Supportive Care, Complication Prevention, and Monitoring in Hypertensive Crises
Learning Objective
- Recommend supportive care and monitoring strategies to manage complications of hypertensive crises and its treatment.
I. Indications and Considerations for Supportive Care Measures
Short summary: In hypertensive emergencies, adjunctive supportive care—ventilatory and hemodynamic—preserves organ perfusion during blood-pressure control.
A. Mechanical Ventilation
Indications
- Respiratory failure (PaO₂/FiO₂ <200, refractory hypoxemia)
- Airway protection: decreased consciousness (GCS ≤8) from encephalopathy or intracranial hemorrhage
- Cardiogenic pulmonary edema unresponsive to noninvasive support
Ventilation strategy
- Lung-protective tidal volume: 6 mL/kg predicted body weight
- PEEP: lowest level to maintain SpO₂ ≥92%
- Avoid excessive hyperventilation in neurologic injury (target PaCO₂ 35–40 mm Hg)
- Minimize sedation to facilitate neurologic exams and reduce delirium risk
Monitoring
- Arterial blood gases every 4–6 h or after ventilator changes
- Plateau pressure <30 cmH₂O, track respiratory compliance
Key Clinical Pearls: Mechanical Ventilation
- In intracerebral hemorrhage or hypertensive encephalopathy, abrupt PaCO₂ drops worsen cerebral ischemia.
- Early intubation may prevent aspiration in fluctuating mental status; weigh risks of sedation.
Case Vignette
A 70-year-old with ICH and GCS 7 is intubated; set Vt to 6 mL/kg PBW, maintain PaCO₂ at 38 mm Hg, and perform daily spontaneous breathing trials.
B. Hemodynamic Support
Indications
- Hypotension from over-reduction of BP (MAP <65 mm Hg)
- Cardiogenic shock in acute pulmonary edema
Fluid resuscitation
- Isotonic crystalloid boluses (250–500 mL) guided by dynamic indices (stroke volume variation, passive leg raise)
- Avoid fluid overload in heart failure or renal impairment
Vasopressors/inotropes
- Norepinephrine first-line for persistent hypotension: start 0.05 µg/kg/min, titrate to MAP ≥65 mm Hg
- Low-dose vasopressin (0.03 units/min) adjunct in refractory vasodilatory shock
- Dobutamine for cardiogenic shock with adequate BP: 2–10 µg/kg/min
Mechanical circulatory support (refractory cases)
- IABP, Impella, VA-ECMO as bridges in reversible cardiac failure
Invasive monitoring
- Arterial line: real-time BP for IV antihypertensive titration
- Central venous catheter: vasopressor delivery, CVP trending
- Pulmonary artery catheter: reserved for mixed or unclear shock
Key Clinical Pearls: Hemodynamic Support
- Always secure invasive BP monitoring before aggressive IV antihypertensives.
- In post-nitroprusside hypotension, restore MAP with norepinephrine rather than rapid fluid loading.
II. Prevention of ICU-Related Complications
Short summary: Prophylactic measures minimize thrombotic, gastrointestinal, and infectious risks during ICU stays.
A. VTE Prophylaxis
| Agent | Dosing | Monitoring & Adjustments |
|---|---|---|
| Low-molecular-weight heparin (enoxaparin) | 40 mg SC q24h (reduce to 30 mg if CrCl <30 mL/min) | Platelet count q2–3 days (HIT surveillance); Anti-Xa levels in extremes of weight or renal dysfunction |
| Unfractionated heparin | 5,000 units SC q8–12h | Platelet count q2–3 days (preferred if high bleeding risk or renal failure) |
Contraindications
- Active bleeding
- Platelets <50 ×10⁹/L
- Recent hemorrhagic stroke (relative, weigh risk/benefit)
B. Stress Ulcer Prophylaxis
Indications
- Mechanical ventilation >48 h
- Coagulopathy: INR >1.5 or platelets <50 ×10⁹/L
| Agent | Dosing | Risks and Monitoring |
|---|---|---|
| Pantoprazole (PPI) | 40 mg IV q24h | Watch for C. difficile, hospital-acquired pneumonia. Discontinue when risk factors resolve. |
| Famotidine (H₂RA) | 20 mg IV q12h |
C. Infection Prevention Strategies
Ventilator-associated pneumonia (VAP) bundle
- Elevate head of bed 30–45°
- Daily sedation interruption and extubation assessment
- Oral care with chlorhexidine
Central line-associated bloodstream infection (CLABSI) bundle
- Maximal sterile barriers at insertion
- Chlorhexidine dressings, daily line necessity review
General measures
- Rigorous hand hygiene
- Antimicrobial stewardship
Editor’s Note
Insufficient source material for detailed coverage. A complete section would include rates of VAP/CLABSI, specific stewardship protocols, and outcomes data.
III. Management of Iatrogenic Complications
Short summary: Recognize and reverse complications from overly rapid BP lowering and drug toxicities.
A. Overcorrection-Induced Ischemia
Recognition
- New focal neurologic deficits, chest pain, oliguria, rising creatinine
Immediate actions
- Slow or stop antihypertensive infusion
- Raise BP target (MAP +10-15 mm Hg), consider small IV fluid bolus
- Low-dose vasopressors (norepinephrine 0.01–0.05 µg/kg/min) if hypovolemia excluded
Prevention
- Limit initial BP reduction to ≤25% within first hour (except aortic dissection, eclampsia)
Key Clinical Pearl: Overcorrection Ischemia
Loss of autoregulation in chronic hypertension increases ischemic risk when BP falls too fast.
B. Drug-Induced Organ Dysfunction
Nitroprusside toxicity
- Mechanism: cyanide and thiocyanate accumulation during high-dose/prolonged infusion
- Monitoring: lactate, methemoglobin, thiocyanate levels, renal function
- Treatment: discontinue nitroprusside, give sodium thiosulfate (150 mg/kg IV over 15 min), consider hemodialysis
Other considerations
- Excessive diuresis → prerenal AKI
- Evaluate for methemoglobinemia with nitrates
IV. Multidisciplinary Goals-of-Care Conversations
Short summary: Early, structured discussions align high-burden therapies with patient values and prognosis.
A. Indications
- Refractory shock, multi-organ failure
- Need for mechanical circulatory support or prolonged life support
- Poor baseline functional status or terminal illness
B. Stakeholder Involvement
- ICU team: physicians, pharmacists
- Nursing staff: bedside assessment, family updates
- Palliative care: symptom management, prognostication
- Social work/ethics: psychosocial support, advance directives
C. Communication Frameworks
- SPIKES: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary
- NURSE statements: Name emotion, Understand, Respect, Support, Explore
- Document patient values, advance directives, and agreed-upon care plans
Key Clinical Pearl: Goals-of-Care
Structured goals-of-care conversations reduce nonbeneficial treatments and ICU length of stay.
References
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA guideline for prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension. 2018;71(6):e13–e115.
- Rossi GP, Rossitto G, Maifredini C, et al. Management of hypertensive emergencies: a practical approach. Blood Pressure. 2021;30(4):208–219.
- Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage. Stroke. 2015;46(7):2032–2060.
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344–e418.
- Anderson CS, Heeley E, Huang Y, et al. Antihypertensive treatment of acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–2365.
