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Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical.

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Landmark Advances and Complex Cases in Cardiovascular Anesthesiology Emerging Perspectives and Strategies for Optimizing Perioperative Blood Pressure.

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Presentation on theme: "Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical."— Presentation transcript:

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

2 Case Studies of Acute Hypertension Case Study #1 Type A Aortic Dissection

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

4 Case Study 1: Type A Aortic Dissection HPI: presented to ED complaining of sudden onset of severe chest pain and shortness of breath.HPI: presented to ED complaining of sudden onset of severe chest pain and shortness of breath. PHM/PSH: obesityPHM/PSH: obesity Allergies: NKDAAllergies: NKDA Medications: noneMedications: none Fam Hx: noncontributoryFam Hx: noncontributory ROS: unremarkableROS: unremarkable 44-year-old female presents for surgical correction of a Type A dissection

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

6 Chem: Heme: ECG: no ischemic changes CT: TEE: < < > LFTs Coags WNL WNL Case Study 1: Type A Aortic Dissection

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

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

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

10 In the OR

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

12 In the OR – The Zone CPB Induction Incision Case Study 1: Type A Aortic Dissection

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

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

15 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. Case Study 1: Type A Aortic Dissection

16 Case Studies of Acute Hypertension Case Study #2 Acute Coronary Syndrome

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

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 SOB58 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 HgTriage vital signs were pulse 92/min, resp 24/min, and BP 212/126 mm Hg PMH included known CAD, CHF, and hyperlipidemiaPMH included known CAD, CHF, and hyperlipidemia ECG performed in TriageECG performed in Triage

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

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

21 Hemodynamic Control Case Study #2: Acute Coronary Syndrome

22 Clevidipine (mg/hr) Case Study #2: Acute Coronary Syndrome Hemodynamic Control

23 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 patients chest pain. Target BP control was obtained in less than 10 minutes. Case Study #2: Acute Coronary Syndrome

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

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

26 General: fatigued appearingGeneral: fatigued appearing Ht: 72 inches Wt: 90 kgHt: 72 inches Wt: 90 kg VS: 128/62 (R=L) ; HR 60s reg ; Resp 18; SpO2 98% RAVS: 128/62 (R=L) ; HR 60s reg ; Resp 18; SpO2 98% RA Neuro: alert & oriented x3; no gross deficitsNeuro: alert & oriented x3; no gross deficits Pulmonary: CTA bilaterallyPulmonary: CTA bilaterally Cardiac: S 1 S 2 reg, grade IV syst. murmurCardiac: S 1 S 2 reg, grade IV syst. murmur Extrem: 2+ palpable B/L UE & LE; no edemaExtrem: 2+ palpable B/L UE & LE; no edema Case Study 3: Aortic Valve Replacement

27 Chem: Heme: ECG: no ischemic changes TEE: Aortic stenosis (AVA 0.7 cm 2 ), gradient (P 51/M 32 mmHg w/CI 2.9 L/min/m 2 ) < < > LFTs Coags WNL WNL Case Study 3: Aortic Valve Replacement

28 Diagnosis Severe Aortic Stenosis with left ventricular hypertrophy Management Surgical aortic valve replacement with a bioprosthesisSurgical aortic valve replacement with a bioprosthesis Control heart rate, maintain NSR, manage SBP with an IV antihypertensive to prevent LV wall stress and MVO 2, avoid hypotensive overshootsControl heart rate, maintain NSR, manage SBP with an IV antihypertensive to prevent LV wall stress and MVO 2, avoid hypotensive overshoots Case Study 3: Aortic Valve Replacement

29 In the OR Case Study 3: Aortic Valve Replacement

30 In the OR Case Study 3: Aortic Valve Replacement

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

32 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. Case Study 3: Aortic Valve Replacement


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