pulmonary edema/diastolic dysfunction

Acute myocardial ischemia

Hypertensive encephalopathy

Pre-eclampsia, eclampsia

ARF

Sympathetic crisis / cocaine overdose

Acute ischemic stroke / intra cerebral bleed

Nicardipine, fenoldopam,or nitropruside in combination with nitroglicerin and a loop diuretic

Esmolol, metoprolol, labetalol, or verapamil in combination with low dose nitroglicerin and a loop diuretic

Labetalol or esmolol, in combination with nitroglicerin

Nicardipine, Labetalol, or fenoldopam

Labetalol, or Nicardipine

Nicardipine or fenoldopam

Verapamil, diltiazem, or nicardipine in combination with a benzodiazepine

Nicardipine, labetalol or fenoldopam.

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Nicardipine

Inhibits the trans membrane influx of calcium Inhibits the trans membrane influx of calcium ions into cardiac muscle and smooth muscle ions into cardiac muscle and smooth muscle without changing serum calcium without changing serum calcium concentrationconcentrationMore selective to vascular smooth muscle More selective to vascular smooth muscle than cardiac musclethan cardiac muscle

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Basic properties of the CCB nicardipine (Nc), nifedipine (Nf), diltiazem (D) and verapamil (V)

Nc Nf D V

Systemic vasodilationMyocardial depressionBlocks AV conductionVasoselectivity

++00++++

+++0+++

++++

++++++0

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COMPARISON BETWEEN CALCIUM ANTAGONISTS

Drug Coronary Vasodilation

Suppressionof Cardiac

Contractility

Suppressionof SA Node

Suppressionof AV Node

Verapamil(phenylalkylamine)

++++ ++++ +++++ +++++

Diltiazem(benzothiazepin)

+++ ++ +++++ ++++

+++++ 0 + 0Nicardipine(dihydropyridine)

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Nifedipine

Pemberian Nifedipine secara sublingual tidak direkomendasikan untuk Hipertensi Emergensi oleh FDA dan sejak JNC VIDapat terjadi penurunan tekanan darah yang tiba-tiba dan tidak terkontrol yang akan menyebabkan kejadian iskemik di otak,ginjal, dan jantung

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Dosage and Administration

Hypertensive emergencies

Acute hypertensive crises during surgery

IV

(mcg/kg/min)

Bolus(mcg/kg)

Acute hypertensive crises during surgery 2 - 10 10 – 30

Hypertensive emergencies 0.5 – 6

(mcg/kg/min)0.5 2 6 10

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Perhitungan Dosis

BB = 50 KgDosis terapi yang diinginkan : 0.5 mcg/KgBB/Menit

Pengenceran : 1 ampul (10 mg) dlm 50 ml cairan

= 10 x 1000 mcg = 10.000 mcg 10.000 mcg = 200 mcg/ml

Untuk BB 50 kg maka kecepatan syring pump adalah= 0.5 x 50 x 60 = 7.5 ml / jam = 8 ml / jam

200

Untuk BB 50 kg maka kecepatan Drip paediatric adalah

= 7.5 ml / jam = 7.5 x 60 tetesl / menit = 7.5 tetes / menit

6060

50

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PANDUAN DOSIS & PENGGUNAAN NICARDIPINE INJEKSI

Perdipine Injeksi1 ampul 10mg BERAT

Spuit 50 cc BADAN 0.5 1.0 1.5 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0

( mL/jam) 40 kg 6 12 18 24 36 48 60 72 84 96 108 120

50 kg 8 15 23 30 45 60 75 90 105 120 135 150 60 kg 9 18 27 36 54 72 90 108 126 144 162 180

Pediatric Drip 70 kg 11 21 32 42 63 84 105 126 147 168 189 210

(≈ 1cc = 60 tetes) 80 kg 12 24 36 48 72 96 120 144 168 192 216 240

90 kg 14 27 41 54 81 108 135 162 189 216 243 270

DOSIS PERDIPINE INJEKSI (mcg/kgBB/menit)

atau

SYRINGE PUMP

INDIKASIKRISIS HIPERTENSI AKUT SELAMA OPERASI

HIPERTENSI EMERGENSI

SOAL :

Pasien BB : 60 kg, hendak diberikan Perdipine infus drip dengan dosis 0,5 mcg/kgBB/menit dalam cairan infus 100 cc. (Mikro drip --> 1 cc = 60 tetes)Berapa tetes/menit yang diperlukan ??

JAWABAN :

Pada cairan infus/pelarut 100 cc, kita ambil 1 ampul Perdipine 10mg.Maka pengencerannya adalah 1 x 10mg = 10mg x 1000 = 10.000 mcg = 100 mcg/cc

100 cc

Dosis yang akan diberikan 0,5 x 60 x 60 (untuk dijadikan ke jam) = 18 mL/jam atau 18 cc/jam 100

Bila kita memakai mikro drip yang 1 cc=60 tetes maka 18 cc x 60 tetes = 18 tetes/menit

60 menit

PERHITUNGAN DOSIS

( Infus Pump)

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PANDUAN DOSIS & PENGGUNAAN NICARDIPINE INJEKSI

Perdipine Injeksi1 ampul 10mg BERAT

Dalam larutan 100 cc BADAN 0.5 1.0 1.5 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0

( Tetes/menit) 40 kg 12 24 36 48 72 96 120 144 168 192 216 240

50 kg 15 30 45 60 90 120 150 180 210 240 270 300

Mikro Drip 60 kg 18 36 54 72 108 144 180 216 252 288 324 360

(1 cc = 60 tetes) 70 kg 21 42 63 84 126 168 210 252 294 336 378 420

80 kg 24 48 72 96 144 192 240 288 336 384 432 480

90 kg 27 54 81 108 162 216 270 324 378 432 486 540

DOSIS PERDIPINE INJEKSI (mcg/kgBB/menit)

INFUS DRIP

INDIKASIKRISIS HIPERTENSI AKUT SELAMA OPERASI

HIPERTENSI EMERGENSI

- Dapat diberikan pada keadaan emergensi 1 ampul 2mg (2 cc) selama 2-5 menit yang dilanjutkan dengan maintenance drip infus/syringe pump.

- Dosis : 10 - 30 mcg/kgBB IV

Misal : BB = 60 kg Dosis yang mau dipakai 20 mcg/kgBB --> 20 mcg X 60 kgBB = 1200 mcg = 1,2mg = 1,2 cc

Catatan : Perdipine 1 mg = 1 cc

PENGGUNAAN BOLUS INJEKSI

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Nicardipine (Perdipine)

Perdipine mempunyai 2 kemasan :Perdipine mempunyai 2 kemasan : - 2 mg (isi 2 cc) - 2 mg (isi 2 cc) untuk untuk bolus injeksibolus injeksi - 10 mg (isi 10 cc) - 10 mg (isi 10 cc) untuk untuk infus dripinfus drip

Untuk pemakaian dengan infus drip, Untuk pemakaian dengan infus drip, direkomendasikan menggunakan cairan infus 100cc direkomendasikan menggunakan cairan infus 100cc dan mikro drip (1cc=60 tetes)dan mikro drip (1cc=60 tetes)

Lamanya pemakaian setelah tekanan darah turun Lamanya pemakaian setelah tekanan darah turun dan terkontrol dan terkontrol tergantung dari keputusan klinisi tergantung dari keputusan klinisi untuk pindah ke oraluntuk pindah ke oral

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Dosis dan Cara Pemberian

Dimulai dengan dosis terendah. Penambahan tetesan tergantung dari dosis.Mis 0.5 dengan 15 tetesan monitor, bila dalam 5-15 menit tidak ada perubahan TD naikkan tetesan menjadi 20 tetes ( Tidak harus langsung menjadi 30 tetes) tapi dapat bertahap

Pada pemakaian Perdipine harus disertai dengan monitor tekanan darah & detak jantungApabila ada keputusan untuk pindah ke oral, maka 1 jam sebelum Perdipin di aff obat oral diberikan dahulu Dosis Perdipin mulai di turunkan (Tappering Off).

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CONCLUSION

1. Hypertensive emergencies require immediate BP reduction.

This is most safely accomplished in the intensive care setting with use of an Intravenous agent.

2. With the advent of better tolerated, long-acting anti hypertensive agents, hypertensive crisis become less common, with an estimated prevalence rate of 1- 2 % among hypertensive patients.

3. Nicardipine I.V.injection) for hypertensive emergencies has a fast BP lowering effect which is predictable

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Terima kasih