Management of severe

hypertension in children

Dr Nick Plant,

Consultant Paediatric Nephrologist,

Royal Manchester Children’s Hospital

12th June 2015

Follow the department on Twitter: @nephrology_RMCH

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Overview

• What is severe hypertension?

• How do we measure it?

• How do they present?

• Common causes

• Acute history & examination

• Acute investigations & management

• Transfer

• Management & investigations at RMCH

• Conclusions

What is severe hypertension?

• Nothing agreed regarding a definition

• Usually means: Stage 2 hypertension &

symptoms

How do we measure it?

• Dinamap

– “we can’t get a reading”

• Aneroid – Accoson Green Light

• IA line – gold standard

How do they present?

• Signs/symptoms of heart failure

• Signs/symptoms of pulmonary oedema

• Failure to thrive

• CNS features:

– Nausea, vomiting, seizures (25%), headaches,

encephalopathy (25%), focal neurology,

hemiplegia (8%), VIIn palsy (12%), blindness

(retinal bleeds, acute ischaemic optic neuropathy,

cortical blindness, papilloedema), PRES

CNS features

Common causes

• Renal disease

– Reflux nephropathy

– Glomerulonephritides (esp MPGN)

– AKI

– Polycystic kidney disease (ARPKD, ADPKD)

– CKD5

• Malignancy

– Phaeo

– Wilm’s

– Neuroblastoma

Common causes

• Vascular

– Aortic coarctation

– Renal artery stenosis

– HUS (aHUS > STEC-HUS)

• Others

– Drugs (OCP, MDMA, cocaine)

– Non compliance in children with hypertension

– Rapid withdrawal of clonidine & β blockers

– Fluid overload in dialysis patients

Common causes

• Renal disease

– Reflux nephropathy

– Glomerulonephritides (esp MPGN)

– AKI

– Polycystic kidney disease (ARPKD, ADPKD)

– CKD5

• Malignancy

– Phaeo

– Wilm’s

– Neuroblastoma

Common causes

• Vascular

– Aortic coarctation

– Renal artery stenosis

– HUS (aHUS > STEC-HUS)

• Others

– Drugs (OCP, MDMA, cocaine)

– Non compliance in children with hypertension

– Rapid withdrawal of clonidine & β blockers

– Fluid overload in dialysis patients

Acute history and examination

• Acute history

– PH UTIs, haematuria, poor stream in boys, FTT, rashes, lethargy, headaches, visual disturbances, FH (diabetes, hypertension, sudden death, etc), medication (steroids, cyclosporin, OCP, drugs)

• Acute examination

– Cardiac status, neurological status (eye exam?), volume status, radio-femoral delay, abdominal mass, abdominal bruit, BMI, thyroid enlargement, café au lait spots, Cushingoid, CKD (short stature, anaemia, renal rickets, etc) ambiguous genitalia

Acute investigations and management

• Acute investigations (no need for many)

– CXR, echo(?), blood gas, CT head, FBC, U&E, toxicology screen

• Take care to exclude conditions that mimic

– Seizures, intracranial pathology, dysautonomia

• Acute management

– Not usually PO treatment

– IV labetolol infusion typically (start at 0.5mg/kg/hr, can increase to max of 3.0mg/kg/hr) – bolus alternative

– IV sodium nitroprusside (infusion) or hydralazine (infusion or bolus) are alternatives

Acute investigations and management

• Acute management continued

– Ideally should have IA line

– If not, consider Dinamap, Accoson every 1-2

minutes, initially

– Time now for prompt transfer

Transfer

• Will probably need to involve NWTS

• Try to avoid delays

• Don’t wait for our Bed Manager

• Consider ventilation in the most severely

affected cases

• Usually need transfer to a HDU/PICU

Management & investigation at RMCH

• Management

– Slow reduction in BP - 25% over 8-12 hours, 25%

over next 8-12 hours and remaining 50% in the

following 24 hours, with IV agents

• Labetolol, hydralazine, Nipride, esmolol, diazoxide,

enalaprilat (IM too)

– Switch to PO agents after 2-3 days if possible

• Investigations

– Led by likely cause: huge list…

Conclusions

• Severe hypertension is rare

• It is a medical emergency requiring prompt

treatment

• Slow fall in BP mandatory to avoid significant

complications

• Rapid, safe transfer needed

• Likely to be of renal or vascular aetiology

Conclusions

• Still, JL & Cottom, D. Arch Dis Child 1967 42: 34-39

Conclusion