What are the recommended prn (as needed) medication orders for severe hypertension and hypotension?

PRN Blood Pressure Orders for Severe Hypertension and Hypotension

For severe hypertension, first-line PRN medications include intravenous labetalol, nicardipine, or nitroprusside for emergencies, while oral labetalol or nicardipine are recommended for urgencies. For hypotension, intravenous norepinephrine is the first-line agent for restoration of blood pressure in acute hypotensive states.

Severe Hypertension Management

Hypertensive Emergencies (with acute organ damage)

Hypertensive emergencies require immediate BP reduction with careful monitoring in a higher dependency clinical setting.

First-line medications:

• Labetalol IV: 0.25-0.5 mg/kg IV bolus; 2-4 mg/min continuous infusion 1
• Nicardipine IV: 5-15 mg/h as continuous infusion, starting at 5 mg/h 1
• Sodium Nitroprusside IV: 0.3-10 μg/kg/min, increase by 0.5 μg/kg/min every 5 min 1, 2

Target BP reduction:

• Reduce MAP by 20-25% within the first hour
• Then gradually to 160/100-110 mmHg over next 2-6 hours
• Further gradual decrease over 24-48 hours 1, 3

Special considerations by condition:

1. Acute aortic dissection:

   • Immediate reduction to systolic BP <120 mmHg and heart rate <60 bpm
   • First-line: Esmolol + Nitroprusside/Nitroglycerin
   • Alternative: Labetalol or Metoprolol + Nicardipine 1

2. Acute cardiogenic pulmonary edema:

   • First-line: Nitroprusside or Nitroglycerin (with loop diuretic)
   • Alternative: Urapidil (with loop diuretic) 1

3. Acute coronary event:

   • First-line: Nitroglycerin
   • Alternative: Urapidil, Labetalol 1

4. Acute stroke:

   • For ischemic stroke with BP >220/120 mmHg: Labetalol (alternative: Nicardipine)
   • For hemorrhagic stroke with systolic BP >180 mmHg: Labetalol (alternative: Urapidil, Nicardipine) 1

5. Eclampsia/severe pre-eclampsia:

   • First-line: Labetalol or Nicardipine + Magnesium sulfate 1

Hypertensive Urgencies (without acute organ damage)

Hypertensive urgencies can be managed with oral medications and do not typically require hospital admission.

First-line medications:

• Oral labetalol
• Oral captopril
• Oral nicardipine 1, 4

Target BP reduction:

• Gradual lowering over 24-48 hours
• Avoid aggressive BP lowering 3

Hypotension Management

Acute Hypotensive States

First-line medication:

• Norepinephrine IV:
  • Dilute 4 mg in 1000 mL of 5% dextrose solution
  • Initial dose: 2-3 mL/min (8-12 μg/min)
  • Maintenance: 0.5-1 mL/min (2-4 μg/min) 5

Important considerations:

• Always correct blood volume depletion before or concurrently with vasopressor administration
• Administer into a large vein, preferably with central venous access
• Titrate according to patient response
• For previously hypertensive patients, aim to raise BP no higher than 40 mmHg below preexisting systolic pressure 5

Practical Implementation Tips

1. Monitoring requirements:

   • Continuous or frequent BP monitoring during treatment of hypertensive emergencies
   • ECG monitoring when using beta-blockers or calcium channel blockers
   • Monitor for signs of end-organ damage

2. Common pitfalls to avoid:

   • Excessive or too rapid BP reduction can lead to organ hypoperfusion, especially in patients with chronic hypertension
   • Failure to identify and treat the underlying cause of hypertensive crisis
   • Using beta-blockers as first-line in cocaine or methamphetamine-induced hypertension 1
   • Neglecting to transition to oral therapy after stabilization

3. Follow-up considerations:

   • Screen for secondary causes of hypertension in patients with hypertensive emergencies 1
   • Establish long-term oral antihypertensive regimen after acute management
   • Arrange appropriate outpatient follow-up

By following these evidence-based recommendations for PRN blood pressure management, clinicians can effectively address both severe hypertension and hypotension while minimizing risks of adverse outcomes related to inappropriate treatment.