fadhilatulkhair krisis hipertensi

8/10/2019 Fadhilatulkhair krisis hipertensi

1/11

Definisi HIPERTENSI KRISISsuatu kedaruratan medik

yang ditandai dengan peningkatan TD secaramendadak dan dengan atau tanpa kerusakanorgan.

1 % dari populasi hipertensi dewasa Hipertensi Emergensi

- > 50% penderita di ICU- karena terapi tak adekuat


2/11

Klasifikasi berdasarkan prioritas pengobatan

1. Hipertensi emergensi (darurat )2. Hipertensi urgensi ( mendesak )


3/11

Table 2 : Algorithm for Triage Evaluation

Parameter

Severe Hypertension (Urgency)Hypertensive Emergency

symptomatic Symptomatic

Blood pressure

(mmHg)

> 180/110 > 180/110 Usually > 220/140

Symptoms Headache, anxiety;

often asymtomatic

Severe headache,

shortness of breath

Shortness of breath, chest pain,

nocturia, dysarthria, weakness,

altered consciousness

Examination No target organ

damage, no clinical

cardiovascular

disease

Target organ

damage; clinical

cardiovascular

disease present,

stable

Encephalopathy,pulmonary

edema, renal insufficiency,

cerebrovascular accident,

cardiac ischemia

Therapy Observe 1-3 hr;

initiate, resume

medication; increase

dosage of inadequte

agent

Observe 3-6 hr;

lower BP with

shortacting oral

agent; adjust

current therapy

Baseline laboratory tests;

intravenous line; monitor BP, may

initiate parenteral therapy in

emergency room

Plan Arrange follow-up

within 3-7 days; if no

prior evaluation,

schedule appointment

Arrange follow-up

evaluation in less

than 72 hr

Immediate admission to ICU;

treat to initial goal BP, additional

diagnostic studies

BP, Blood pressure; ICU, Intensive care unit

Sumber : Hebert e.j Prim Care 2008. 35 (3)


4/11

DIAGNOSIS

ANAMNESIS

- Lama menderitahipertensi

- Obat-obat yangdikonsumsi

- Penyakit penyerta

PEMERIKSAAN FISIS

- Pengukuran tekanandarah

- Perabaan a. radialis,a. karotis

PEMERIKSAAN KHUSUS- Funduskopi

- Tes Urin

- dll


5/11

Table : Manifestasi klinis hipertensi emergensi

BloodPressure(mmHg)

FunduscopicFindings

NeurologicStatus CardiacFindings RenalSymptoms GastrointestinalSymptoms

Usually

>220/140

Hemorrhages,

exudatespapiledema

Headache,confusion,

somnolence,stupor,visual loss,seizures,focalneurologicdeficits,

coma

Prominent

apical

pulsation,cardiaceniargement, congestiveheart failure

Azotemia,proteinuria

, oliguria

Nausea.vomiting



6/11

PENGOBATANHipertensi Emergensi- Dirawat di ICU- Obat anti hipertensi parenteral- Target : - Penurunan tekanan darah pd jam

pertama 20-25 % MAP- Minimalisir hipoperfusi organ vital(eg: otak)

- Penurunan tekanan darah selanjutnya dl 24 jam


7/11

Table : Treatment of Hypertensive EmergenciesAgent

Parenteral

Vasodilators

Dosage Onset/Duration of

Action (after

discontinuation)

Precautions

Sodium

Nitroprusside

0.25-10 g/kg/min as

IV infusion

Immediate/2-3 min

after infusion

Nausea, vomiting; prolonged use

may cause thiocyanate

intoxication,

methemoglobinemia, acidosis,

cyanide poisoning; bags, bottles,

delivery sets must be light

resistant

Nitroglycerin 5-100 g as IV

infusion

2-5 min/5-10 min Headache, tachycardia,

vomiting; flushing.

Methemoglobinemia; requiresspecial delivery system because

of drug binding to PVC tubing

Nicardipine 5-15 mg/hr as IV

infusion

1-5 min/15-30 min,

but may exceed 12

hr after prolonged

infusion

Tachycardia, nausea, vomiting,

headache, increased intracranial

pressure; hypotension may be

protracted after prolonged

infusions

Fenoldopam

Mesylate

0.1-0.3 g/kg/min as IV

infusinon

1 hr (IV);

20-30 min IM/4-6 hr

(IM

Tachycardia, headache,

vomiting, aggravation of angina

pectoris, sodium and water

retension, increased intracranial

pressure



8/11

Tabel : Medikamentosa untuk keadaan2 khusus hipertensiemergensi

Emergenci dengan

keadaan khusus

Pengobatan Target TD

Aortic dissection

AMI, ischemia

Pulmonary edema

Renal emergencies

Catecholamine excess

Hypertensive encphalopathy

Subarachnoid hemorrhage

Ischemic stroke

Nitroprusside + esmolol

Nitroglycerin, nitroprusside, nicardipine

Nitroprusside, nitroglycerin, labetalol

Fenoldopam, nitroprusside, labetalol

Phentolamine, labetalol

Nitroprusside

Nitroprusside, nimodipine, nicardipine

Nitroprusside (controversial), nicardipine

110-120 SBP as soon as possible

Secondary to ischemia relief

Improve symptoms 10%-15% in 1-2hr

Target BP 20%-25% in 2-3 hr

Control paroxysms, 10 %-15% in 1-2hr

20%-25% in 2-3 hr

20%-25% in 2-3 hr

0%-20% in 6-12 hr



9/11

PENGOBATAN

Hipertensi Urgensi- Medikamentosa Oral anti hipertensi yg

bekerja cepat

- Jika Target tidak tercapai, tingkatkandosis

- Target tercapai dalam 3-7 hari


10/11

Table : Management of Hypertensive Urgencies

GENT DOSE

ONSET/DURATION OF

ACTION

(AFTERDISCONTINUATION)

PRECAUTIONS

Captopril 25 mg p.o., repeat as

needed SL, 25 mg

15-30 min/6-8 h SL,

15-30 min/2-6 h

Hypotension, renal

failure in bilateral

renal artery

stenosis

Clonidine 0.1-0.2 mg p.o., repeat

hourly as required tototal dose of 0.6 mg

30-60 min/8-16 h Hypotension,

drowsiness, drymouth

Labetalol 200-400 mg p.o repeat

every 2-3 h

30 min-2 h/2-12 h Bronchoconstrictio

n, heart block,

orthostatic

hypotension

Amblodipin 2,5-5 mg 1-2 hr/12-18 hr Tachycardia,hypotension

Nifedipin 5 mg sl 5-20 min/2-6 hr Tachycardio,

hypotension

Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens

(Greenwich). 2004;6:520-525Sumber :

-Hebert C.J Hypertensive Crises Prim Care 2008. 35 (3)


11/11

PROGNOSIS

Angka kematian tinggi

Tanpa terapi : 1 year survival rate 10-

20% Terapi adekuat : 5 year survival rate

50-60%

Kaplan, clinical hypertension

fadhilatulkhair krisis hipertensi

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