YPERTENSIVE MERGENCIES - TriHealth...HYPERTENSIVE EMERGENCIES: SCOPE OF THE PROBLEM Critical Care...

HYPERTENSIVE

EMERGENCIES

CRITICAL CARE OBSTETRICS

#TRIHEALTHCRITICALCAREOB

Critical Care OBstetrics

HYPERTENSIVE EMERGENCIES

Learning Objectives

• Understand the scope of the problem

• Rationale

• Readiness

• Recognition

• Response

• Reporting


HYPERTENSIVE EMERGENCIES: SCOPE OF THE PROBLEM





MMR (Maternal Mortality Ratio) = # Maternal

Deaths / 100,000 live births (per year)

– Worldwide – MMR dropped 2.3% annually from 1990-

2015 (216/100,000 L.B’s.)

– U.S. – 1.7% annual increase (17.2/100,000 L.B’s.)

– TriHealth – equates to potentially 1-2 per year

Attributable Factors

– Increased: Maternal Age, BMI, Co-Morbidities

– Race (Non-Hispanic Black Women)




27.1

14

10.7

7.9

3.2

0 5 10 15 20 25 30

HEMORRHAGE

HYPERTENSIVE DISORDERS

SEPSIS

ABORTION

EMBOLISM

Percentage

Causes of Maternal Death

Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a

WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323.



RATIONALE: OPPORTUNITY FOR PREVENTION


Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths:

results of a state-wide review. Obstet. Gynecol. Dec 2005;106(6):1228-1234.

HYPERTENSIVE EMERGENCIES: RATIONALE

Implementation of “Common Guideline” UK

• 1,087 / 210,631 women with severe

preeclampsia or eclampsia (5.2/1000)

• 151 with serious complications (13.9%)

– 82 with eclampsia (39/10,000)

– 49 required ICU admission (23/10,000)

– 0 maternal deaths

– 25 developed pulmonary edema (12/10,000)

Tuffnell DJ, Jankowicz D, Lindow SW, et al. Outcomes of severe pre-eclampsia/eclampsia in Yorkshire

1999/2003. BJOG May 2005; 112(7):875-80.


HYPERTENSIVE EMERGENCIES: READINESS

Steps

1. Develop Awareness among all providers

2. Ensure Access to medications &

consultants

3. Develop Evidence-Based Protocol



Ancillary Services:

• Laboratory: ability to draw & run stat labs

(CBC, CMP, LDH, Coags, UPCR)

• Pharmacy: available in Pyxis or “HTN Med

Kit”: Labetalol, Hydralazine, Magnesium

Sulfate, Calcium Gluconate, Nitric Oxide, oral

Nifedipine (short acting)

• Radiology: stat chest X ray availability



Equipment:

• Maternal pulse oximetry

• Supplemental O2

• Bag-mask ventilation + suction

• Padding for bed

• Continuous electronic fetal monitoring (if

viable fetus)



Available Consultation: (MFM, Anesthesia, Critical Care Specialists)


HYPERTENSIVE EMERGENCIES: RECOGNITION

Type of Hypertension Criteria / Characteristics

Hypertensive Emergency 2 NEW ONSET BPs > 160 mmHg systolic or 110 mmHg diastolic measured ≥ 15 min apart (does not have to be consecutive but within 1 hr of each other)

Gestational Hypertension SBP ≥ 140 or DBP ≥ 90 mmHg on 2 occasions ≥ 4 hrs apart after 20 weeks’ GA in a woman with previously normal BPs & absence of criteria for preeclampsia or CHTN

Preeclampsia GHTN definition above but in presence of proteinuria (UPCR ≥ 0.3 or 24 hr≥ 300 mg)

Preeclampsia with Severe Features 2 or more BPs > 160 mmHg systolic or 110 mmHg diastolic measured ≥ 4 hrs apart while at rest and / or GHTN definition above but in presence of proteinuria and/or thrombocytopenia (<100k), impaired liver functions (2 x upper limit), severe RUQ pain, progressive renal insufficiency (creat > 1.1 mg/dL or doubling), pulmonary edema, new onset visual or cerebral disturbance

Chronic Hypertension SBP ≥ 140 or DBP ≥ 90 mmHg on 2 occasions ≥ 4 hrs apart PRIOR TO 20 weeks’ GA

Chronic Hypertension with Super-Imposed Preeclampsia

CHTN definition now with new-onset proteinuria, sudden exacerbation of HTN when previously well-controlled, or any severe features



Ensure Proper BP Measurement:

• Sitting or semi-recumbent position with back supported

and arm measured at heart level

• Patient resting quietly for 5 min

• Appropriate cuff size (bladder width encircles 80% arm)

• No dangling legs or legs crossed

• No consumption of caffeine or nicotine within 30 min

• Do not reposition patient to the other side in an attempt

to lower BP



Triage / Admission Risk Assessment:Assess whether low, medium, or high risk for a Hypertensive Emergency

• Medium risk for a Hypertensive Emergency

– Two appropriately measured BPs 140-149 / 90-99 mmHg at least 15 minutes apart within

one hour (does not need to be consecutive readings) OR

– Any history of CHTN, GHTN, morbid obesity (BMI > 40), pre-gestational diabetes, or recent

ingestion of a stimulant such as cocaine, methamphetamine, or PCP

• High risk for a Hypertensive Emergency

– Two appropriately measured BP 150-159 / 100-109 mmHg at least 15 minutes apart within

one hour (does not need to be consecutive readings) AND

– Any history of above

• If “High Risk” criteria are met:

– Notification of chief resident, attending OB, charge nurse

– Labs: coags, PE1 with UPCR or PE2

– Consider Foley cath (urometer), continuous pulse ox, CEFM


HYPERTENSIVE EMERGENCIES: RESPONSE

BP = CO + SVRCardiac Output: Systemic Vascular Resistance

CO = HR x SV SVR = Mean Arterial Pressure (MAP) x CO

“The Pump” “The Pipes”

Wide pulse pressure Narrow pulse pressure

Factors Influencing: Factors Influencing:

- Volume (high) - Stress

- Anxiety - Volume (low)

- Pain - Caffeine, nicotine


HYPERTENSIVE EMERGENCIES: SYSTOLIC VS DIASTOLIC

Systolic hypertension = most important

predictor of cerebral injury & infarction

• Series 28 women with severe preeclampsia & stroke

– 27/28 women had severe systolic hypertension prior to stroke

– 54% died

– Only 13% had severe diastolic HTN prior

– Similar findings among non-pregnant adults

Tuffnell DJ, Jankowicz D, Lindow SW, et al. Outcomes of severe pre-eclampsia/eclampsia in Yorkshire

1999/2003. BJOG May 2005; 112(7):875-80.



Whom to Activate the Protocol:

• Two NEW ONSET blood pressure values

greater than 160 mmHg (systolic) or 110 mmHg

(diastolic) appropriately measured at least 15

minutes apart (does not have to be consecutive

but do occur within 1 hour of each other)

• “New Onset” denotes blood pressure elevations

into the severe range for the first time in at least

72 hours



Goal: initiation of treatment within 30-60 min

• Target BP: 2 consecutive BP readings measured appropriately <

160 mm Hg (systolic) or < 110 mm Hg (diastolic) no sooner than 15

minutes apart

• Adequate reduction is a witnessed drop in systolic BP > 20 mmHg

and/or drop in diastolic BP > 10 mmHg – if this is witnessed,

withhold additional treatment doses for 10 minutes and repeat BP

measurements



Steps:1. Initiate Magnesium Sulfate protocol if suspicion for

preeclampsia

2. Base determination of initial anti-HTN med by patient’s

PMHx, allergies, whether the HTN is predominantly

systolic or diastolic, and pulse pressure– If underlying heart failure, asthma, cocaine or methamphetamine abuse,

bradycardia (HR < 60 bpm) – avoid Labetalol

– If predominantly systolic HTN and pulse pressure is > 70, consider

Labetalol

– If predominantly diastolic HTN and pulse pressure is < 50, consider

Hydralazine

– If mixed picture or no IV access, initiate oral Nifedipine




Stage:

Definition

Nurse

to

Patient

Ratio:

Monitoring:

Notify:

At

Bedside:

Meds & Frequency:

1 Hypertensive Emergency:

either systolic or diastolic BP >

160 / 110 mmHg on 2 separate

occasions > 15 min apart

(does not need to be

consecutive)

1:1 • CEFM

• Continuous pulse ox

• IV access – single 18 g

• CBC, CMP, uric acid,

coag panel, LDH

• Provider to consider placement of Foley catheter

• Charge

nurse

• Chief

resident

• Primary OB

• Primary

resident

• Primary

nurse

Labetalol Protocol

Labetalol* 20 mg IV over 2 min

initially

If BP still > 160/110 in 10

min, give 40 mg IV over 2

min

Hydralazine Protocol

Hydralazine* 10 mg IV over 2

min initially


min, give another 10 mg IV

over 2 min

Nifedipine Protocol-No IV access Nifedipine* 10 mg PO every 20

minutes up to 3 doses

If adequate reduction** in BP is NOT witnessed despite the above treatments, notify unit clerk of Stage 2 HTN Emergency

2 Persistent hypertensive

emergency despite having

given maximum cumulative

dosages of the medications

listed above for stage 1

2:1 • CEFM



• Foley catheter with

urometer

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

Labetalol Protocol

Labetalol 80 mg IV over 2 min



over 2 min

Hydralazine Protocol Switch to Labetalol 20 mg IV

over 2 min



min




administered the maximum

cumulative dosages of both IV

labetalol & IV hydralazine OR

oral Nifedipine or Labetalol

2:1 • CEFM


• IV access – two IV’s of

18 g


urometer

• Telemetry

• Consider Arterial Line

• Repeat all labs in

Stage1

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• MFM

• Lab

• ICU team

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

• Attending

OB

• Anesthes

iologist

Labetalol Protocol

If Labetalol 220 mg

administered, switch to


min initially



over 2 min

Hydralazine Protocol If Hydralazine 20 mg


Nifedipine 10 mg po and can

repeat every 20 min x 3

doses.

If still HTN Emergency, elicit

input from MFM,

anesthesiologist, and ICU

team. Prepare for transfer to

ICU



Stage:

Definition

Nurse

to

Patient

Ratio:

Monitoring:

Notify:

At

Bedside:

Meds & Frequency:






consecutive)

1:1 • CEFM




coag panel, LDH


• Charge

nurse

• Chief

resident

• Primary OB

• Primary

resident

• Primary

nurse

Labetalol Protocol


initially



min



min initially



over 2 min









2:1 • CEFM




urometer

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

Labetalol Protocol




over 2 min


over 2 min



min








2:1 • CEFM



18 g


urometer

• Telemetry



Stage1

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• MFM

• Lab

• ICU team

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

• Attending

OB

• Anesthes

iologist

Labetalol Protocol

If Labetalol 220 mg



min initially



over 2 min





doses.


input from MFM,



ICU

Stage:

Definition

Nurse

to

Patient

Ratio:

Monitoring:

Notify:

At

Bedside:

Meds & Frequency:






consecutive)

1:1 • CEFM




coag panel, LDH


• Charge

nurse

• Chief

resident

• Primary OB

• Primary

resident

• Primary

nurse

Labetalol Protocol


initially



min



min initially



over 2 min









2:1 • CEFM




urometer

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

Labetalol Protocol




over 2 min


over 2 min



min








2:1 • CEFM



18 g


urometer

• Telemetry



Stage1

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• MFM

• Lab

• ICU team

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

• Attending

OB

• Anesthes

iologist

Labetalol Protocol

If Labetalol 220 mg



min initially



over 2 min





doses.


input from MFM,



ICU



Stage:

Definition

Nurse

to

Patient

Ratio:

Monitoring:

Notify:

At

Bedside:

Meds & Frequency:






consecutive)

1:1 • CEFM




coag panel, LDH


• Charge

nurse

• Chief

resident

• Primary OB

• Primary

resident

• Primary

nurse

Labetalol Protocol


initially



min



min initially



over 2 min









2:1 • CEFM




urometer

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

Labetalol Protocol




over 2 min


over 2 min



min








2:1 • CEFM



18 g


urometer

• Telemetry



Stage1

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• MFM

• Lab

• ICU team

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

• Attending

OB

• Anesthes

iologist

Labetalol Protocol

If Labetalol 220 mg



min initially



over 2 min





doses.


input from MFM,



ICU

Stage:

Definition

Nurse

to

Patient

Ratio:

Monitoring:

Notify:

At

Bedside:

Meds & Frequency:






consecutive)

1:1 • CEFM




coag panel, LDH


• Charge

nurse

• Chief

resident

• Primary OB

• Primary

resident

• Primary

nurse

Labetalol Protocol


initially



min



min initially



over 2 min









2:1 • CEFM




urometer

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

Labetalol Protocol




over 2 min


over 2 min



min








2:1 • CEFM



18 g


urometer

• Telemetry



Stage1

• Charge

nurse

• Chief

resident

• Primary OB

• Anesthesia

• MFM

• Lab

• ICU team

• Primary

resident

• Primary

nurse

• Charge

nurse

• Chief

resident

• Attending

OB

• Anesthes

iologist

Labetalol Protocol

If Labetalol 220 mg



min initially



over 2 min





doses.


input from MFM,



ICU



Key Points:

• Notify unit clerk and “rally the troops”

• Perform a “huddle” & appoint a leader

• Reassess every 10-15 minutes and follow

protocol

• Ensure the patient’s family is supported

• Continue until 2 consecutive BP readings no

sooner than 15 minutes apart are obtained at or

below goal



Upon Resolution:

• Repeat BPs q 15 min x 1 hr

– Then every 30 min x 1 hr

– Then every 60 min x 4 hrs

• Initiate an ORAL agent aligned with what worked

best in protocol



If NO Resolution with Protocol:

• Consider consultation by MFM, Anesthesia, or

Intensivist

• Patient may need to be transported to a higher

acuity bed like ICU for

initiation of “drip” agent

• Additional triggers for

consultation

REPORTING / SYSTEMS LEARNING

• Establish a culture of huddles for high-risk

patients and post-event debriefs

• Conduct a multidisciplinary review of

serious Hypertensive Emergencies for

systems issues

• Monitor outcomes and processes metrics


TAKE-AWAY POINTS

• Most maternal major morbidity & mortality

from Hypertensive Emergencies are

preventable

• Preparation and awareness are

ESSENTIAL

• Requires reliance not on individuals but on

team approach


Thank You


CRITICAL CARE OBSTETRICS

#TRIHEALTHCRITICALCAREOB

Date post:	25-Feb-2021
Category:	Documents
Upload:	others
View:	3 times
Download:	0 times

YPERTENSIVE MERGENCIES - TriHealth...HYPERTENSIVE EMERGENCIES: SCOPE OF THE PROBLEM Critical Care...

Documents