Question

Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensive suddenly because of the cost of the medications and she recently lost her job to outsourcing. The patient is slightly drowsy and complains of headache and blurring vision. The patient's blood pressure is 220/130 mm Hg upon presentation .

a. According to the definition set by the Seventh report of the joint National Committee of Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), which type of hypertensive crisis is the patient currently experiencing?

b. Describe the treatment goals for handling the hypertensive crisis and apply the goals to the case study. Determine the current mean arterial pressure (MAP) and the goals for treatment. The physician orders nicardipine hydrochloride 25mg/250ml, NS for peripheral IV starting at 2.5mg/hr, and titrate by 2.5mg/hr every 15 minutes to reach the goal for the first hour, which is to achieve 25% reduction of the initial MAP. · Call the physician if the dosing range of 15mh/hr has been reached and the MAP is still not at target goal for the first hour treatment or up to four dose increases. · Lower the BP within 6hours to 160/100mmhg · Adjust the IV rate so that the IV fluids plus the nicardipine drip are equal to100ml/hr. in total. Cal the physician if the IV fluids must go above 100ml/hr to provide the nicardipine.

c. Explain what rate to set initially for both the nicardipine drip and the NS maintenance fluids

d. Explain the process of titrating the nicardipine drip for the first hour to achieve the final MAP goal of 25% reduction of the original MAP

Answer 1

a. The patient is experiencing Hypertensive urgency

- severe blood pressure elevation without evidence of end - organ dysfunction

- examples include upper level of stage II hypertension either asymotomatic or associated with headache, dyspnoea, epistaxis, palpitation, or anxiety.

- most patients have inadequately treated hypertension or noncompliant with treatment regimen

b. Treatment goals for hypertensive crisis

The main goal is to reduce Mean Arterial Pressure by no more than 20- 25%, Diastolic Blood Pressure to 100- 110 mmHg with in few minutes(1 min) to 2 hours.

c. The initial infusion rate of intravenous nicardipine is 5mg/h. the maximum infusion rate is 30mg/h. The target systolic pressure reaches normal in patients treated with nicardia with in 30 min of administration.

d. The treatment is initiated at 50ml/hr (5mg/hr). If desired blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 25mL/hr (2.5mg/hr) every 5 minutes (for rapid titration) to 15 minutes (for gradual titration) up to a maximum of 150mL/hr (15mg/hr), until desired blood pressure reduction is achieved

Following achievement of the blood pressure goal utilizing rapid titration, decrease the infusion rate to 30mL/hr (3mg/hr)