What should be done for a 60-year-old female with a right hip fracture, acute kidney injury (AKI), severe anemia (Hb 6.2), and recent blood transfusions, who develops sudden dyspnea and severe hypertension (BP 210/110) while receiving IV fluids at 110 ml/hour?

Management of Hypertensive Emergency with Pulmonary Edema in a Patient with Hip Fracture and AKI

The patient is experiencing acute pulmonary edema due to a hypertensive emergency and requires immediate treatment with intravenous labetalol or nicardipine to reduce blood pressure by 20-25% within the first few hours, along with non-invasive ventilation and diuretic therapy.

Clinical Assessment

This 60-year-old female presents with a classic hypertensive emergency complicated by acute pulmonary edema, as evidenced by:

• Sudden dyspnea
• Severe hypertension (BP 210/110 mmHg)
• Risk factors: AKI (creatinine 6), anemia (Hb 6.2 after 2 transfusions)
• Volume overload (receiving IV fluids at 110 ml/hour)
• Fully collapsible IVC (suggesting initial hypovolemia, now likely overcorrected)

Immediate Management

1. Airway and Breathing

• Non-invasive ventilation (NIV) with PEEP
  • Apply PEEP of 5-7.5 cmH2O initially, titrate up to 10 cmH2O as needed 1
  • Target FiO2 of 0.40 initially, adjust based on oxygen saturation
  • Continue NIV for approximately 30 minutes per hour until dyspnea and oxygen saturation improve 1

2. Blood Pressure Management

• Intravenous antihypertensive therapy
  • First-line: Labetalol IV or Nicardipine IV 1
  • Target: Reduce mean arterial pressure by 20-25% within the first few hours 1
  • Avoid excessive or rapid BP reduction to prevent organ hypoperfusion 1

3. Volume Management

• Loop diuretics
  • Furosemide 40 mg IV bolus initially 1
  • Consider continuous infusion if inadequate response
  • Monitor urine output closely (bladder catheterization recommended) 1
  • Total furosemide dose should remain <100 mg in first 6 hours and <240 mg in first 24 hours 1

4. Monitoring

• Transfer to ICU/CCU for close monitoring 1
• Continuous ECG, pulse oximetry, and frequent BP measurements
• Arterial line placement if using sodium nitroprusside 1
• Monitor renal function, electrolytes, and fluid balance

Special Considerations for This Patient

Acute Kidney Injury

• Hypertension is common in AKI (70% prevalence) and highest in post-renal AKI (85%) 2
• Use caution with vasodilators that may worsen renal perfusion
• Consider nephrology consultation for potential dialysis if fluid overload persists despite diuretics

Anemia and Blood Transfusions

• Recent blood transfusions may have contributed to volume overload
• Monitor for transfusion-associated circulatory overload (TACO)
• Hold additional transfusions until pulmonary edema resolves

Hip Fracture

• Delay surgical intervention until hemodynamic stability is achieved
• Consider DVT prophylaxis once blood pressure is controlled 1

Medication Selection

First-line options:

1. Labetalol IV:

   • Initial dose: 20 mg IV over 2 minutes
   • May repeat or double dose every 10 minutes to maximum of 300 mg
   • Advantages: Balanced alpha and beta blockade, less reflex tachycardia 1

2. Nicardipine IV:

   • Initial dose: 5 mg/hr, increase by 2.5 mg/hr every 5-15 minutes to maximum of 15 mg/hr
   • Advantages: Potent arterial vasodilator with minimal negative inotropic effects 1

Alternative options:

• Nitroglycerin IV: Primarily a venodilator, helpful for pulmonary congestion and coronary ischemia, but tachyphylaxis may develop within 24 hours 1, 3
• Sodium nitroprusside: Balanced vasodilator but requires arterial line monitoring and risk of thiocyanate toxicity, especially with renal dysfunction 1, 3

Common Pitfalls to Avoid

1. Excessive BP reduction: Avoid reducing BP by >25% in the first few hours to prevent cerebral, renal, or coronary hypoperfusion 1

2. Fluid overload: The patient was likely initially hypovolemic (collapsible IVC) but received excessive fluid resuscitation (110 ml/hr) leading to pulmonary edema

3. Inadequate monitoring: Hypertensive emergencies require continuous monitoring in an ICU setting 1

4. Using short-acting nifedipine: Can cause unpredictable BP drops and should be avoided in hypertensive emergencies 1

5. Delaying treatment: Hypertensive emergency with pulmonary edema requires immediate intervention to prevent further organ damage 1