1 / 32

Case Studies in Acute Hypertension

Investigations ● Advances ● Applications. Case Studies in Acute Hypertension. Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical School . Case Study #1. Case Studies of Acute Hypertension. Type A Aortic Dissection.

Mia_John
Download Presentation

Case Studies in Acute Hypertension

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Investigations ● Advances ● Applications Case StudiesinAcute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical School

  2. Case Study #1 Case Studies of Acute Hypertension Type A Aortic Dissection www.radpod.org

  3. Case Study #1 Case Studies of Acute Hypertension Acknowledgement Thank you to Dr. Michael England for sharing this interesting case

  4. Case Study 1: Type A Aortic Dissection 44-year-old female presents for surgical correction of a Type A dissection • HPI: presented to ED complaining of sudden onset of severe chest pain and shortness of breath. • PHM/PSH: obesity • Allergies: NKDA • Medications: none • FamHx: noncontributory • ROS: unremarkable www.edpma.com

  5. Case Study 1: Type A Aortic Dissection • General: anxious, grossly obese. • Ht: 62 inches Wt: 102 kg • VS: 141/45(R=L); HR 80’s reg; Resp 18; SpO2 96% RA • Neuro: alert & oriented x3; no gross deficits • Pulmonary: B/L rales • Cardiac: S1S2reg, grade IV syst. murmur • Extrem: 2+ palpable B/L UE & LE; no edema turbosquid.com

  6. Case Study 1: Type A Aortic Dissection 12.3 > < < 112 20 4.0 24 1.2 LFTs Coags WNL WNL Chem: Heme: ECG: no ischemic changes CT: TEE: 10 250 110 39

  7. Diagnosis Case Study 1: Type A Aortic Dissection Type A Aortic Dissection w/severe aortic insufficiency Management www.radiologyassistant.nl • Immediate β-blockade • Control SBP with IV antihypertensive to prevent aortic rupture & further extension of dissection • Proceed to the OR for immediate surgical correction (ascending aortic replacement, +/- AVR)

  8. Case Study 1: Type A Aortic Dissection Management • β-blockade: reduces dP/dt • IV antihypertensive: reduces shear forces on the weakened aortic wall • Surgical correction: reduces observed Type A dissection mortality (~↑2% per hour). Uncorrected in-hospital mortality (58%) vs. surgically corrected (27.4%)1. www.radiologyassistant.nl Hagan et al. Jama 2000;283:897

  9. Case Study 1: Type A Aortic Dissection In the OR

  10. Case Study 1: Type A Aortic Dissection In the OR

  11. Case Study 1: Type A Aortic Dissection In the OR CPB Incision Induction

  12. Case Study 1: Type A Aortic Dissection In the OR – “The Zone” CPB Induction Incision 120 95

  13. Case Study 1: Type A Aortic Dissection In the OR – the drugs NTG nitroglycerin CPB SNP sodium nitroprusside Induction Incision CLV clevidipine NTG SNP CLV

  14. Case Study 1: Type A Aortic Dissection In the OR – the drugs NTG nitroglycerin CPB SNP sodium nitroprusside Induction Incision CLV clevidipine NTG SNP CLV 2 4 10 6 0 8 Clevidipine dose adjustment (mg/hr)

  15. Case Study 1: Type A Aortic Dissection Summary The ultra-short acting dihydropyridine calcium channel blocker, clevidipine, can be used to safely and effectively manage the acute hypertension that accompanies one of the most morbid and potentially mortal disorders of the cardiovascular system.

  16. Case Study #2 Case Studies of Acute Hypertension Acute Coronary Syndrome http://library.med.utah.edu

  17. Case Study #2 Case Studies of Acute Hypertension Acknowledgement Thank you to Dr. Charles Pollack at the University of Pennsylvania for sharing this interesting case

  18. Case Study #2: Acute Coronary Syndrome 58 y/o male presents to ED with chest pain of acute onset radiating to left jaw and shoulder, accompanied by SOB Triage vital signs were pulse 92/min, resp 24/min, and BP 212/126 mm Hg PMH included known CAD, CHF, and hyperlipidemia ECG performed in Triage http://mykentuckyheart.com

  19. Case Study #2: Acute Coronary Syndrome Acute Anterior STE Myocardial Infarction

  20. Physical examination: symmetrical bounding pulses, diaphoresis, and rales in both lung bases Management: ASA 325 mg Clopidogrel 600 mg Unfractionated heparin by IV infusion Nitroglycerin by IV infusion Beta-blockers are held because of concern over heart failure Prior to cath lab transfer: recheck BP is 196/118; and patient is diagnosed with Case Study #2: Acute Coronary Syndrome www.etopiamedia.net STEMI + Hypertensive Emergency

  21. Case Study #2: Acute Coronary Syndrome Hemodynamic Control 170 160

  22. Case Study #2: Acute Coronary Syndrome Hemodynamic Control 12 10 196 192 188 176 8 168 166 162 162 6 Clevidipine (mg/hr) 4 2 0

  23. Case Study #2: Acute Coronary Syndrome Summary Clevidipine can be used safely and effectively to care for a patient with an acute coronary syndrome using a peripheral IV and a blood pressure cuff. There was no evidence of coronary steal or worsening of this patient’s chest pain. Target BP control was obtained in less than 10 minutes.

  24. Case Studies of Acute Hypertension Case Study #3 Aortic Valve Replacement

  25. Case Study 3: Aortic Valve Replacement 78-year-old male presents for aortic valve replacement • HPI: presented with symptoms of shortness of breath and DOE. • PHM/PSH: AS, MI, CAD (stents x2), HTN (brittle), Chol, TIAs secondary to spontaneous cholesterol emboli • Allergies: NKDA • Medications: metoprolol • FamHx: noncontributory • ROS: as per HPI o/w unremarkable

  26. Case Study 3: Aortic Valve Replacement • General: fatigued appearing • Ht: 72 inches Wt: 90 kg • VS: 128/62 (R=L); HR 60’s reg; Resp 18; SpO2 98% RA • Neuro: alert & oriented x3; no gross deficits • Pulmonary: CTA bilaterally • Cardiac: S1S2reg, grade IV syst. murmur • Extrem: 2+ palpable B/L UE & LE; no edema

  27. Case Study 3: Aortic Valve Replacement > < 14.1 < 139 103 25 4.5 24 1.3 LFTs Coags WNL WNL Chem: Heme: ECG: no ischemic changes TEE: Aortic stenosis (AVA 0.7 cm2), gradient (P 51/M 32 mmHg w/CI 2.9 L/min/m2) 6.8 172 91 41.2

  28. Diagnosis Case Study 3: Aortic Valve Replacement Severe Aortic Stenosis with left ventricular hypertrophy Management • Surgical aortic valve replacement with a bioprosthesis • Control heart rate, maintain NSR, manage SBP with an IV antihypertensive to prevent LV wall stress and MVO2, avoid hypotensive overshoots

  29. Case Study 3: Aortic Valve Replacement In the OR

  30. Case Study 3: Aortic Valve Replacement In the OR

  31. Case Study 3: Aortic Valve Replacement In the OR - The Zone Induction CPB F F 8 0 2 0 2 4 4 2 16 - Fentanyl bolus Clevidipine (mg/hr) F

  32. Case Study 3: Aortic Valve Replacement Summary Clevidipine can be used safely and effectively to provide hemodynamic support for patients with complex cardiovascular disease profiles (i.e. need to strictly ovoid overshoot hypotension [AS] & reflex tachycardia [AS, LVH, CAD]). Target BP control was expeditiously obtained and maintained in this patient.

More Related