Question about BP control in your ICU

[IheartICUnursing]

In my short time working in MICU (started as a new grad in June) I have noticed that our docs are very conservative about treating hypertension. Obviously, pts will be on whatever PO meds they are usually on for HTN and we may increase the dosage of those sometimes, but we never really treat with IV meds unless they sustain a systolic over 180 and then there is usually a PRN order for hydralazine.

I get it that we are always scared of the even more dangerous hypotension (which we see much more often) and that we don't want to bring them down too low.

I have recently seen a couple of pts on Nitro or Nipride drips and they seemed to do very well when they were titrated appropriately.

I am just wondering, how does your ICU manage HTN and what are your opinions?

[meandragonbrett]

We generally don't even bat an eyelash until we're talking 180's unless it's some sort of vascular surgery....Then we'll use Nipride, NiTG, and cardene as needed until we can start PO BP meds.

Otherwise we use the full gamut of drugs.....Beta blockers, Vasotec, veno/arterial dilators, alpha agonists, etc.

[hodgieRN]

Mainly see HTN management with bleeds. But if someone has been living at 150's-160's, then 170 isn't that bad.

[mbdirt]

My ICU typically sees more hyPOtension than HTN. I had a patient recently who was in A.Fib/Flutter with HR in 150's. BP was 170/80's. We gave IV metoprolol twice, NTP, lasix, diltiazem, hydralazine. Finally got him more normalized on double his home dose of metoprolol, but every time he was active, his HR shot up to 140-150, with a mild rise in BP. He is probably going for an ablation for the Fib/Flutter. We'll see what happens with the BP.

In general, I would say anything less than SBP

[knightlycomic]

Much the same here in NZ, the concern is that lowering a patients BP that normally sits around the 180 just to have a lower number can cause other system problems. Unless the patient is compromised I believe in the take the lesser evil.

[detroitdano]

Unless their SBP is over 170 or MAP over 120 I usually don't see our docs jumping up to write any orders. If someone is consistently hypertensive and they've known about it, they'll give some push meds and increase scheduled meds, but for the most part it's just push meds as times one orders.

We see a lot of HTN with agitated patients and you don't want to ram in 5 of Haldol and 20 of Labetalol and then watch their MAP drop to 45 once they fall asleep. Typically if you treat the agitation the BP will improve dramatically. On the average we're trying that route more than scheduling new BP meds.

[daleosby]

Also keep in mind that if the patient is in with stroke or stroke sx (non hemorrhagic) the docs do not want to lower the BP too much. They want to keep the BP up to perfuse the brain. Lower the BP of an embolic CVA patient too much or too rapidly, and you could very well see their sx worsen.

[cbreuklander]

Much the same in our ICU. The treatment protocols haven't changed a lot in the last few years. I think the perfusion issue is what keeps the docs conservative with BP control. Also, once it starts to drop as the pt stabilizes, it is difficult to control if there are aggressive meds on board.

[TakeBack]

Cardiac Surgical ICU

acute control, target

IVP- hydralazine, metoprolol/labetalol

gtt- NTG, nicardipine, fenoldopam, esmolol