Hypertensive Crises

  • John H. Tinker


Critically ill patients can become severely hypertensive—often to their detriment. In this chapter, we are not particularly concerned with the precise causes of these hypertensive crises, but rather with their acute therapy. Here, perhaps contrary to the best principles of general medicine, we are interested in getting the blood pressure under control rapidly and safely. The pharmacology (and toxicology) of various acutely-used vasodilator drugs will be discussed with emphasis on sodium nitroprusside (SNP) because it is widely used and is immediately effective but not clinically easy to use, and because of the possible problems of cyanide (CN) toxicity [60]. Although other drugs, such as nitroglycerine and phentolamine, may possess theoretical advantages over SNP in certain circumstances, in fact they are not as widely employed in critical care situations, probably because they are less effective in achieving the immediate objective, namely taking and keeping control of a severely elevated blood pressure.


Sodium Nitroprusside Hypertensive Crisis Cyanide Toxicity Ganglionic Blocking Agent Venous Capacitance Vessel 
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  1. 1.
    Albrecht RF, Toyooka ET, Polk SLH, et al (1978) Hydralazine therapy for hypertension during the anesthetic and postanesthesia periods. Little Brown, Boston, pp 299–312 (Int Anesth Clin 16/2)Google Scholar
  2. 2.
    Andersson O, Sivertsson R (1979) Minoxidil in refractory hypertension. Acta Med Scand 205: 213–219PubMedCrossRefGoogle Scholar
  3. 3.
    Aronow WS, Van Herick R, Greenfield R, et al (1978) Effect of timolol plus hydrochloro-thiazide plus hydralazine on essential hypertension. Circulation 57: 10171021Google Scholar
  4. 4.
    Aronow WS, Lurie M, Turbow M, et al (1979) Effect of prazocin vs. placebo on chronic left ventricular heart failure. Circulation 59: 344–350PubMedCrossRefGoogle Scholar
  5. 5.
    Bartorelli C, Magrini F, Moruzzi P, et al (1978) Hemodynamic effects of a calcium antagonistic agent (nifedipine) in hypertension. Clin Sci Mol Med [Suppl] 55: 291s - 292sGoogle Scholar
  6. 6.
    Chatterjee K, Parmley WW, Ganz W, et al (1973) Hemodynamic and metabolic responses to vasodilator therapy in acute myocardial infarction. Circulation 48: 1183–1193PubMedCrossRefGoogle Scholar
  7. 7.
    Chiariello M, Gold HK, Leinback RC, et al (1976) Comparison between the effects of nitroprusside and nitroglycerin on ischemic injury during acute myocardial infarction. Circulation 53: 766CrossRefGoogle Scholar
  8. 8.
    Compese JM, Stein D, DeQuattro V (1979) Treatment of severe hypertension with minoxidil: Advantages and limitations. J Clin Pharmacol 19: 231–241Google Scholar
  9. 9.
    Davies DW, Kadar D, Steward DJ, et al (1975) A sudden death associated with the use of sodium nitroprusside for induction of hypotension during anesthesia. Can Anaesth Soc J 22: 547–552PubMedCrossRefGoogle Scholar
  10. 10.
    Davies DW, Greiss L, Steward DJ, et al (1975b) Sodium nitroprusside in children: Observations on metabolism during normal and abnormal responses. Can Anaesth Soc J 22: 553–560Google Scholar
  11. 11.
    Dawson A, Johnson BF, Smith IK, et al (1979) A comparison of the effects of labetalol, bendrofluazide and their combination in hypertension. Br J Clin Pharmacol 8: 149–154PubMedCrossRefGoogle Scholar
  12. 12.
    Delaney TJ, Miller ED (1979) Blood flow alteration induced by saralasin on SNP. Anesthesiology [Suppl] 51: 573Google Scholar
  13. 13.
    Desch CE, Magorien RD, Triffon DW, et al (1979) Development of pharmacodynamie tolerance to prazocin in congestive heart failure. Am J Cardiol 44: 11781182Google Scholar
  14. 14.
    El-Etr A, Glisson SN (1978) Alpha-adrenergic blocking agents. Little Brown, Boston, pp 239–259 (Int Anesth Clin, vol 16/2)Google Scholar
  15. 15.
    Fahmy NH (1980) Vitamin B12 levels decrease during sodium nitroprusside administration. Proc Cong Int Anesth Res SocGoogle Scholar
  16. 16.
    Fauchald P, Helgeland A (1979) Treatment of hypertension with prazocin. An open study in general practice. Acta Med Scand [Suppl] pp 141–142Google Scholar
  17. 17.
    Franciosa JA, Guiha NH, Limas CJ, et al (1972) Improved left ventricular function during nitroprusside infusion in acute myocardial infarction. Lancet 1: 650654Google Scholar
  18. 18.
    Gifford RW (1959) Current practices in general medicine. 7. Treatment of hypertensive emergencies including use of sodium nitroprusside. Proc Mayo Clin 34: 387–394Google Scholar
  19. 19.
    Goodman LS, Gilman A (1975) The pharmacological basis of therapeutics, 5th edn. MacMillan, New York, pp 715–717Google Scholar
  20. 20.
    Grayling GW, Miller ED, Peach MJ (1978) Sodium cyanide antagonism of the vasodilator action of sodium nitroprusside in the isolated rabbit aortic strip. Anesthesiology 49: 21–24PubMedCrossRefGoogle Scholar
  21. 21.
    Greiss L, Tremblay NAG, Davies DW (1976) The toxicity of sodium nitroprusside. Can Anaesth Soc J 23: 480–486PubMedCrossRefGoogle Scholar
  22. 22.
    Hermann L (1886) Ueber die Wirkung des Nitroprussidnatriums. Arch Ges Physiol 39: 419–424CrossRefGoogle Scholar
  23. 23.
    Hua AS, Myers JB, Kincaid-Smith P (1978) Studies with prazosin-a new effective antihyypertensive agent. Med J Aust 1: 45–48PubMedGoogle Scholar
  24. 24.
    Johnson CC (1929) The actions and toxicity of sodium nitroprusside. Arch Int Pharmacodyn Ther 35: 489–496Google Scholar
  25. 25.
    Karatzas NB, Papazchos G, Clouva P, et al (1979) Timolol and bendroflumethiazide in the treatment of hypertension. J Int Med Res 7: 215–220PubMedGoogle Scholar
  26. 26.
    Kerber RE, Martins JB, Marcus ML (1979) Effect of acute ischemia, nitroglycerin and nitroprusside on regional myocardial thickening, stress and perfusion. Circulation 60: 121PubMedCrossRefGoogle Scholar
  27. 27.
    Klowden AJ, Ivankovich AD, Miletich DJ (1978) Ganglionic blocking drugs, general considerations and metabolism. Little Brown, Boston, pp 113–150 (Int Anesth Clin, vol 16/2)Google Scholar
  28. 28.
    Koch-Weser J, Graham RM, Pettinger WA (1979) Drug therapy, Prazocin. N Engl J Med 300: 232–236Google Scholar
  29. 29.
    Kuokkanen K, Mattila MJ (1979) Antihypertensive effect of prazocin in combination with methyldopa, chlonidine, or propranolol. Ann Clin Res 11: 18–24PubMedGoogle Scholar
  30. 30.
    Kuwajima I, Ueda K, Kamata C, et al (1978) A study of the effects of nifedipine in hypertensive crises and severe hypertension. Jpn Heart J 19: 455–467PubMedCrossRefGoogle Scholar
  31. 31.
    Lang K (1933) Die Rhodanbildung im Tierkörper. Biochem Z 259: 243–256Google Scholar
  32. 32.
    Lilja M, Jounela AJ, Juustila H, et al (1979) Anti-hypertensive effects of clonidine. Clin Pharmacol Ther 25: 864–869PubMedGoogle Scholar
  33. 33.
    Loeb HS Sandje A, Croke RP, et al (1978) Effects of pharmacologically-induced hypertension on myocardial ischemia and coronary hemodynamics in patients with fixed coronary obstruction. Circulation 57: 41–46Google Scholar
  34. 34.
    Mann T, Cohn PF, Holman LB, et al (1978) Effect of nitroprusside on regional myocardial blood flow in coronary artery disease. Results in 25 patients and comparison with nitroglycerin. Circulation 57: 732–738PubMedCrossRefGoogle Scholar
  35. 35.
    McGrath BP, Matthews PG, Walter NM, et al (1978) Emergency treatment of severe hypertension with intravenous labetalol. Med J Aust 2: 410–411PubMedGoogle Scholar
  36. 36.
    Michenfelder JD (1977) Cyanide release from sodium nitroprusside in the dog. Anesthesiology 46: 196–201PubMedCrossRefGoogle Scholar
  37. 37.
    Michenfelder JD, Tinker JH (1977) Cyanide toxicity and thiosulfate protection during chronic administration of sodium nitroprusside in the dog: Correlation with human case. Anesthesiology 47: 411–448Google Scholar
  38. 38.
    Miletich DJ, Ivankovich AD (1978) Cardiovascular effects of ganglionic blocking drugs. Little Brown, Boston, pp 151–170 (Int Anesth Clin, vol 16/2)Google Scholar
  39. 39.
    Mitchell HC, Pettinger WA (1978) Long-term treatment of refractory hypertensive patients with minoxidil. JAMA 239: 2131–2138Google Scholar
  40. 40.
    Moraca PP, Bitte EM, Hale DE, et al (1962) Clinical evaluation of sodium nitroprusside as a hypotensive agent. Anesthesiology 23: 193–199PubMedCrossRefGoogle Scholar
  41. 41.
    Mushett CW, Kelley KL, Boxer GE, et al (1952) Antidotal efficacy of vitamin B12 ( Hydroxocobalamine) in experimental cyanide poisoning. Proc Soc Exp Biol Med 81: 234–237Google Scholar
  42. 42.
    Needleman P, Jakschik B, Johnson EM (1973) Sulfhydryl requirement for relaxation of vascular smooth muscle. J Pharmacol Exp Ther 187: 324–331PubMedGoogle Scholar
  43. 43.
    Niarchos AP (1978) Evaluation of intravenous clonidine for hypertensive emergencies. J Clin Pharmacol 18: 220228Google Scholar
  44. 44.
    Nourok DS, Glassock RJ, Solomon DH, et al (1964) Hypothyroidism following prolonged sodium nitroprusside therapy. Am J Med Sci 248: 129–138PubMedCrossRefGoogle Scholar
  45. 45.
    Onesti G, Fernandes J (1978) Recent acquisitions in antihypertensive therapy, clonidine, minoxidil, and prazocin. Cardiovasc Clin 9: 273–289PubMedGoogle Scholar
  46. 46.
    Page IH (1951) Treatment of essential and malignant hypertension. JAMA 147: 1311–1318Google Scholar
  47. 47.
    Page IH, Corcoran AC, Dustan HP, et al (1955) Cardiovascular actions of sodium nitroprusside in animals and hypertensive patients. Circulation 11: 188–198PubMedCrossRefGoogle Scholar
  48. 48.
    Palmer RF, Lasseter KD (1975) Sodium nitroprusside. N Engl J Med 293: 294–297CrossRefGoogle Scholar
  49. 49.
    Paulissian R (1978) Diazoxide. Little Brown, Boston, pp 201–231 (Int Anesth Clin, vol 16/2)Google Scholar
  50. 50.
    Pearson RM, Havard CW (1978) Intravenous labetalol in hypertensive patients given by fast and slow injection. Br J Clin Pharmacol 5: 401–405PubMedCrossRefGoogle Scholar
  51. 51.
    Pederson OL, Mikkelson E, Christensen NJ, et al (1979) Effect of nifedipine on plasma renin, aldosterone and catecholamines in arterial hypertension. Eur J Clin Pharmacol 15: 235–240CrossRefGoogle Scholar
  52. 52.
    Posner MA, Tobey RA, McElroy H (1976) Hydroxocobalamine therapy of cyanide intoxication in guinea pigs. Anesthesiology 44: 157–160PubMedCrossRefGoogle Scholar
  53. 53.
    Ram CV, Kaplan NM (1979) Alpha receptor blocking drugs in the treatment of hypertension. Curr Probl Cardiol 3: 1–53PubMedGoogle Scholar
  54. 54.
    Rowe GG, Henderson RH (1974) Systemic and coronary hemodynamic effects of sodium nitroprusside. Am Heart J 87: 83–87PubMedCrossRefGoogle Scholar
  55. 55.
    Salem MR (1978) Therapeutic uses of ganglionic blocking drugs. Little Brown, Boston, pp 171–200 (Int AnesthGoogle Scholar
  56. Clinics, vol 16/2)Google Scholar
  57. 56.
    Smith RP (1973) Cyanate and thiocyanate: Acute toxicity. Proc Soc Exp Biol Med 142: 1041–1044PubMedGoogle Scholar
  58. 57.
    Smith RP, Kruszyna H (1974) Nitroprusside produces cyanide poisoning via a reaction with hemoglobin. J Pharmacol Exp Ther 191: 557–563PubMedGoogle Scholar
  59. 58.
    Stokes GS, Frost GW, Graham RM, et al (1979) Indora-min and prazocin as adjuncts to beta adrenoceptor blockade in hypertension. Clin Pharmacol Ther 25: 783789Google Scholar
  60. 59.
    Thien TA, Huysmans FT, Gerlag PG, et al (1979) Diazoxide infusion in severe hypertension and hypertensive crisis. Clin Pharmacol Ther 25: 795–799PubMedGoogle Scholar
  61. 60.
    Tinker JH, Michenfelder JD (1976) Sodium nitroprusside: Pharmacology, toxicology, and therapeutics. Anesthesiology 45: 340–354Google Scholar
  62. 61.
    Tinker JH, Michenfelder JD (1978) Cardiac cyanide toxicity induced by nitroprusside in the dog: Potential for reversal. Anesthesiology 49: 109–116Google Scholar
  63. 62.
    Tinker JH, Michenfelder JD (1980) Increased resistance to nitroprusside-induced cyanide toxicity in anurie dogs. Anesthesiology 52: 40–47PubMedCrossRefGoogle Scholar
  64. 63.
    Vesey CJ, Cole PV, Linnell JC, et al (1974) Some metabolic effects of sodium nitroprusside in man. Br Med J ií: 140–142Google Scholar
  65. 64.
    Vesey CJ, Cole PV, Simpson PJ (1976) Cyanide and thiocyanate concentrations following sodium nitroprusside infusion in man. Br J Anaesth 48: 651–654PubMedCrossRefGoogle Scholar
  66. 65.
    Vesey CJ, Cole PV, Simpson PJ (1977) Nitroprusside and cyanide (correspondence). Br J Anaesth 49: 395CrossRefGoogle Scholar
  67. 66.
    Whitsett TL, Chrysant SG, Dillard BL, et al (1978) Abrupt cessation of clonidine administration. Am J Cardiol 41: 1285–1290PubMedCrossRefGoogle Scholar
  68. 67.
    Wilson L (1965) Leber’s optic atrophy: A possible defect of cyanide metabolism. Clin Sci 29: 505–515PubMedGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 1983

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  • John H. Tinker

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