Department of Child Health

Nephrology Division
FKUI RSCM
Jakarta
Hypertensive crisis:

uncommon medical emergency

Hypertension stage 1: Hypertension stage 2:

2.6% 0.6%

Diagnosis and rapid treatment prevent

irreversible brain damage or death
2004
The fourth report on the diagnosis, evaluation, and
treatment of high blood pressure in children and
adolescents:

Hypertension:
Stage 1 hypertension: BP 95th percentile to 5 mmHg above 99th percentiles
for gender, age, and height
Stage 2 hypertension: BP > 5 mmHg above 99 th percentile for gender, age,
and height

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and
Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in
children and adolescents. Pediatrics 2004;114:555-76.
Hypertensive crisis
(Joint National committee on Detection, Evaluation and
Treatment of Hypertension, JNC7)

-SBP > 180 mmHg

-DBP > 120 mmHg
-Hypertension (BP < 180/120 mmHg) with
encephalopathy, heart failure, retinopathy
Hypertensive crisis:
Hypertensive urgency
Without organ target damage
Clinical manifestations: headache, vomiting
Possibility progressive to a hypertensive
emergency
Perioperative hypertension

Hypertensive emergency:
Severe Hypertension with end-organ injury of
the brain, heart, kidney
Hypertensive emergency Hypertensive urgency
(organ target damage: +) (organ target damage:-)

Hypertensive encephalopathy Accelerated hypertension

Congestive heart failure Malignant hypertension
Pulmonary edema Peri-operative hypertension
ARF/CRF
Adrenergic crisis
Head trauma
Stroke
Myocardial infarction
Dissecting aortic aneurysm
Etiology

1. Renal parenchymal disease

a. Glomerulonephritis
b. Systemic vasculitis with renal
involvement
c. Hemolytic uremic syndrome
d. Interstitial nephritis (chronic
pyelonephritis)
e. Hereditary diseases
2. Renovascular
a. Intrinsic renal artery disease:
Fibromuscular dysplasia
Arteritis (Kawasaki, Takayasu, Moyamoya disease)
Renal transplant artery stenosis
Newborn with umbilical vessel catheters
Renal transplant renal artery or venous thrombosis
Renal trauma
b. Extrinsic compression
Neoplasia: Wilms tumor, neuroblastoma,
pheochromocytoma, paraganglioma, neurofibroma,
lymphoma
Perirenal hematoma, trauma
Retroperitoneal fibrosis
3. Cardiovascular

a. Coarctation of aorta
b. Middle aortic syndrome
c. Williams syndrome
d. Turner syndrome
4. Endocrine abnormalities
a. Tumor secreting vasoactive substance (cathecholamines, renin)
b. Thyroid disorders
c. Cushing syndrome
d. Hyperaldosteronism
e. Congenital adrenal hyperplasia
f. Hypercalcemia

5. Miscellaneous causes
a. Neurologic abnormalities
- Elevated intracranial pressure
- Recent seizure, status epilepticus
- Familial dysautonomia
b. Cyclic vomiting syndrome
c. Polycythemia, recombinant erythropoietin therapy
d. Anesthetic drugs : ketamine, naloxone
e. Drug abuse: cocaine, amphetamine, methamphetamine,
phencyclidine, methylphenidate
Pathophysiology

Renin angiotensin system

Fluid overload
Sympathetic stimulation
Endothelial dysfunction
Medication and other substances

Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12

 Clinical Presentation
Confirm Blood pressure with proper size cuff and
technique
Depend on organ target damage
CNS findings
Weakness
Nausea and vomiting
Severe headache
Seizures
Altered mental status
Loss of vision
Neurologic deficits
 Heart failure symptoms : Tachypnea,
Shortness of breath, edema
Suggest renal disease: hematuria, flank
pain, cola colored urine
Exophtalmos : hyperthyroidism
Abdomial mass: Wilms tumor, polycystic
kidney, neuroblastoma

Important !! sign of child abuse with CNS

trauma
Retinopathy hypertension : 27%
Encepalopathy hypertension : 25%
Seizure : 25%
Left Ventrikel hypertrophy : 13%
Facial Palsy : 12%
Vision Changes : 9%
Hemiplegia : 8%
Cranial bruits : 5%
BP >99 without organ damage : 24%
Management

Antihypertensive drugs
Evaluation for target organ damage
Investigation of causes
Supportive management
a. Antihypertensive drugs
Should be initiated prior to obtaining the results of
laboratory and radiologic
Preferably in intensive care setting with
continuous cardiac monitor
Goal of therapy: BP to normal or near normal
level as quickly as possible
Target :<95th percentiles
 BP measure:
@ 5 minute ( First 15 minute)
@ 15 minute ( First hour)
@ 30 minute until Diastolic BP 100
@ 1-3 hour

Intravenous or Oral anti hypertensive

Lowering BP
25-30% in 8-12 hour
25-30% in 24-36 hour
b. Investigation of causes
Evaluations: - causes
- co-morbidity
- target organ damage
Evaluation should be individualized
Majority causes: renoparenchym or renovascular
screening to this condition
Diagnostic tests:
Urinalysis
BUN,SC
CBC
c. Evaluation for target organ damage

Abnormality of brain, heart, kidney, eyes

d. Supportive management
Antihypertensive for hypertensive crisis

Drug of choice:
Short acting
Can be titrated
Indonesia:
Nifedipine, Na nitroprusside, clonidine,
nicardipine
 Nifedipine

Calcium-channel blockers
Direct vasodilators by inhibiting vascular smooth muscle
contraction by interfering with cellular calcium influx
Sublingually: start 0,1 mg/kg max 10 mg/dosage or 120
mg/day
Effective within 10 minutes with peak effect in 30 - 40 min.
Sublingual more rapid than oral for 10 to 15 minutes
Side effects: headache, flushing, dizziness, tachycardia
 Scheme: Treatment of crisis/encephalopathy hypertension
with nifedipine
Nifedipine sublingually 0.1 mg/kgbw
Increased 0.1 mg/kgbw/dose every 30 minutes

Max. dose: 10 mg/dose

+ Furosemide 1 mg/kgbw/dose, 2 x per day i.v.

(Orally: in good condition)
Diastolic
90 100 mmHg
If blood pressure is not decreased,
+ Captopril 0.3 mg/kgbw/dose 2-3 x per day
(max. 2 mg/kgbw/dose)

STABILE
MAINTENANCE NIFEDIPINE
0.2 mg 1 mg/kgbw/day, 3-4 x

Alatas H. Naskah simposium dan workshop sehari: Kegawatan pada penyakit ginjal anak.
Makasar, 27-28 Mei, 2006,17-28.
Nitroprusside

Nitric oxide donor vasodilatory effect on venous and

arteriolar
renal blood flow
Continuous infusion
Dose: begin at 0.3 g/kg/min,
and titrated to a max. dose of 8 g/kg/min
Requires continuous BP monitoring
Toxic metabolites: cyanide, thiocyanate
Nitroprusside
Side effects:
Cyanide/thiocyanate toxicity:
- anxiety, headache, dizziness, confusion, jaw stiffness,
seizures,
- metabolic acidosis and hypoxemia
Hypotension, methemoglobinemia, hypothyroidism, tinnitus,
visual disturbances, tachyphylaxis
> 72 hours or renal failure:
- monitor cyanide levels
- co-administer with Na-thiosulfate
(infusion of nitroprusside to thiosulfate: 10 : 1)
Contraindicated:
- intracranial pressure
- caution in aorta coarctation
Solution should be protected from light

Rust RS, Chun RWM. IPediatric Neurology, Principles & Practice, 4th ed., Philadelphia, Mosby Elsevier,
2006,p.2233-83
Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220
Li SPS, Wong SN. Practical Paediatric Nephrology, 1st ed., Hong Kong, Medcom Limited, 2005;p.89-95
2. Clonidine

Central agonist
Useful when intensive care monitoring facilities are not available
Side effects:- drowsiness
- decreased alertness
- elevations in liver enzymes
- muscle or joint pain, weight gain, and rash.
Clonidine difficult to follow the course of hypertensive
encephalopathy
Cause rebound hypertension if suddenly withdrawn

Brazy PC. Primer on Kideny Diseases, 1st ed, San Diego, Academic Press, 1994;p. 355-61
Alatas H. Naskah simposium dan workshop sehari: Kegawatan pada penyakit ginjal anak, Makasar, 27-28 Mei, 2006,17-28.
Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220.
 Scheme. Treatment of crisis/encephalopathy hypertension
with clonidine

Clonidine drip 0.002 mg/kgbw/8 hours

in 100 cc dextrose 5% (12 drops micro)
Inceased every 30 minutes until max. dose
0.006 mg/kgbw/8 hours

+ Furosemide 1 mg/kgbw/dose IV Diastolic 90-100 mmHg

Captopril orally 0.3 mg/kgbw/dose

(max. 2 mg/kgbw/dose), 2-3 times/day
STABILE

Clonidine stop
Captopril continue

Alatas H. Naskah simposium dan workshop sehari: Kegawatan pada penyakit ginjal anak.
Makasar, 27-28 Mei, 2006,17-28.
Nicardipine
Calcium channel blockers

Direct vasodilators by inhibiting vascular smooth muscle contraction by

interfering with cellular calcium influx
Rapid, safe, effective

Continuous infusion: 0,5 to 5,0 g/kg/min (max. = 5 mg/hour)

Cause tachycardia, headache, flushing, dizziness

Contraindicated: head trauma, intracranial haemorrhage

Alternative to nitroprusside or intravenous labetalol

Diazoxide
Nondiuretic thiazide
Potent arteriole vasodilator
Dose: 1 to 3 mg/kg per dose
IV infusion over 5 to 10 minutes and may be given every 10 to 15 minutes
Max. dose: 10 mg/kg or 150 mg
Causes sodium retention and requires diuretic: furosemide
Side effects: = other systemic vasodilators
- hyperglycemia, hyperuricemia, nausea, vomiting, constipation,
- hypertrichosis, skin rash, fever, leucopenia, thrombocytopenia
Contraindicated: -intracerebral hemorrhage
-dissecting aortic aneurysm
-acute myocardial infarction
-coarctation of the aorta
 Labetalol
-blocker or -adrenergic antagonist with peripheral -adrenergic
antagonism vasodilatation of peripheral vasculature
antihypertensive effect
blood pressure by reducing heart rate and myocardial contractility,
and reduce cardiac output
Is not cardioselective and does not have intrinsic symphatomimetic
activity
Dose: 0,2-1,0 mg/kg/dose IV push over 2 minutes
If no response, may redose q5-10 minutes incrementally to max. dose
= 60 mg, or 0,25-2,0 mg/kg/hour IV continuous infusion

Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-
1220.
Rust RS, Chun RWM. Pediatric Neurology, Principles & Practice, 4th ed., Philadelphia, Mosby Elsevier,
2006,p.2233-83
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12
Hydralazine
Induces relaxation of vascular smooth muscles arteriolar
vasodilatation
Short half-life
Tachycardia, plasma renin activity, sodium retention
Best used with diuretic and -blocker
IV bolus or IM: 0,2-0,5 mg/kg/dose q4-6 hr
(max. 3,5 mg/kg/day)
Side effects: headache, palpitation, sweating, nausea,
dizziness.
Hydralazine (> 200 mg/day) lupus-like syndrome

Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220.
Brazy PC. Primer on Kideny Diseases, 1st ed, San Diego, Academic Press, 1994;p. 355-61
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12
Fenoldopam

Dopamine-1 receptor agonist

0,5-2 g/kg/min

Contraindicated: glaucoma

Cause headaches, tachycardia

Li SPS, Wong SN. Practical Paediatric Nephrology, 1st ed., Hong Kong, Medcom Limited, 2005;p.89-95
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12
Esmolol, Enalaprilat

Rare used in children

Esmolol:
Cardioselective adrenoreceptive -blocker
IV bolus: 100-500 g/kg over 1-2 min,
then 50-500 g/kg/min
Enalaprilat:
ACE inhibitor
IV: 0,005-0,01 mg/kg/dose q8-24hr
up to 1,25 mg/dose

Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220.
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12
Summary
Hypertensive crisis may lead to encephalopahty, heart
failure, and retinopathy

Secondary hypertension is commonest causes and

investigations is necessary to identify the etiology

Management consisted of antihypertensive agents,

evaluation for target organ damage, investigation of
causes, and supportive management