Krisis Hipertensi

Salli Roseffi Nasution

1

Krisis Hipertensi
Krisis hipertensi mewakili 27% dari kegawatdaruratan 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
2

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.

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

HYPERTENSIVE EMERGENCY

HYPERTENSIVE URGENCY

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
5

Hypertensive Emergencies
A situation that requires immediate reduction in BP with parenteral agents because of acute or progressing target organ damage
6

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
7

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
8

Differences

The distinction between an emergency and an urgency is often ambiguous

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
10

Autoregulation
150
Cerebral Blood Flow (ml/100 gm/min)

100

Normotensi
50

Hipertensi

50

100

150

200

Mean arterial pressure (mmHg)

11

Pathophysiology
Circulating vasoconstrictors Abrupt SVR Abrupt BP Arteriolar fibrinoid necrosis Endothelial damage
Loss of autoregulatory function

End-organ ischemia
Adapted from Wu MM. Hypertension. In: Tintinalli J. Emergency Medicine: 12 A Comprehensive Study Guide. 5th ed. McGraw-Hill; 2000:403.

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

13

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
14

Signs and symptoms

Chest pain Dyspnea 27 % 22 %

Neurologic defisits 21 %
15

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
16

Tatalaksana Hipertensi Emergensi

Penanggulangan hipertensi emergensi harus dilakukan di RS dengan monitoring yang memadai (ICU) Pengobatan parenteral diberikan secara bolus atau infus sesegera mungkin Tekanan darah harus diturunkan dalam hitungan menit sampai jam dengan langkah sebagai berikut:
17

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 mmHg 6-24 jam berikutnya diturunkan sampai < 140/90 mmHg bila tidak ada gejala iskemia organ
19

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.
20

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

21

The ideal properties of IV agents for Hypertensive emergencies

Have ability to regulate easily blood pressure Allow to control of blood pressure reduction Minimize the risk of hypotension Treatment preparation should be rapid and predictable to reduce BP The agent should have minimal side effects/few adverse effect
22

Parenteral Drugs for Treatment of Hypertensive Emergencies Vasodilator

Drugs Nicardipine * Sodium Nitropruside

Fenoldopam Nitroglycerin * Enalaprilat Hydralazine Diltiazem * Trimetaphan
* Available in Indonesia

Onset of action 5 min immediate

< 5 min 2-5 min 15-30 min 10-20 min 5 min 5-10 min

Duration of action 1 hr 1-2 min

30 min 5-10 min 6 hr 4-6 hr 30 min 10 min
23

Dosage and adverse effects of commonly used Parenteral antihypertensive medications

Agents
Enalaprilat

Dosage
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

Adverse effects
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.

Esmolol

Labetalol

Nicardipin Nitroglycerin Nitroprusside

24

Parenteral Drugs for Treatment of Hypertensive Emergencies

Sodium nitroprusside Nitroglycerin Clonidin Diltiazem Nicardipine

25

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

Sediaan
150 mcg/ampul

Perhatian
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
Labetalol Nitroprusside

2 mg dan 10 mg/ amp Belum beredar di Indonesia Belum beredar di Indonesia 26

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
27

Nicardipine vs Clonidin
Nicardipine
Target organ Clinical effect Arteriole (Ca channel) Vasodilatation BP decreased

Clonidin (*)
CNS (2-agonist) Vasoconstriction increased BP then soon followed by decreasing of BP (caused by stimulation of central adrenoceptor in CNS lower part)

Heart Rate

Increasing reflex HR

Decreasing stimulate central parasympathetic

++
28

Rebound Effects

No effect

Nicardipine vs Diltiazem

Target organ Clinical effect

Nicardipine Arteriole (Ca channel) Vasodilatation BP decreased

Diltiazem Arteriole (Ca channel) Vasodilatation BP decreased

Heart Rate

29

Recommended antihypertensive agent for hypertensive crises

Conditions
Acut 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

Preferred Antihypertensive agents

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.

30

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

31

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

Nc

Nf ++ + 0 +++

D + + + +

V + +++ ++ 0

Systemic vasodilation Myocardial depression Blocks AV conduction Vasoselectivity

++ 0 0 ++++

32

COMPARISON BETWEEN CALCIUM ANTAGONISTS

Drug

Coronary Vasodilation

Suppression of Cardiac Contractility ++++

Suppression of SA Node

Suppression of AV Node

Verapamil (phenylalkylamine)

++++

+++++

+++++

Diltiazem (benzothiazepin)

+++

++

+++++

++++

Nicardipine (dihydropyridine)

+++++

0
33

Nifedipine
Pemberian Nifedipine secara sublingual tidak direkomendasikan untuk Hipertensi Emergensi oleh FDA dan sejak JNC VI Dapat terjadi penurunan tekanan darah yang tiba-tiba dan tidak terkontrol yang akan menyebabkan kejadian iskemik di otak,ginjal, dan jantung
34

Dosage and Administration

IV (mcg/kg/min) Acute hypertensive crises during surgery Hypertensive emergencies 2 - 10 0.5 6 Bolus (mcg/kg) 10 30

Acute hypertensive crises during surgery Hypertensive emergencies

0.5

(mcg/kg/min)

10

35

Perhitungan Dosis
BB = 50 Kg Dosis 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 50

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

60

36

PANDUAN DOSIS & PENGGUNAAN NICARDIPINE INJEKSI

SYRINGE PUMP Perdipine Injeksi 1 ampul 10mg Spuit 50 cc ( mL/jam) atau Pediatric Drip ( 1cc = 60 tetes)
INDIKASI BERAT BADAN 40 kg 50 kg 60 kg 70 kg 80 kg 90 kg KRISIS HIPERTENSI AKUT SELAMA OPERASI HIPERTENSI EMERGENSI DOSIS PERDIPINE INJEKSI (mcg/kgBB/menit) 1.5 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 18 24 36 48 60 72 84 96 108 23 30 45 60 75 90 105 120 135 27 36 54 72 90 108 126 144 162 32 42 63 84 105 126 147 168 189 36 48 72 96 120 144 168 192 216 41 54 81 108 135 162 189 216 243

0.5 1.0 6 12 8 15 9 18 11 21 12 24 14 27

10.0 120 150 180 210 240 270

37

PERHITUNGAN DOSIS
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 cc

= 100 mcg/cc

Dosis yang akan diberikan 0,5 x 60 x 60 (untuk dijadikan ke jam) = 18 mL/jam atau 18 cc/jam ( Infus Pump) 100 Bila kita memakai mikro drip yang 1 cc=60 tetes maka 18 cc x 60 tetes = 18 tetes/menit 60 menit

PANDUAN DOSIS & PENGGUNAAN NICARDIPINE INJEKSI

INFUS DRIP Perdipine Injeksi BERAT 1 ampul 10mg Dalam larutan 100 cc BADAN ( Tetes/menit) 40 kg Mikro Drip (1 cc = 60 tetes)
50 kg 60 kg 70 kg 80 kg 90 kg INDIKASI KRISIS HIPERTENSI AKUT SELAMA OPERASI HIPERTENSI EMERGENSI DOSIS PERDIPINE INJEKSI (mcg/kgBB/menit) 1.5 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 36 48 72 96 120 144 168 192 216 45 60 90 120 150 180 210 240 270 54 72 108 144 180 216 252 288 324 63 84 126 168 210 252 294 336 378 72 96 144 192 240 288 336 384 432 81 108 162 216 270 324 378 432 486

0.5 1.0 12 24 15 30 18 36 21 42 24 48 27 54

10.0 240 300 360 420 480 540

39

PENGGUNAAN BOLUS INJEKSI - 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

Nicardipine (Perdipine)
Perdipine mempunyai 2 kemasan : - 2 mg (isi 2 cc) untuk bolus injeksi - 10 mg (isi 10 cc) untuk infus drip
Untuk pemakaian dengan infus drip, direkomendasikan menggunakan cairan infus 100cc dan mikro drip (1cc=60 tetes) Lamanya pemakaian setelah tekanan darah turun dan terkontrol tergantung dari keputusan klinisi untuk pindah ke oral
41

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 jantung Apabila ada keputusan untuk pindah ke oral, maka 1 jam sebelum Perdipin di aff obat oral diberikan dahulu Dosis Perdipin mulai di turunkan (Tappering Off).
42

CONCLUSION
1. Hypertensive emergencies require immediate BP
reduction. This is most safely accomplished in the intensive care setting with use of an Intravenous agent. hypertensive agents, hypertensive crisis become less common, with an estimated prevalence rate of 1- 2 % among hypertensive patients.

2. With the advent of better tolerated, long-acting anti

3. Nicardipine I.V.injection) for hypertensive emergencies has a fast BP lowering effect which is predictable
43

Terima kasih

44