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1
Krisis Hipertensi
Salli Roseffi Nasution
2
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
3
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
5
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
6
Hypertensive Emergencies
A situation that requires immediate reduction in BP with parenteral agents because of acute or progressing target organ damage
7
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
10
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)
12
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
13
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
14
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
15
Signs and symptoms
• Chest pain 27 %
• Dyspnea 22 %
• Neurologic defisits 21 %
16
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
20
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.
21
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
22
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
24
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.
25
Parenteral Drugs for Treatment of Hypertensive Emergencies
Sodium nitroprussideNitroglycerinClonidinDiltiazem Nicardipine
26
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
-
27
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
28
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 ++
29
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
30
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
32
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
33
COMPARISON BETWEEN CALCIUM ANTAGONISTS
Drug Coronary Vasodilation
Suppressionof Cardiac
Contractility
Suppressionof SA Node
Suppressionof AV Node
Verapamil(phenylalkylamine)
++++ ++++ +++++ +++++
Diltiazem(benzothiazepin)
+++ ++ +++++ ++++
+++++ 0 + 0Nicardipine(dihydropyridine)
34
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
37
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)
39
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
41
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).
43
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
44
Terima kasih