Hypertensive crisis or “elevated” bp

[nikolaite]

For ICU/PCU patients in hypertensive crisis in the context of conservative ischemic stroke management, let’s say hypothetically the patients’ vitals have been described thus by nursing: “blood pressures have been elevated.” 😬“Elevated” is a specific range of systolic 120-129 with diastolic over 80....so... If we’re talking about patients in the 200s/100s, how is that designation of “elevated” even nearly legit or helpful from nursing? This seems like it could be a serious incompetence.

If periodic hydralazine has no effect in this patient group and they are persisting in hypertensive crisis...would labetalol or nicardipine iv infusion be the next step? Why (out of curiosity) would a pharmacist approve hydralazine for acute stroke patients as a PRN antihypertensive?

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[jdh71]

I think you're being overly pedantic here. The nurses just mean the BP is UP. They aren't trying nor should we be expected them to be absolutely specific in the language. If it doesn't help you look at the BP then I wonder why you weren't looking at the BP in the first place?

Choice of agent for treating hypertension in this population is going to be very context specific. And we usually let them run quite high at least initially. And then bring them down relatively slowly.

 

[nikolaite]

Thanks for your response.

It would absolutely be reasonable to look at the values if they’re entered in the flowsheets. Such a notation does not really come across as helpful, however, if the “elevated” bp values are not recorded when someone is trying to manage patients to 160 systolic, and they’re not responding to meds, and in reality running at 200 systolic.

Remote monitoring would have no value if the people on the floor don’t provide the data.

Just doing record reviews and software testing, I’m finding the lack of information frustrating. I can’t imagine the frustration that remote physicians experience.

 

[Euxox]

I'm not sure I see what the issue is? Sure, ideally nurses would be good about logging vitals into flowsheets. But if they're not, just go there and cycle the cuff yourself. It only takes two minutes, and you should be doing it on occasion anyway for a patient where BP control is one of the primary active issues.

 

[CCM-MD]

I'm not sure I see what the issue is? Sure, ideally nurses would be good about logging vitals into flowsheets. But if they're not, just go there and cycle the cuff yourself. It only takes two minutes, and you should be doing it on occasion anyway for a patient where BP control is one of the primary active issues.

I don’t believe OP is a physician.

 

[nikolaite]

Thanks for the replies folks.

As CCM-MD said, I am not a physician. I'm trying to coordinate compliance to an analog in a research group to test a software package. In the vet groups I've worked with, we never have this problem of data gaps or unfilable notes, especially with integrated automated remote monitoring systems. But there is something about medical groups that do not want to follow the protocols. I'm ranting a bit because I thought perhaps there would be some insight as to what's going on.

Maybe I'm just short on sleep.

 

[Siggy]

For ICU/PCU patients in hypertensive crisis in the context of conservative ischemic stroke management, let’s say hypothetically the patients’ vitals have been described thus by nursing: “blood pressures have been elevated.” 😬“Elevated” is a specific range of systolic 120-129 with diastolic over 80....so... If we’re talking about patients in the 200s/100s, how is that designation of “elevated” even nearly legit or helpful from nursing? This seems like it could be a serious incompetence.

If periodic hydralazine has no effect in this patient group and they are persisting in hypertensive crisis...would labetalol or nicardipine iv infusion be the next step? Why (out of curiosity) would a pharmacist approve hydralazine for acute stroke patients as a PRN antihypertensive?

1. The current goal for untreated (no neurointervention or TPA) for ischemic stroke is anything less than 220/120. So 200/100 for the first 24 hours is fine.

2. I can't remember the last time I've cared about RNs documenting anything regarding BP other than the numbers. I don't need them to interpret numbers for me in the chart. If they're concerned, they have my specralink number.

3. Patients with acute neurological changes shouldn't be getting PRN hypertensives. Either they're an ischemic stroke, which means that BP is ok, or they meet the definition of hypertensive emergency (high BP, end organ damage). Those patients should be on a continuous infusion in order to provide a controlled decrease.

4. The only true acceptable use for PRN antihypertensives is for people who are strict NPO. Quickly and uncontrollably decreasing BP in asymptomatic patients provides zero benefit (outside of the fact that the number turns black, so the nurses stop calling). However dropping a BP 100 points (250-150 systolic) and then watching the patient have a seizure does not, in fact, help the patient. I would have rather had the other service just put that patient on a cardene drip instead... if they weren't just going to start PO medications.

You can choose how much hydralazine to give... you can't choose how much that hydralazine drops the blood pressure.

 

[Dred Pirate]

If periodic hydralazine has no effect in this patient group and they are persisting in hypertensive crisis...would labetalol or nicardipine iv infusion be the next step? Why (out of curiosity) would a pharmacist approve hydralazine for acute stroke patients as a PRN antihypertensive?

For us nicardipine has replaced labetalol as our first line anti-hypertensive in stroke puts. Hydralazine was used only if a pat’s heart rate was to low to tolerate a beta blocker and we needed to get the pressure below 185 in order to give tpa. A well written order set would give specific indications for when to use it.

 

[Radetzky]

PRN iv antihypertensives should never be given in my opinion. Either you have a need for controlled titratable bp lowering (infusion) or the bp doesn’t need to be treated (most of the time).

 

[agranulocytosis]

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[nikolaite]

Thanks for all the input. You folks are great.