pediatric acute hypertension
DESCRIPTION
definition,types,causes,clinical presentation ,investigations ,managementTRANSCRIPT
Prof .Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah ,UAE
PediatricAcute Hypertension
Background
Adolescents may acquire primary or essential hypertension
In infants and younger children, systemic hypertension is uncommon, but when present, it is usually indicative of an underlying disease process (secondary hypertension).
03/20/2012 2Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Cont.
Correlate with BP tables for age, height, and weight
Accurate blood pressure measurements should be part of the routine annual physical examination of all children 3 yr or older.
A complete family history of hypertension should be elicited
Use appropriate cuff size for blood pressure (BP) measurement.
03/20/2012 3Pediatric Acute hypertension Prof. Dr. Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Etiology and Pathophysiology
Many childhood diseases may be responsible for
both acute and chronic elevation of blood pressure
Secondary hypertension is most common in infants and younger children
03/20/2012 4Pediatric Acute hypertension Prof. Dr. Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Cont.Hypertension in the newborn
is most often associated with:
1. umbilical artery catheterization
and
2. renal artery thrombosis
03/20/2012 5Pediatric Acute hypertension Prof. Dr. Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Cont.
Hypertension during early childhood
may be due to :
1.renal disease
2.coarctation of the aorta
3. endocrine disorders
4.medications.
03/20/2012 6Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Cont. In adolescents
essential hypertension becomes increasingly common
03/20/2012 7Pediatric Acute hypertension Prof. Dr.
Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Cont.
In general, children and adolescents with essential hypertension
have blood pressure values at or only slightly above the 95th
percentile for age
The severity of hypertension is also helpful in distinguishing secondary from primary hypertension
03/20/2012 8Pediatric Acute hypertension Prof. Dr.
Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Cont.
Renal and renovascular hypertension accounts for the majority of children with secondary hypertension
A history of urinary tract infection is present in 25-50% of these patients and is often related to an obstructive lesion of the urinary tract
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Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Conditions Associated with Transient or Intermittent Hypertension in Children
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Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
• Acute postinfectious glomerulonephritis • Anaphylactoid (Henoch-Schönlein) purpura with nephritis • Hemolytic-uremic syndrome
• Acute tubular necrosis • After renal transplantation (immediately and during episodes of
rejection) • After blood transfusion in patients with azotemia
Renal
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• Renal trauma • Leukemic infiltration of the kidney • Obstructive uropathy associated with Crohn
disease
Cont.
• Hypervolemia • After surgical procedures on the genitourinary
tract • Pyelonephritis
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Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Drugsand
Poisons
• Cocaine • Oral contraceptives • Sympathomimetic agents • Amphetamines • Phencyclidine • Corticosteroids and
adrenocorticotropic hormone
• Cyclosporine or sirolimus treatment post-transplantation • Licorice (glycyrrhizic acid) • Lead, mercury, cadmium, thallium • Antihypertensive withdrawal (clonidine, methyldopa, propranolol) • Vitamin D intoxication
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Central and
Autonomic nervous system
• Increased intracranial pressure • Guillain-Barré syndrome • Burns • Familial dysautonomia
• Stevens-Johnson syndrome
• Posterior fossa lesions • Porphyria • Poliomyelitis • Encephalitis
03/20/2012 14Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Miscellaneous
• Preeclampsia • Fractures of long bones • Hypercalcemia
• After coarctation repair • White cell transfusion • Extracorporeal membrane
oxygenation • Chronic upper airway obstruction
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Conditions Associated with Chronic Hypertension
in Children
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Renal
• Chronic pyelonephritis • Chronic glomerulonephritis • Hydronephrosis • Congenital dysplastic kidney
• Multicystic kidney • Solitary renal cyst • Vesicoureteral reflux nephropathy • Segmental hypoplasia (Ask- Upmark
kidney)
03/20/2012 17Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
• Ureteral obstruction • Renal tumors • Renal trauma • Rejection damage following transplantation • Postirradiation damage • Systemic lupus erythematosus (other connective tissue diseases
Cont.
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Vascular
• Coarctation of thoracic or abdominal aorta • Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis,
aneurysm) • Umbilical artery catheterization with thrombus formation • Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen)
• Renal vein thrombosis • Vasculitis • Arteriovenous shunt • Williams- Beuren syndrome • Moyamoya disease
03/20/2012 19Pediatric Acute hypertension Prof. Dr. Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Endocrine
• Hyperthyroidism • Hyperparathyroidism • Congenital adrenal hyperplasia (11 β- hydroxylase
and 17-hydroxylase defect)
• Cushing syndrome • Primary aldosteronism • Dexamethasone-suppressible hyperaldosteronism
• Pheochromocytoma • Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma) • Diabetic nephropathy • Liddle syndrome
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Central Nervous System
• Intracranial mass • Hemorrhage • Residual following brain
injury • Quadriplegia
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Essential hypertension
• Low renin • Normal renin • High renin
03/20/2012 22Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Acute Hypertension
• Hypertensive urgency:
Significant elevation in BP without accompanying end-organ damage; more common in children.
Symptoms include headache, blurred vision, and nausea
• Hypertensive emergency: Elevation of both systolic and diastolic BP with acute end-organ damage (e.g., cerebral infarction or hemorrhage, pulmonary edema, renal failure, hypertensive encephalopathy, or seizures)
03/20/2012 23Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Physical examination
• Four-extremity BP• Funduscopy (papilledema, hemorrhage, exudate) • Visual acuity • Thyroid examination • Evidence for congestive heart failure (tachycardia, gallop rhythm,
hepatomegaly, edema) • Abdominal examination (mass, bruit) • Thorough neurologic examination • Evidence of virilization, cushingoid effect
03/20/2012 24Pediatric Acute hypertension Prof. Dr.
Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Initial diagnostic evaluation
• Urinalysis• Blood urea nitrogen• Creatinine,• Electrolytes• Chest radiograph• Electrocardiogram
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Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Consider
• Renin level• Toxicology screen• Thyroid and adrenal testing • Urine catecholamines• Abdominal ultrasound• Renal Doppler ultrasound • Head CT
03/20/2012 26Pediatric Acute hypertension Prof. Dr.
Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Management
Hypertensive emergency:
Goal: Lower BP promptly but gradually to preserve cerebral autoregulation
(a) Mean arterial pressure (MAP) = 1/3 systolic + 2/3 diastolic BP(b) Lower by 1/3 of planned MAP reduction over first 6 hours, then(c) Lower by additional 1/3 over next 24–36 hours, then(d) Lower final 1/3 over next 48 hours
After elevated ICP is ruled out, do not delay treatment because of further diagnostic workup
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Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
03/20/2012 28Pediatric Acute hypertension Prof. Dr. Saad S Al Ani Khorfakkan Hospital ,Sharjah ,UAE
Hypertensive urgency:
Goal:
To lower MAP by 20% over 1 hour and return to baseline levels over 24 to 48 hours
An oral route may be adequate. (Use of sublingual nifedipine is not recommended, as a precipitous, uncontrolled fall in BP may result.)
03/20/2012 29Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
03/20/2012 30Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Algorithm for identifying children with high blood pressure (BP)
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References
• Flynn JT: What's new in pediatric hypertension? Curr Hypertens Rep 2001;3: 503-10.
• Kay JD, Sinaiko AR, Daniels SR: Pediatric hypertension. Am Heart J 2001;142:422-32.
• Blaszak RT, Savage JA, Ellis EN: The use of short-acting nifedipine in pediatric patients with hypertension. J Pediatr 2001;139:34-7.
• Katherine M. Steffen. Trauma, Burns, and Common Critical Care Emergencies(in) The Harriet Lane handbook. 19th ed. Philadelphia 2012 Ch.4 p:113-115
03/20/2012 32Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE
Thank you
03/20/2012 33Pediatric Acute hypertension Prof. Dr. Saad S Al Ani
Khorfakkan Hospital ,Sharjah ,UAE