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2025 PACUPrep BCCCP Preparatory Course Hypertensive Crises Pharmacologic Management and Blood Pressure Targets in Hypertensive Crises

Lesson 13, Topic 4

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Pharmacologic Management and Blood Pressure Targets in Hypertensive Crises

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Supportive Care in Hypertensive Crises

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

Table 1: VTE Prophylaxis Agents and Monitoring
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

Table 2: Stress Ulcer Prophylaxis Agents and Monitoring
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.

2025 PACUPrep BCCCP Preparatory Course

Pulmonary

Participants 432

Pharmacologic Management and Blood Pressure Targets in Hypertensive Crises

Learning Objective

I. Indications and Considerations for Supportive Care Measures

A. Mechanical Ventilation

Indications

Ventilation strategy

Monitoring

Case Vignette

B. Hemodynamic Support

Indications

Fluid resuscitation

Vasopressors/inotropes

Mechanical circulatory support (refractory cases)

Invasive monitoring

II. Prevention of ICU-Related Complications

A. VTE Prophylaxis

Contraindications

B. Stress Ulcer Prophylaxis

Indications

C. Infection Prevention Strategies

Ventilator-associated pneumonia (VAP) bundle

Central line-associated bloodstream infection (CLABSI) bundle

General measures

Editor’s Note

III. Management of Iatrogenic Complications

A. Overcorrection-Induced Ischemia

Recognition

Immediate actions

Prevention

B. Drug-Induced Organ Dysfunction

Nitroprusside toxicity

Other considerations

IV. Multidisciplinary Goals-of-Care Conversations

A. Indications

B. Stakeholder Involvement

C. Communication Frameworks

References