How to manage hypertension in a patient who is nothing by mouth (NPO)?

Management of Hypertension in NPO Patients

For patients with hypertension who are NPO (nothing by mouth), intravenous antihypertensive medications should be used, with nicardipine or labetalol as first-line agents for most situations. 1

Assessment of Hypertensive NPO Patient

Before initiating treatment, assess:

• Severity of hypertension (urgency vs. emergency)
• Presence of end-organ damage
• Underlying cause of hypertension
• Patient's baseline blood pressure
• Comorbidities (cardiac, renal, neurological conditions)

Treatment Algorithm

1. Hypertensive Emergency (BP ≥180/120 mmHg with end-organ damage)

Immediate treatment required with IV medications:

• First-line agents:

  • Nicardipine IV: Start at 5 mg/hr, titrate by 2.5 mg/hr every 5-15 minutes up to 15 mg/hr maximum 1, 2
  • Labetalol IV: Initial bolus followed by continuous infusion 1

• Alternative agents based on specific conditions:

  • Heart failure/pulmonary edema: IV nitroglycerin + furosemide + short-acting ACE inhibitor 1
  • Ischemia/tachycardia: IV esmolol with IV nitroglycerin 1
  • Aortic dissection: Beta-blocker (esmolol) + vasodilator 1

• Target: Reduce BP by 20-25% within first hour, then gradually to 160/100 mmHg over next 2-6 hours 1

2. Hypertensive Urgency (BP ≥180/120 mmHg without end-organ damage)

• IV options:

  • Nicardipine: More gradual titration (2.5 mg/hr every 15 minutes) 2
  • Labetalol: Lower doses with careful monitoring 1

• Target: Reduce BP gradually over 24-48 hours 1

3. Chronic Hypertension Management When NPO

For patients with chronic hypertension who are temporarily NPO:

• IV options:
  • Nicardipine
  • Enalaprilat (IV ACE inhibitor)
  • Labetalol
  • Hydralazine 3

Medication Administration Guidelines

Nicardipine Administration (Preferred Agent)

• Dilute to 0.1 mg/mL (25 mg in 240 mL compatible IV fluid)
• Compatible with: D5W, NS, D5NS, D5 1/2NS 2
• Not compatible with: Sodium bicarbonate or Lactated Ringer's 2
• Change infusion site every 12 hours if administered via peripheral vein 2
• Monitor for headache, flushing, or phlebitis 4

Monitoring Requirements

• Continuous BP monitoring (arterial line preferred for emergencies)
• Frequent vital signs (every 5-15 minutes during titration)
• Neurological status
• Urine output
• Cardiac monitoring

Special Considerations

Heart Failure Patients

• Use diuretics in addition to vasodilators
• Consider ACE inhibitors or ARBs if hemodynamically stable 1
• Avoid non-dihydropyridine CCBs (verapamil, diltiazem) 1

Elderly Patients

• More susceptible to rapid BP reduction
• Avoid lowering diastolic BP below 60 mmHg 1
• More gradual BP reduction to prevent cerebral hypoperfusion 1

Perioperative Setting

• Continue chronic antihypertensive medications until surgery when possible 1
• For intraoperative hypertension, use IV medications until oral medications can be resumed 1

Transition to Oral Therapy

When patient can resume oral intake:

• Start oral medications 1 hour before discontinuing IV infusion 2
• Consider returning to patient's previous regimen if it was effective
• If starting new oral therapy, begin with long-acting agents

Pitfalls to Avoid

1. Avoid rapid, excessive BP reduction which can cause cerebral, cardiac, or renal hypoperfusion
2. Avoid short-acting nifedipine (risk of precipitous BP drop) 1
3. Avoid sodium nitroprusside for prolonged periods (cyanide toxicity risk) 1
4. Do not abruptly discontinue beta-blockers or clonidine (rebound hypertension) 1
5. Avoid starting beta-blockers on day of surgery in beta-blocker naïve patients 1

By following this structured approach to managing hypertension in NPO patients, you can effectively control blood pressure while minimizing risks of adverse outcomes related to either uncontrolled hypertension or excessive treatment.