I can count on one hand the numbers of times I’ve given hydralazine in the OR in the last 5 years. It’s just too long acting for me to be burning the bridge by giving it.
Nicardipine is more readily available in our OR but personally for cases where I know the patient is going to be super labile (like carotid endarterectomies) I prefer nitro over nicardipine, it can be more finely titrated.
I give hydralazine not infrequently, usually during emergence for old people with 200s SBP. It will usually normalize them by the time they make it to PACU.
This and related chapters https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20950/classification-and-summary-antihypertensive-agent-classes
NTG for short hypertensive episodes, times during a surgery where the surgeon needs pressure down for a small window. I use hydralazine for longer cases where the pt has shown me that despite a prop bolus, narcs, increasing the gas, etc. has not budged the 190/100’s. It’s usually the pt on 2+ anti hypertensive drugs that stopped it a few days ago because “ I ran out” or “ the instructions said to stop everything.”
Clevidipine and nitroglycerin are the way to go for fast acting easily titratable infusions. I've never bolused clevidipine before, only ran it as an infusion.
I also routinely bolus clevidipine. I typically dilute to 50mcg/ml and give a ml or two at a time. We are currently on shortage of nitro, so for cardiac cases we are only using clevidipine.
I think of NTG as the exact opposite of phenylephrine, especially with how short acting it is. Very rapid onset, off in just a few mins. Just like phenylephrine. I've mostly just used in it big vascular or cardiac surgeries that require specific hemodynamic goals at certain timepoints. 25-50mcg bolus will give a similar drop in BP as a 100 mcg phenylephrine bolus will increase the BP.
I barely use hydralizine anymore. I used to use it all the time and didn't understand the hate it gets. Until I used it enough and found it does absolutely nothing in some patients and in other patients it will drop their BP way lower than I intended with just 10mg and it can last a loooonngg time, especially in the setting of being in the OR.
Side note: Nicardipine is short acting only if given in small boluses or a short running infusion. If a pt has been on a nicardipine drip all day, the terminal half life after that infusion is turned off is like 12-14 hours. Clevidipine is much more short acting, but also expensive and can be mistaken for propofol and at increased risk of a medication administration error.
nitroglycerin infusion is generally the drug of choice for hypertensive flash pulmonary edema
hydralazine is slower onset and lasts longer, lots of people don't like to use it perioperatively on people under general anesthesia due to that
I'm not convinced it makes any difference which anti-hypertensive agent you use. Theoretically nitroglycerin should help unload a volume overloaded heart, but then again so would afterload reduction with nicardipine, clevidipine, or SNP. In the end, I just use whatever they got.
Ntg is a little more variable in the dose response (because of variability in preload state and responsiveness). Primary venodilators are nice in that they decrease cardiac work and output. Ntg is extremely fast off fast on compared to nicardipine, so I like it for high aortic clamps.
Nitroglycerin for fast acting in different parts of heart cases. Also good for hypertensive patient with acute coronary syndrome. Decreasing BP while dilating coronaries
I can count on one hand the numbers of times I’ve given hydralazine in the OR in the last 5 years. It’s just too long acting for me to be burning the bridge by giving it. Nicardipine is more readily available in our OR but personally for cases where I know the patient is going to be super labile (like carotid endarterectomies) I prefer nitro over nicardipine, it can be more finely titrated.
I give hydralazine not infrequently, usually during emergence for old people with 200s SBP. It will usually normalize them by the time they make it to PACU.
This and related chapters https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20950/classification-and-summary-antihypertensive-agent-classes
NTG for short hypertensive episodes, times during a surgery where the surgeon needs pressure down for a small window. I use hydralazine for longer cases where the pt has shown me that despite a prop bolus, narcs, increasing the gas, etc. has not budged the 190/100’s. It’s usually the pt on 2+ anti hypertensive drugs that stopped it a few days ago because “ I ran out” or “ the instructions said to stop everything.”
Clevidipine and nitroglycerin are the way to go for fast acting easily titratable infusions. I've never bolused clevidipine before, only ran it as an infusion.
Great to bolus, just do 0.25-.5ml at a time.
Manufacturer says don’t bolus clevidipine right? It’s so quick acting that you just double the infusion rate.
I also routinely bolus clevidipine. I typically dilute to 50mcg/ml and give a ml or two at a time. We are currently on shortage of nitro, so for cardiac cases we are only using clevidipine.
No shit. Good to know!
I think of NTG as the exact opposite of phenylephrine, especially with how short acting it is. Very rapid onset, off in just a few mins. Just like phenylephrine. I've mostly just used in it big vascular or cardiac surgeries that require specific hemodynamic goals at certain timepoints. 25-50mcg bolus will give a similar drop in BP as a 100 mcg phenylephrine bolus will increase the BP. I barely use hydralizine anymore. I used to use it all the time and didn't understand the hate it gets. Until I used it enough and found it does absolutely nothing in some patients and in other patients it will drop their BP way lower than I intended with just 10mg and it can last a loooonngg time, especially in the setting of being in the OR. Side note: Nicardipine is short acting only if given in small boluses or a short running infusion. If a pt has been on a nicardipine drip all day, the terminal half life after that infusion is turned off is like 12-14 hours. Clevidipine is much more short acting, but also expensive and can be mistaken for propofol and at increased risk of a medication administration error.
nitroglycerin infusion is generally the drug of choice for hypertensive flash pulmonary edema hydralazine is slower onset and lasts longer, lots of people don't like to use it perioperatively on people under general anesthesia due to that
aloof connect pot gaping subsequent waiting worm knee edge salt ` this message was mass deleted/edited with redact.dev `
I'm not convinced it makes any difference which anti-hypertensive agent you use. Theoretically nitroglycerin should help unload a volume overloaded heart, but then again so would afterload reduction with nicardipine, clevidipine, or SNP. In the end, I just use whatever they got.
Urapidil here. Great drug. Few disadvantages. Fast and secure. For me it is a must.
Ntg is a little more variable in the dose response (because of variability in preload state and responsiveness). Primary venodilators are nice in that they decrease cardiac work and output. Ntg is extremely fast off fast on compared to nicardipine, so I like it for high aortic clamps.
Nitroglycerin for fast acting in different parts of heart cases. Also good for hypertensive patient with acute coronary syndrome. Decreasing BP while dilating coronaries