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Siersma C, Brouwer CNM, Sojak V, Ten Harkel ADJ, Roeleveld PP. Treatment of Post-Coarctectomy Hypertension With Labetalol-A 9-Year Single-Center Experience. World J Pediatr Congenit Heart Surg 2022; 13:701-706. [PMID: 36300272 PMCID: PMC9615340 DOI: 10.1177/21501351221111797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Although considering the pathophysiology of post-coarctectomy hypertension, β-blockers should be effective, experience with labetalol for treatment is limited in the literature. Methods Retrospective collection and analysis of data in children aged ≤6 years following coarctectomy in our tertiary care university medical center between January 2009 and June 2018. Results 96 patients were included, 45 were treated with intravenous labetalol and 51 received no treatment. Median time to maximum dose received (median 1.1 mg/kg/h) was 2.7 h, and median time to the reduction of labetalol dose was 8.3 h. No antihypertensives had to be added. In one child, labetalol was switched to nitroprusside due to bronchoconstriction. Of patients receiving intravenous labetalol, 48% had been switched to oral labetalol at discharge. Conclusions Intravenous labetalol is a fast, effective, and safe drug to treat hypertension following aortic coarctation repair. Labetalol is easily converted to oral therapy when the continuation of treatment is considered necessary.
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Affiliation(s)
- Carolien Siersma
- Pediatric Intensive Care Unit, 4501Leiden University Medical Center, Leiden, the Netherlands
| | - Carole N M Brouwer
- Pediatric Intensive Care Unit, 4501Leiden University Medical Center, Leiden, the Netherlands
| | - Vladimir Sojak
- Department of Thoracic Surgery, 4501Leiden University Medical Center, Leiden, the Netherlands
| | - Arend D J Ten Harkel
- Willem Alexander Children's Hospital - Division of Pediatric Cardiology, 4501Leiden University Medical Center, Leiden, the Netherlands
| | - Peter P Roeleveld
- Pediatric Intensive Care Unit, 4501Leiden University Medical Center, Leiden, the Netherlands
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Seeman T, Hamdani G, Mitsnefes M. Hypertensive crisis in children and adolescents. Pediatr Nephrol 2019; 34:2523-2537. [PMID: 30276533 DOI: 10.1007/s00467-018-4092-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 12/28/2022]
Abstract
Hypertensive crisis is a relatively rare condition in children. However, if not treated, it might be life-threatening and lead to irreversible damage of vital organs. Clinical presentation of patients with hypertensive crisis can vary from very mild (hypertensive urgency) to severe symptoms (hypertensive emergency) despite similarly high blood pressure (BP). Individualized assessment of patients presenting with high BP with emphasis on the evaluation of end-organ damage rather than on the specific BP number is a key in guiding physician's initial management of a hypertensive crisis. The main aim of the treatment of hypertensive crisis is the prevention or treatment of life-threatening complications of hypertension-induced organ dysfunction, including neurologic, ophthalmologic, renal, and cardiac complications. While the treatment strategy must be directed toward the immediate reduction of BP to reduce the hypertensive damage to these organs, it should not be at a too fast rate to cause hypoperfusion of vital organs by an excessively rapid reduction of BP. Thus, intravenous continuous infusions rather than intravenous boluses of antihypertensive medications should be the preferable mode of initial treatment of children with hypertensive emergency.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics and Biomedical Center, 2nd Faculty of Medicine and Faculty of Medicine in Pilsen, Charles University in Prague, V Uvalu 84, 15006, Prague 5, Czech Republic. .,Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic.
| | - Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Epidurals for Coarctation Repair in Children Are Associated with Decreased Postoperative Anti-Hypertensive Infusion Requirement as Measured by a Novel Parameter, the Anti-Hypertensive Dosing Index (ADI). CHILDREN-BASEL 2019; 6:children6100112. [PMID: 31658735 PMCID: PMC6826390 DOI: 10.3390/children6100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/10/2019] [Accepted: 09/27/2019] [Indexed: 11/18/2022]
Abstract
Background: Sympathetically-associated hypertension after coarctation repair is a common problem often requiring anti-hypertensive infusions in an intensive care unit. Epidurals suppress sympathetic output and can reduce blood pressure but have not been studied following coarctation repair in children. We sought to determine whether epidurals for coarctation repair in children were associated with decreased requirement for postoperative anti-hypertensive infusions, if they were associated with changes in hospital course, or with complications. Methods: In this observational retrospective cohort study, we evaluated all patients age 1–18 years undergoing coarctation repair at our institution during a 10-year period and compared the requirement for postoperative anti-hypertensive infusions in patients with and without epidurals using an anti-hypertensive dosing index (ADI) incorporating total dose-hours of all anti-hypertensive infusions (primary outcome). We also assessed intensive care unit (ICU) and hospital length of stay, discharge on oral anti-hypertensive medication, and complications potentially related to epidurals (secondary outcomes). Results: Children undergoing coarctation repair with epidurals had decreased requirements for postoperative anti-hypertensive infusions compared to children without epidurals (cumulative ADI 65.0 [28.5–130.3] v. 157.0 [68.6–214.7], p = 0.021; mean ADI 49.0 [33.3–131.2] v. 163.0 [66.6–209.8], p = 0.01). After multivariable cumulative logit mixed-effects regression analysis, mean ADI was decreased in patients with epidurals throughout the postoperative period (p < 0.001). Patients with epidurals were 1.6 years older and weighed 10.6 kg more than patients without epidurals but were otherwise comparable. Epidural complications included pruritus (three patients), agitation (one patient), somnolence (one patient), and transient orthostatic hypotension (one patient). Duration of intensive care unit admission, duration of hospital stays, and requirement for anti-hypertensive medication at discharge were similar in patients with and without epidurals. Conclusions: This is the first study of children receiving an epidural for surgical repair of aortic coarctation via open thoracotomy. In this small, single-institution, observational retrospective cohort study, epidurals for coarctation repair in children were associated with decreased postoperative anti-hypertensive infusion requirements. Epidurals were not associated with length of ICU or hospital stay, or with discharge on anti-hypertensive medication. No significant epidural complications were noted. Prospective study of larger populations will be necessary to confirm these associations, address causality, verify safety, and assess other effects.
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Evaluation and management of elevated blood pressures in hospitalized children. Pediatr Nephrol 2019; 34:1671-1681. [PMID: 30171355 DOI: 10.1007/s00467-018-4070-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 08/14/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
Elevated blood pressures (BP) are common among hospitalized children and, if not recognized and treated promptly, can lead to potentially significant consequences. Even though we have normative BP data and well-developed guidelines for the diagnosis and management of hypertension (HTN) in the ambulatory setting, our understanding of elevated BPs and their relationship to HTN in hospitalized children is limited. Several issues have hampered our ability to diagnose and manage HTN in the inpatient setting including the common presence of physiologic conditions, which are associated with transient BP elevations (i.e., pain or anxiety), non-standard approaches to BP measurement, a lack of clarity regarding appropriate diagnostic and therapeutic thresholds, and marginal outcome data. The purpose of this review is to highlight the issues and challenges surrounding BP monitoring, assessment of elevated BPs, and the diagnosis of HTN in hospitalized children. Extrapolating from currently available clinical practice guidelines and utilizing the best data available, we aim to provide guidelines regarding evaluation and treatment of elevated BP in hospitalized children.
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Roeleveld PP, Zwijsen EG. Treatment Strategies for Paradoxical Hypertension Following Surgical Correction of Coarctation of the Aorta in Children. World J Pediatr Congenit Heart Surg 2017; 8:321-331. [PMID: 28520538 PMCID: PMC5439537 DOI: 10.1177/2150135117690104] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Paradoxical hypertension after repair of coarctation of the aorta is a well-known phenomenon. The pathogenesis involves the activation of the sympathetic nervous system (first phase) and renin-angiotensin system (second phase). Only a limited number of different treatment strategies have been published in the literature, without any comparative studies. METHODS Our aim was to describe the current international practice variation surrounding pharmacological treatment currently being employed to treat paradoxical hypertension following the repair of coarctation of the aorta in children. We performed an online survey among 197 members of the Pediatric Cardiac Intensive Care Society. We also conducted a systematic review of the literature regarding the treatment of paradoxical hypertension. RESULTS Eighty-eight people (45%), from 62 different centers, responded and answered the questions regarding blood pressure control. Nitroprusside is the first drug of choice for initial blood pressure control in 66% of respondents, esmolol in 11%, labetalol in 11%, and angiotensin-converting enzyme inhibitors (ACEIs) are used by 3% of respondents. For oral blood pressure control after discharge from the pediatric intensive care unit, 75% of respondents use ACEIs, 18% use labetalol, and 12% use other beta-blockers (propranolol, carvedilol, atenolol, metoprolol). The systematic review identified 14 articles reporting pharmacological treatment of direct postoperative hypertension following coarctation repair. CONCLUSION There is wide practice variability, due to the lack of sufficient compelling evidence. The majority (66%) of caregivers use nitroprusside to control blood pressure in the acute postoperative phase. The ACEIs are the drug of choice for chronic blood pressure control.
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Affiliation(s)
- Peter P. Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
- Peter P. Roeleveld, Department of Pediatric Intensive Care, Leiden University Medical Center, IC Kinderen, J4-32, 2300 RC, Leiden, The Netherlands.
| | - Eline G. Zwijsen
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
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Variability in Treatment of Post-coarctectomy Hypertension: A Multicenter Study. Pediatr Cardiol 2016; 37:772-7. [PMID: 26897371 DOI: 10.1007/s00246-016-1349-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
Many pharmacologic therapies are available for treatment of post-coarctectomy hypertension in pediatric patients, which may lead to variability in care. Evaluation of trends in pharmacotherapy is necessary to evaluate quality of care. The Pediatric Health Information System database was queried from 2004 to 2013 for patients >30 days of age who had an ICD-9 code for coarctation of the aorta repair of coarctation by end-to-end anastomosis and had a RACHS-1 score of 2. Patients were excluded if they were admitted for >30 days, underwent mechanical circulatory support, or expired during the admission. Patient demographic and hospital data were collected along with antihypertensive pharmacotherapy. Trends in antihypertensive, analgesic, and sedative pharmacotherapy were evaluated, and multivariable statistical analysis was used to determine variables that significantly influenced cost. A total of 1636 patients [66.6 % male, median age 1.5 years (IQR 0.31-5.3)] met study criteria. Patients received a median of 3 (IQR 2-4) antihypertensive medications for a median of 8 days (IQR 5-11). Intravenous antihypertensive therapy was prescribed for a median 3 days (IQR 2-5) and oral therapy for a median of 1 day (IQR 1-2). Antihypertensive therapy was continued at discharge in 79.8 % of patients. Hospital cost increased by 36 % over the study period (p < 0.01), and nicardipine, dexmedetomidine, and intravenous acetaminophen were most strongly associated with increased cost (p < 0.001). Variability in the pharmacotherapy of post-coarctectomy hypertension in pediatric patients exists, and the use of newer agents may be influencing the cost of care.
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Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crises in children. Integr Blood Press Control 2016; 9:49-58. [PMID: 27051314 PMCID: PMC4803257 DOI: 10.2147/ibpc.s50640] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hypertensive crises in children are medical emergencies that must be identified, evaluated, and treated promptly and appropriately to prevent end-organ injury and even death. Treatment in the acute setting typically includes continuous intravenous antihypertensive medications with monitoring in the intensive care unit setting. Medications commonly used to treat severe hypertension have been poorly studied in children. Dosing guidelines are available, although few pediatric-specific trials have been conducted to facilitate evidence-based therapy. Regardless of what medication is used, blood pressure should be lowered gradually to allow for accommodation of autoregulatory mechanisms and to prevent cerebral ischemia. Determining the underlying cause of the blood pressure elevation may be helpful in guiding therapy.
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Affiliation(s)
- Deborah R Stein
- Division of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael A Ferguson
- Division of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Antihypertensives. Pediatr Crit Care Med 2016; 17:S101-8. [PMID: 26945324 DOI: 10.1097/pcc.0000000000000621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypertension remains a common condition in pediatric cardiac intensive care. The physiologic effects of hypertension in this population are complex and are impacted by patient age, comorbidities, and primary cardiac disease. The objective of this study is to review current pharmacotherapies for the management of systemic hypertension in the pediatric cardiac ICU. DATA SOURCES Relevant literature to the treatment of systemic hypertension in children was included. Specific focus was given to literature studying the use of therapies in critically ill children and those with heart disease. Reference textbooks and drug packaging inserts were used for drug-specific pediatric guidelines. STUDY SELECTION A search of MEDLINE, PubMed, and the Cochrane Database was performed to find literature about the management of hypertension in children. Metaanalyses and pediatric-specific studies were primarily considered and cross-referenced. Pertinent adult studies were included. DATA EXTRACTION Once the studies for inclusion were finalized, priority for data extraction was given to pediatric-specific studies that focused on children with heart disease and critical illness. CONCLUSIONS Systemic hypertension is common, and there is significant heterogeneity in the patient population with critical heart disease. There are limited large, prospective analyses of safety and efficacy for pediatric drug antihypertensive agents. Despite patient heterogeneity, most pharmacotherapies are safe and efficacious.
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LaDisa JF, Bozdag S, Olson J, Ramchandran R, Kersten JR, Eddinger TJ. Gene Expression in Experimental Aortic Coarctation and Repair: Candidate Genes for Therapeutic Intervention? PLoS One 2015. [PMID: 26207811 PMCID: PMC4514739 DOI: 10.1371/journal.pone.0133356] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Coarctation of the aorta (CoA) is a constriction of the proximal descending thoracic aorta and is one of the most common congenital cardiovascular defects. Treatments for CoA improve life expectancy, but morbidity persists, particularly due to the development of chronic hypertension (HTN). Identifying the mechanisms of morbidity is difficult in humans due to confounding variables such as age at repair, follow-up duration, coarctation severity and concurrent anomalies. We previously developed an experimental model that replicates aortic pathology in humans with CoA without these confounding variables, and mimics correction at various times using dissolvable suture. Here we present the most comprehensive description of differentially expressed genes (DEGs) to date from the pathology of CoA, which were obtained using this model. Aortic samples (n=4/group) from the ascending aorta that experiences elevated blood pressure (BP) from induction of CoA, and restoration of normal BP after its correction, were analyzed by gene expression microarray, and enriched genes were converted to human orthologues. 51 DEGs with >6 fold-change (FC) were used to determine enriched Gene Ontology terms, altered pathways, and association with National Library of Medicine Medical Subject Headers (MeSH) IDs for HTN, cardiovascular disease (CVD) and CoA. The results generated 18 pathways, 4 of which (cell cycle, immune system, hemostasis and metabolism) were shared with MeSH ID’s for HTN and CVD, and individual genes were associated with the CoA MeSH ID. A thorough literature search further uncovered association with contractile, cytoskeletal and regulatory proteins related to excitation-contraction coupling and metabolism that may explain the structural and functional changes observed in our experimental model, and ultimately help to unravel the mechanisms responsible for persistent morbidity after treatment for CoA.
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Affiliation(s)
- John F. LaDisa
- Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin, United States of America
- Department of Medicine, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Biotechnology and Bioengineering Center, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Serdar Bozdag
- Department of Mathematics, Statistics, and Computer Science, Marquette University, Milwaukee, Wisconsin, United States of America
| | - Jessica Olson
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Ramani Ramchandran
- Departments of Pediatrics and Obstetrics and Gynecology, Medical College of Wisconsin and the Developmental Vascular Biology Program, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Judy R. Kersten
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Thomas J. Eddinger
- Department of Biological Sciences, Marquette University, Milwaukee, Wisconsin, United States of America
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Hypertension in children and adolescents: An approach to management of complex hyper tension in pediatric patients. Curr Hypertens Rep 2009; 11:315-22. [DOI: 10.1007/s11906-009-0054-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tabbutt S, Nicolson SC, Dominguez TE, Wells W, Backer CL, Tweddell JS, Bokesch P, Schreiner M. Perioperative course in 118 infants and children undergoing coarctation repair via a thoracotomy: a prospective, multicenter experience. J Thorac Cardiovasc Surg 2008; 136:1229-36. [PMID: 19026808 DOI: 10.1016/j.jtcvs.2008.06.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 05/07/2008] [Accepted: 06/15/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The hospital course for pediatric coarctation repair has not been described. We had 4 aims: (1) to determine the influence of age, anatomy, and type of repair on aortic crossclamp time, (2) to determine the impact of age or aortic crossclamp time on postoperative morbidity, (3) to describe current antihypertensive strategies, and (4) to describe antihypertensive medications at hospital discharge. METHODS Data were obtained from a prospective randomized multicenter esmolol safety and efficacy trial. The study included patients who were scheduled for a coarctation repair receiving esmolol as their first-line antihypertensive medication in the operating room (n = 118; weight > or = 2.5 kg and age < 6 years). RESULTS (1) Patient age and type of coarctation did not affect the aortic crossclamp time. (2) Younger age, but not aortic crossclamp time, was associated with a significantly longer time to extubation and longer hospital length of stay. (3) A combination of esmolol and sodium nitroprusside (Nipride, Roche, Basel, Switzerland) provided excellent early blood pressure control. (4) At discharge, 64% of patients were receiving antihypertensive medications. Older patients were more likely to be discharged with antihypertensive medication (91% of patients aged 2-6 years, P < .0002). CONCLUSION The study describes a multi-institutional approach to the repair of isolated coarctation in infants and children. Patients repaired by end-to-end anastomosis had shorter aortic crossclamp time, younger patients had longer hospital length of stay, a majority of patients had sodium nitroprusside (Nipride) added to esmolol for early blood pressure control, and older patients were more likely to be discharged with antihypertensive medication.
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Affiliation(s)
- Sarah Tabbutt
- Cardiac Intensive Care Unit, The Cardiac Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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