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By: Kelly C. Rogers, PharmD, FCCP

  • Professor, Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee


Children with toxicity from diphenhydramine pregnancy 6 weeks symptoms , a widely used menstrual 10 days , over-the-counter antihistamine women's health center elmhurst hospital , generally present with symptoms reflecting an anticholinergic toxidrome womens health resource center lebanon nh . Symptoms may include agitation, confusion, hyperactivity, hallucinations, dry mouth and eyes, dry flushed skin, urinary retention, dilated pupils, tachycardia, tremor, and even seizures in severe cases. The patient in the vignette presented with constricted rather than dilated pupils, and bradycardia, rather than the tachycardia that would be expected from diphenhydramine overdose. Children with acute toxicity from lithium may present with a range of clinical findings, including gastrointestinal upset (nausea, vomiting, and diarrhea), dehydration, tremor, weakness, hyperreflexia, slurred speech, visual disturbances, mental status changes, and even seizures with severe toxicity. Lithium toxicity would not explain the significant respiratory depression, miosis, or decreased reflexes observed in the girl in the vignette. Profound somnolence would also not be a characteristic early finding in a child with acute lithium toxicity. Verapamil is a calcium channel blocker used (most commonly in adult patients) in the treatment of hypertension, coronary artery disease, and atrial fibrillation, and to prevent cerebral vasospasm. The predominant clinical findings in patients with calcium channel blocker toxicity are bradycardia and hypotension. Neurologic and respiratory system derangements can occur from calcium channel blocker overdose, but these generally arise secondary to cardiovascular toxicity and shock. The pregnancy history is significant for a known fetal tachyarrhythmia that has been well controlled by maternal treatment with digoxin. Continuous monitoring reveals a fetal heart rate of 160 beats/min with rare variable decelerations seen with infrequent contractions. Further evaluation of fetal well-being includes a nonreactive nonstress test and a biophysical profile of 4 out of 10. Due to the late preterm status of the pregnancy and history of fetal arrhythmia, the obstetrician seeks your input in the subsequent management of the mother and fetus. Pregnancies in which maternal and/or fetal complications develop require increased surveillance to decrease the risk of fetal death. Methods of monitoring include maternal perception of fetal movement, nonstress testing, and biophysical profile evaluation. Maternal perception of fetal movement has long been recognized as a measure of fetal wellbeing; with any concerns of decreased fetal movement prompting further evaluation. Each is assigned either 0 or 2 points, with a composite score of 8 to 10 being normal, 6 being equivocal, and 4 or less being abnormal. The early identification of a fetal arrhythmia allows close fetal monitoring for complications such as hydrops fetalis. Some fetal arrhythmias are amenable to therapies delivered transplacentally, such as digoxin for supraventricular tachycardia. Undiagnosed arrhythmias presenting in the third trimester may be interpreted as fetal distress, leading to premature delivery. The mother in the vignette presented with a complaint of decreased fetal movement. Continued observation with intermittent monitoring or discharge from the hospital would not be recommended because of the increased risk of fetal death with these findings. The maternal digoxin dosing does not need to be increased in this case, because the fetal heart rate appears to be well controlled. Each measure is assigned either 0 or 2 points, with a composite score of 8 to 10 being normal, 6 being equivocal, and 4 or less abnormal. He experiences 2 to 3 migraine headaches per week and has to go home from school at least once a week. He has been taking ibuprofen 3 or 4 days every week for the past month and it no longer relieves the migraine symptoms. His blood pressure is 118/68 mm Hg, heart rate is 86 beats/min, respiratory rate is 16 breaths/min, and body mass index is 18. His physical examination, including neurological examination and fundoscopy, is unremarkable. Frequent, excessive use of ibuprofen is a likely contributor by causing medication overuse headaches. The best first step in improving his headache severity and frequency is to discontinue the ibuprofen. A migraine prophylaxis plan addresses the multifactorial causes of migraine headaches. Migraines often worsen during times of stress, such as the start of an academic year. Improving stress management skills is an important part of a migraine prophylaxis plan. Prophylactic medications are indicated when the severity and frequency of migraines interfere with functioning. Other important elements of a migraine prophylaxis plan are the promotion of regular, restful sleep, and a regular, nutritious diet. For the boy in the vignette, who is nearly an adult, migraine prophylactic medications used for adults would be effective. For instance, topiramate can cause weight loss and should be used cautiously in a person who is already thin. Isotretinoin has been associated with pseudotumor cerebri and should be stopped if a person develops signs of this condition. The boy in the vignette has typical migraines and his fundoscopic examination findings are normal, so he does not have signs of pseudotumor cerebri. An abortive therapy plan for migraines starts with over-the-counter medications such as acetaminophen or ibuprofen. If these are ineffective, prescription medications such as one of the triptan class of medications can be tried. Medications for abortive therapy should not be used more than 2 to 3 times a week; otherwise medication overuse headache can develop. The only treatment for medication overuse headache is to discontinue the inciting medication. Patients should know that the headaches will transiently worsen, but discontinuing the inciting medication is a necessary step as the migraines are unlikely to improve in the setting of ongoing medication overuse. In your office, the newborns vital signs include a pulse of 175 beats/min and a blood pressure of 75/40 mm Hg. Initial laboratory results include a serum sodium of 129 mEq/L (129 mmol/L), potassium of 6. Based on the newborns diagnosis, clinical status, and laboratory results, you administer a normal saline bolus of 20 mL/kg intravenously. As female patients would be expected to have some degree of ambiguous genitalia, the newborn screen is primarily designed to diagnose male infants before they can present in extremis with a salt-wasting crisis. Patients with a positive screen should have a confirmatory serum 17-hydroxyprogesterone level (sometimes written as 17-alphahydroxyprogesterone) as well as glucose and electrolyte levels obtained. The infant in the vignette has abnormal vital signs, and his electrolytes show that he is already experiencing salt wasting and is dehydrated. Treatment with high-dose steroids (stress dose steroids) is needed to mimic the high doses of steroids normally produced under stress in patients with sufficient adrenal function. The treatment of choice for adrenal crisis, of any cause, is fluid replacement, hydrocortisone hemisuccinate intravenously, and if hypoglycemia is present, intravenous dextrose. Hydrocortisone is quick acting and at an emergency stress dose (100 mg/m2) saturates all steroid receptors, causing a mineralocorticoid and glucocorticoid effect. Intramuscular hydrocortisone is commonly given to patients to take at home before coming to the hospital if they are severely ill, but once in the hospital or emergency department, intravenous hydrocortisone should be used because of its quick onset of action. Pediatricians should recognize that some steroids, such as methylprednisolone, commonly used in asthma, have no mineralocorticoid activity at any dose and would not be appropriate for this patient. Dexamethasone and betamethasone can act quickly but have limited mineralocorticoid effect, and would be used in much smaller doses than those listed in the responses. It is helpful to be familiar with recommended hydrocortisone stress doses (Item C39. He started to exhibit symptoms of an acute upper respiratory infection 2 days ago. The child was born full term and has no prior history of hospitalization or respiratory failure.

The use of actigraphy in the treatment of obstructive sleep apnea does not meet the Kaiser Permanente Medical Technology Assessment Criteria women's health clinic toledo ohio . Most studies were conducted in sleep laboratories where recording conditions are standardized menopause what to expect , and the artifacts controlled menopause 2 periods in one month . These controls would be lost when the actigraphy devices are used in the home environment menstrual cycle 8 years old , where it is intended for use. Also, the algorithms that were validated for a specific model, mode of operation, or in a selected population may by not be equally accurate when used with a different brand of device, different gender or age group. The overall results of the studies reviewed, indicate that compared to polysomnography, actigraphy had a high sensitivity (92-98%) but very low specificity (28-48%) in detecting insomnia. Actigraphy tends to overestimate sleep in people with insomnia when they are lying quietly as quiet wakefulness could be miscoded as sleep. Insomnia patients can remain inactive for a period of time attempting to fall asleep. On the other hand, actigraphy may underestimate the amount of sleep and overestimate the duration 2007 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 39 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History awake among those who are asleep but are restless or have large amounts of movements during sleep. The use of actigraphy for the assessment of periodic leg movements in sleep was evaluated in only a few small studies with methodological limitations. One records electrical activity of a certain muscle and the other records leg acceleration. Leg activity may be due to movement artifacts produced by obstructive sleep apnea. Kemlink et al (2007) did not exclude patients with suspicious sleep apnea and did not adjust for it in the analysis. Articles: the following questions were considered in screening the published articles: 1) What is the diagnostic accuracy of actigraphy in the evaluation of patients with sleep disordersff Due to the continuing development in the actigraphic devices, operating procedures, software, and scoring algorithms, the literature was screened to identify the more recent studies. Many of these used actigraphy to assess treatment effects or compared results from one actigraphy scoring algorithm to another. There were a number of nonrandomized studies that compared actigraphy with other tools for the evaluation of patients with insomnia, periodic leg movement, narcolepsy and other medical disorders other than sleep disorders. The literature search did not reveal any study that would determine the influence of the technology on management decisions or its impact on patient outcome. A comparison of actigraphy, polysomnography in older adults treated for chronic primary insomnia. A comparison of polysomnographic and actigraphic evaluation of periodic limb movement in sleep. The validation of a new actigraphy system for the measurement of periodic leg movement in sleep. The use of actigraphy in the treatment of sleep disorders does not meet the Kaiser Permanente Medical Technology Assessment Criteria. The accuracy of one devise cannot be extrapolated to others even from the same class due to the differences in the number and types of signals recorded, sensors used, and the processing of signals. It is unknown which sensors or combinations have the highest sensitivity and specificity. The actometer estimated the total sleep time while the tests of respiratory function were used to calculate the apnea severity, and apnea hypopnea index. The sensitivity tended to be lower, and specificity higher with increasing severity the disorder. The in-home study was considered positive if the respiratory 2007 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 40 these criteria do not imply or guarantee approval. In addition, the studies were powered as superiority and not equivalence trials, and lack of significant differences does not necessarily indicate equivalence. Berry and colleagues powered their trial as noninferiority, but only for the compliance outcome. The technology was frequently used to determine response of therapies for insomnia, mainly melatonin. There were few small validation studies on different portable monitor devices for diagnosing obstructive sleep apnea. Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. The use of actigraphy in the treatment of sleep disorders does not meet the Kaiser Permanente Medical Technology Assessment Criteria. The majority of sleep studies were conducted in sleep laboratories where the recording conditions are standardized, and the artifacts controlled. These controls would be lost when the actigraphy devices are used in the home environment, which is the primary intention for their use. Generalization of the results of the published studies may be limited to similar devices and population groups as the algorithms that were validated for a specific model, mode of operation, or in a selected population may not be equally accurate when used with a different brand of device, different gender, or age group. These older as well as the more recent studies showed that actigraphy in general underestimates wake and overestimates the total sleep time and sleep efficiency. Individuals with insomnia can remain inactive for a period of time attempting to fall asleep, and actigraphy tends to overestimate sleep in these people as quiet wakefulness could be miscoded as sleep. On the other hand, actigraphy may underestimate the amount of sleep and overestimate the duration awake among those who are asleep but are restless or have large amounts of movements during sleep. These modes were the proportional 2007 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 41 these criteria do not imply or guarantee approval. In addition, the authors did not explain whether the study participants were asked to complete sleep diaries. These results, however, may not be generalized to populations in different age groups or to other actigraphy devices. The level of this disagreement decreased with subjective and actigraphic measures of sleep quality and increased with male gender, poor cognitive function, and functional disability. In a smaller study, Levenson and colleagues 2013 (Evidence Table 3) also compared the accuracy of actigraphy versus sleep diary among a group of older insomniac patients participating in a larger study that examined the effect of behavioral therapy on insomnia in older adults. The participants completed at least 7 nights of sleep diary and actigraphy (using the Minimitter Actiwatch. The results of the analyses indicate that the sleep diary parameters discriminated individuals with insomnia from good sleepers more accurately than actigraphy. Johnson and colleagues, 2007 (Evidence Table 4) examined the level of agreement between actigraphy and polysomnography among 181 adolescents 1216 years of age. The results of the analysis showed significant differences between the assessments of total sleep time by actigraphy vs. Articles: the literature search revealed over 800 articles published on actigraphy and sleep in the last 5 years. There was a lack of published studies on the use of actigraphy in patients with circadian rhythm sleep disorders. Sleep estimation using wrist actigraphy in adolescents with and without sleep disordered breathing: a comparison of three data modes. A quantitative approach to distinguishing older adults with insomnia from good sleeper controls. Disagreement between subjective and actigraphic measures of sleep duration in a population-based study of elderly persons. The use of actigraphy in the treatment of obstructive sleep apnea does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 3/24/2020 42 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 43 these criteria do not imply or guarantee approval. The Clinical Review Criteria only apply to Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. Use of the Clinical Review Criteria or any Kaiser Permanente entity name, logo, trade name, trademark, or service mark for marketing or publicity purposes, including on any website, or in any press release or promotional material, is strictly prohibited.

Severe exacerbations are potentially life threatening and their treatment requires careful assessment and close monitoring womens health pavilion . Patients with severe exacerbations should be advised to see their health care provider promptly or menstrual 24 , depending on the organization of local health services 3 menstrual cycles in one month , to proceed to the nearest facility that provides emergency access for patients with acute asthma menopause fragile x . Treatment options for written asthma action plans A written asthma action plan helps patients to recognize and respond appropriately to worsening asthma. The criteria for initiating an increase in controller medication will vary from patient to patient. This is particularly important if there has been a lack of response to increased use of beta2-agonist therapy. The recommended maximum total dose of formoterol in 24 hours with this regimen is 72 mcg. The benefit of this regimen in preventing exacerbations appears to be due to intervention at a very early 493,494 stage of worsening asthma. This regimen was also effective in reducing exacerbations in children aged 411 217 years, (Evidence B), but it is not approved for this age group in many countries. Patients should be advised about common side-effects, including sleep disturbance, increased 503 appetite, reflux, and mood changes. Management of worsening asthma and exacerbations 105 Reviewing response Patients should see their doctor immediately or present to an acute care unit if their asthma continues to deteriorate despite following their written asthma action plan, or if their asthma suddenly worsens. Follow up after a self-managed exacerbation After a self-managed exacerbation, patients should see their primary care health care provider for a semi-urgent review (e. The written asthma action plan should be reviewed to see if it met the patients needs. Maintenance controller treatment can generally be resumed at previous levels 24 weeks after the exacerbation (Evidence D), unless the history suggests that the exacerbation occurred on a background of long-term poorly controlled asthma. In this situation, provided inhaler technique and adherence have been checked, a step up in treatment is indicated (Box 3-5, p. Adult and adolescent patients with more than 1-2 exacerbations per year despite Step 4-5 therapy should be referred to a specialist center for assessment (see decision tree in Chapter 3E, p. Maintenance and reliever regimen is not approved for children <12 years in many countries. Milder exacerbations can usually be treated in a primary care setting, depending on resources and expertise. History the history should include: Timing of onset and cause (if known) of the present exacerbation Severity of asthma symptoms, including any limiting exercise or disturbing sleep Any symptoms of anaphylaxis Any risk factors for asthma-related death (Box 4-1, p. Physical examination the physical examination should assess: Signs of exacerbation severity (Box 4-3, p. Saturation levels <90% in children or adults signal the need for aggressive therapy. The aim is to rapidly relieve airflow obstruction and hypoxemia, address the underlying inflammatory pathophysiology, and prevent relapse. Because of the static charge on plastic spacers, they should be pre-washed with detergent and air-dried to be ready for immediate use. Controlled oxygen therapy (if available) Oxygen therapy should be titrated against pulse oximetry (if available) to maintain oxygen saturation at 9395% (94 98% for children 611 years. Controlled or titrated oxygen therapy gives better clinical outcomes than high-flow 100% 507-509 oxygen therapy (Evidence B. Oxygen should not be withheld if oximetry is not available, but the patient should be monitored for deterioration, somnolence or fatigue. The recommended dose for adults is 1 mg prednisolone/kg/day or equivalent up to a maximum of 50 mg/day, and 12 mg/kg/day for children 611 years up to a maximum of 40 510,511 mg/day. Patients should be advised about common 503 side-effects, including sleep disturbance, increased appetite, reflux and mood changes. Controller medication Patients already prescribed controller medication should be provided with advice about increasing the dose for the next 24 weeks, as summarized in Box 4-2 (p. An exacerbation requiring medical care indicates that the patient is at increased risk of future exacerbations (Box 2-2, p. Antibiotics (not recommended) Evidence does not support a role of antibiotics in asthma exacerbations unless there is strong evidence of lung infection 512 (e. Aggressive treatment with corticosteroids should be implemented before antibiotics are considered. Reviewing response During treatment, patients should be closely monitored, and treatment titrated according to their response. Patients who present with signs of a severe or life-threatening exacerbation (Box 4-3, p. A decision can then be made whether to send the patient home or transfer them to an acute care facility. Patients should be advised to use their reliever inhaler only as-needed, rather than routinely. A follow-up appointment should be arranged for about 27 days later, depending on the clinical and social context. They should assess the patients level of symptom control and risk factors; explore the potential cause of the exacerbation; and review the written asthma action plan (or provide one if the patient does not already have one. Maintenance controller treatment can generally be stepped back to pre-exacerbation levels 24 weeks after the exacerbation, unless the exacerbation was preceded by symptoms suggestive of chronically poorly controlled asthma. In this situation, provided inhaler technique and adherence have been checked, a step up in treatment (Box 3-5, p. Management of asthma in the intensive care unit is beyond the 513 scope of this report and readers are referred to a recent comprehensive review. Assessment History A brief history and physical examination should be conducted concurrently with the prompt initiation of therapy. Physical examination the physical examination should assess: Signs of exacerbation severity (Box 4-4), including vital signs (e. Objective assessments Objective assessments are also needed as the physical examination alone may not indicate the severity of the 514,515 exacerbation. However, patients, and not their laboratory values, should be the focus of treatment. Lung function should be monitored at one hour and at intervals until a clear response to treatment has occurred or a plateau is reached. In children, oxygen saturation is normally >95%, and saturation <92% 516 is a predictor of the need for hospitalization (Evidence C. Subject to clinical urgency, saturation should be assessed before oxygen is commenced, or 5 minutes after oxygen is removed or when saturation stabilizes. Supplemental controlled oxygen should be continued while blood gases are obtained. Treatment in acute care settings such as the emergency department 521 the following treatments are usually administered concurrently to achieve rapid improvement. Oxygen To achieve arterial oxygen saturation of 9395% (9498% for children 611 years), oxygen should be administered by nasal cannulae or mask. In severe exacerbations, controlled low flow oxygen therapy using pulse oximetry to maintain 507-509 saturation at 9395% is associated with better physiological outcomes than with high flow 100% oxygen therapy (Evidence B. However, oxygen therapy should not be withheld if pulse oximetry is not available (Evidence D. Once the patient has stabilized, consider weaning them off oxygen using oximetry to guide the need for ongoing oxygen therapy. One found no significant differences in lung function or hospital admissions but a later review with additional studies found reduced hospitalizations and better lung function with continuous compared with intermittent nebulization, 523 particularly in patients with worse lung function. An earlier study in hospitalized patients found that intermittent ondemand therapy led to a significantly shorter hospital stay, fewer nebulizations and fewer palpitations when compared 524 with 4-hourly intermittent therapy. There is no evidence to support the routine use of intravenous beta2-agonists in patients with severe asthma 525 exacerbations (Evidence A. Epinephrine (for anaphylaxis) Intramuscular epinephrine (adrenaline) is indicated in addition to standard therapy for acute asthma associated with anaphylaxis and angioedema. Management of worsening asthma and exacerbations 113 Systemic corticosteroids Systemic corticosteroids speed resolution of exacerbations and prevent relapse, and should be utilized in all but the 526-528 mildest exacerbations in adults, adolescents and children 611 years. Where possible, systemic 527,528 corticosteroids should be administered to the patient within 1 hour of presentation. The oral route is preferred because it is quicker, less 529,530 invasive and less expensive. Intravenous corticosteroids can be administered when patients are too dyspneic to swallow; if the patient is vomiting; or when patients require non-invasive ventilation or intubation. However, there is 533 insufficient evidence to recommend intramuscular over oral corticosteroids.


  • Severe disturbances in body chemistry
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In general menopause rash , the patients physical this patient would qualify as an exception to the general examination and presenting symptoms will lead toward treatment principles for hypertensive emergency queens women's health center honolulu . Although Laboratory values do not indicate specifc target-organ rapid womens health of mansfield , aggressive blood pressure lowering has been shown damage women's health clinic erina . Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. When selecting an gency, it is challenging to label one medication as the drug agent, these parameters must be considered. Preferable traits of medications used to Because it works directly at smooth muscle, sodium nitrotreat hypertensive emergencies include intravenous adminprusside reduces both afterload and preload, giving it wide istration, ability to be titrated to desired effect allowing for a applicability for various hypertensive emergencies. Coronary steal is the concept be used with acute and profound lowering of blood pressure, of redistributing oxygenated blood from diseased coronary given that over-normalization has led to the induction of ischarteries toward non-diseased coronary arteries because emic complications (Strandgaard 1984. Investigations have non-diseased coronary arteries can preferentially vasodishown that 10%66% of patients may have over-normalization late. In theory, this would then shunt oxygenated blood away of blood pressure during their treatment of hypertensive emerfrom ischemic areas. Sodium nitroprusside may result in this gency, demonstrating the challenge of this goal of smooth, preferential vasodilation, leading to reduced coronary pertarget-associated blood pressure reduction (Grise 2012; fusion pressure (Mann 1978), and thus should be avoided Vuylsteke 2011. Updates in Therapeutics: Critical Care Pharmacy Preparatory Review Course, 2017 ed. Sodium nitroprusside contains cyausing supportive care, or using hemodialysis to enhance nide molecules that are released during administration. The remaining cyanide molecules are converted to thionitroprusside has considerably increased by around 200% cyanate by transsulfuration in the liver, which is then excreted in some instances. Patients with chronic liver dising more available, cost analyzes are vital in evaluating the ease, alcoholism, and malnourishment may have a decreased use of these products on a larger scale. One such analysis capacity for transsulfuration, leading to an impaired ability to showed a yearly reduction of around $300,000 in 1 year at detoxify cyanide (Kwon 2009; Villanueva 2006; Kim 2003. Continuing analyzes yarrhythmias, tachypnea, blood pressure lability, unexplained such as this should be performed in this era of considerable lactic acid, anion gap, metabolic acidosis, shock, and death drug inflation. Although cyanide accumulation is a risk Because of the aforementioned concerns surrounding with sodium nitroprusside, under normal conditions, patients the use of sodium nitroprusside as a frst-line agent, other can detoxify 50 mg of sodium nitroprusside, which will then agents have been investigated extensively. Of note, a boxed warning exists regarding non-dihydropyridine agents diltiazem and verapamil (Rhoney cyanide exposure, with a recommendation to avoid maximum 2009. High doses are rarely used in clinical practice; therefore, vascular smooth muscle. This inhibition prevents smooth cyanide toxicity is unlikely in most patients during the acute muscle contractility, leading to vasodilation and reduction in treatment phase. These agents preferentially bind to bin and/or methemoglobin serum concentrations can be sent peripheral L-type calcium channels in the cerebral, coronary, in addition to laboratory tests to elucidate lactic acidosis, and peripheral, and renal vascular smooth muscle (Fugit 2000; arterial and venous blood gases can be obtained to compare Sabbatini 1995. Cyanide concentrations are in the order of the conduction systems and contractile myousually not processed at most institutions and serve mainly cardial cells in addition to their peripheral effects. Thiocyanate accumulation may cause toxicity but is acute stroke as the target-organ damage on presentation of considered less toxic than cyanide. The most common adverse events metoprolol and the combination ff and ff-antagonist labeta1 associated with nicardipine are related to vasodilation, includlol (Rhoney 2009. Because of their ff-selectivity, neither of these agents products, or those with defective lipid metabolism. Because has direct vasodilatory effects, and blood pressure control is of the lipid load associated with infusion, it is recommended solely through the negative inotropic and chronotropic effects to give less than 1000 mL of clevidipine per 24-hour period (Melandri 1987; Bourdillon 1979. Labetalol is a combina(average of 21 mg/hour) with consideration of triglyceride tion ff and ff-antagonist, which, according to the prescribed1 monitoring and coadministration of other lipid emulsions. Of interest, though labetalol is often given well tolerated with minimal adverse effects. Early studies of high-dose (1 mg/ headache, nausea, vomiting, and tachyarrhythmias as well kg, or 50 mg) intravenous bolus dosing compared with conas fever. Finally, nicardipine is about one-third the cost of tinuous intravenous infusions showed a better safety profle clevidipine, which is about one-fourth the cost of sodium with continuous infusions, leading to the conclusion that nitroprusside per vial. Although clinical considerations often labetalol should be given as a continuous infusion (Cumming supersede cost considerations, in the era of cost contain1979a; Cumming 1979b. This data should be cautiously interment and reimbursement uncertainty, drug costs are very preted as the intravenous bolus dosing at the time was much important considerations. Because of the extended duration of action with nitroglycerin, it can reduce relative venous return and (see Table 1-5), each dose should be titrated cautiously. In addilabetalol is one of the medications of choice for pregnancy-retion to the peripheral effects of nitroglycerin, coronary artery lated hypertensive crisis. All ff-antagonists must be avoided in vasodilatory effects occur without the complication of coropatients with acute presentations of systolic heart failure for nary steal (Adebayo 2015; Mann 1978. Hydralazine can be delivered tions in dosing to maintain hemodynamic effects (Hirai 2003; either by intravenous or intramuscular injection at similar Larsen 1997; Needleman 1975. His vital signs include blood pressure includes cigarette smoking, 1 pack/day, for the past 15 years. The patients physical examination with acute aortic dissections, the goals change to targetand presenting symptoms will lead toward which diagnosing heart rate reduction to a goal heart rate of less than tic tests and laboratory assays to obtain. The laboratory 60 beats/minute as well as blood pressure reduction to values do not indicate specifc target-organ damage. In addition, fenoldopam contains ing dose adjustment diffcult and raising signifcant safety sodium metabisulfte, which can trigger anaphylactic reacconcerns. In addition, enalaprilat must be avoided in pregtions in those with sulfa or sulfte allergies. Common adverse nant patients, and use may be associated with deterioration effects of fenoldopam include headache, nausea, vomiting, of renal function, especially in states of poor renal perfusion and flushing as well as inducing tachycardia; of note, fenoldothat potentially occur in hypertensive emergency, warranting pam may cause hypokalemia. Phentolamine is a peripheral ff a1 nd ff2 receptor antagoComparative Data in Hypertensive Emergency nist leading to direct vasodilation. In general, phentolamine Because systematic review has failed to show major clinical is reserved for catecholamine-excess presentations of outcome differences between agents, other considerations, hypertensive emergency (e. Because of the percent attainment of goal, need for other blood pressure mechanism of phentolamine, adverse effects such as flushagents), will distinguish the agents from one another. Table 1-6 ing and headache are common (Rhoney 2009; Chobanian highlights some of the key fndings of analyses comparing 2003. In addition, rebound tachycardia can occur, which can agents for hypertensive emergency. Patients with stroke with acute Prospective, Greater attainment of blood pressure goal labetalolc hypertension pseudo(100% vs. Emergence hypertension after Prospective, Fewer treatment failures with nicardipine vs. Comparative Data for Agents in Hypertensive Emergency (continued) Agents Compared Population Study Design Key Findings Nicardipine vs. Perioperative acute hypertension before, Prospective, No difference in clinical outcomes in incidence nitroglycerin, during, or after cardiac surgery randomized, of myocardial infarction, stroke, or renal sodium n=1512 open-label, dysfunction nitroprusside, and parallel Clevidipine associated with greater time in nicardipinej,k comparison goal range than nitroglycerin (p=0. Comparative Data for Agents in Hypertensive Emergency (continued) Agents Compared Population Study Design Key Findings Labetalol vs. Intravenous labetalol compared with intravenous nicardipine in the management of hypertension in critically ill patients. A comparison of nicardipine and labetalol for acute hypertension management following stroke. A prospective evaluation of labetalol versus nicardipine for blood pressure management in patients with acute stroke. A multicenter comparison of outcomes associated with intravenous nitroprusside and nicardipine treatment among patients with intracerebral hemorrhage. Postoperative hypertension: a multicenter, prospective, randomized comparison between intravenous nicardipine and sodium nitroprusside. Nicardipine versus nitroprusside infusion as antihypertensive therapy in hypertensive emergencies. Nicardipine is superior to esmolol for the management of postcraniotomy emergence hypertension: a randomized open-label study. Comparison of intravenous nicardipine and nitroglycerin to control systemic hypertension after coronary artery bypass grafting.

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