BLISTRA

USING NICARDIPINE ON USING NICARDIPINE ON HYPERTENSIVE HYPERTENSIVE

EMERGENCYEMERGENCY

Optimal : <120 and < 80Normal : 120-129 and/or 80 - 84High Normal : 130-139 and/or 85-89 Pre-hypertension

Isolated Sys.Hpt (ISH) : > 140 and <90

Normal

Grade 1 : 140-159 and/or 90-99Grade 2 : 160-179 and/or 100-109Grade 3 : > 180 and/or > 110

Stage 1

Stage 2

ESC-ESH 2007 JNC-VII

Definition and Classification of Blood Definition and Classification of Blood Pressure LevelPressure Level

Crisis: What is it?Crisis: What is it? SBP >180 or DBP >120SBP >180 or DBP >120

Urgency = no signs of end-organ damageUrgency = no signs of end-organ damage Days to WeeksDays to Weeks

Emergency = signs of end-organ damageEmergency = signs of end-organ damage Minutes to HoursMinutes to Hours

Need to know pt’s baseline before crisisNeed to know pt’s baseline before crisis

Incidence: only <1% Incidence: only <1% But >50 million have HTN!But >50 million have HTN!

Hypertensive Crisis

Hypertensive EmergencyHypertensive Urgency

Markedly elevated BP Without severe symptoms or

progressive target organ damageBP should be reduced within hours

Oral agents

Markedly elevated BP With acute or progressing

target organ damageBP should be reduced immediate

Parenteral agents

Kaplan NM ,Hypertensive Crises in : Clinical hypertension 9 th Ed, Lippincott Williams & Wilkins 2006:609-630

Prevalence of Hypertensive Emergencies Prevalence of Hypertensive Emergencies ManifestationManifestation

Cerebral InfarctionCerebral Infarction 24,524,5Acute Pulmonary EdemaAcute Pulmonary Edema 22,522,5Hypertensive EncephalopathyHypertensive Encephalopathy 16,316,3Acute Congestive Heart FailureAcute Congestive Heart Failure 14,314,3Acute Myocardial Infarction or Unstable AnginaAcute Myocardial Infarction or Unstable Angina 12,012,0Intracerebral or Subarachnoid BleedIntracerebral or Subarachnoid Bleed 4,5 4,5Aortic DissectionAortic Dissection 2,02,0EclampsiaEclampsia 2,02,0

End Organ Damage Type Case (%)

Clanigan JS & Vitberg D. Med Clin N Am 2006Clanigan JS & Vitberg D. Med Clin N Am 2006

Therapeutic Guideline (inaSH 2008)

• Penanggulangan harus dilakukan di RS (ICU) dengan fasilitas pemantauan

yang memadai

• Pengobatan parenteral diberikan secara bolus atau infus sesegera mungkin

• Tek.Darah harus diturunkan dalam hitungan menit sampai jam dengan

langkah sbb :

- 5 menit s/d 120 menit pertama Tek.Darah rata-rata diturunkan 20-

25%

- 2 s/d 6 jam kemudian, tek.darah diturunkan sampai 160/100 mmHg

- 6 s/d 24 jam berikutnya, diturunkan sampai < 140/90 mmHg bila tidak

ada gejala iskemi organ

TreatmentTreatment

Medication optionsMedication options

1.1. Oral antihypertensivesOral antihypertensives Chronic hypertensiveChronic hypertensive Hypertensive urgencyHypertensive urgency

2.2. IV antihypertensivesIV antihypertensives Hypertensive emergencyHypertensive emergency

Pharmacology – IV antihypertensionPharmacology – IV antihypertension

1.1. VasodilatorsVasodilators Sodium nitroprussideSodium nitroprusside NitroglycerinNitroglycerin NicardipineNicardipine FenoldapamFenoldapam HydralazineHydralazine EnalaprilEnalapril

2.2. Adrenergic inhibitorsAdrenergic inhibitors LabetalolLabetalol EsmololEsmolol PhentolaminePhentolamine

Parenteral Drugs for Treatment of Parenteral Drugs for Treatment of Hypertensive Emergencies based on JNC 7Hypertensive Emergencies based on JNC 7

DrugsDrugs DoseDose OnsetOnset Duration Duration of Actionof Action

Sodium Sodium nitroprussidenitroprusside

0.25-10 ugr/kg/min0.25-10 ugr/kg/min ImmediateImmediate 1-2 minutes 1-2 minutes after infusion after infusion stopped stopped

NitroglycerinNitroglycerin 5-500 ug/min5-500 ug/min 1-3 minutes1-3 minutes 5-10 minutes5-10 minutes

Labetalol HClLabetalol HCl 20-80 mg every 10-15 20-80 mg every 10-15 min or 0.5-2 mg/min min or 0.5-2 mg/min

5-10 minutes5-10 minutes 3-6 minutes3-6 minutes

Fenoldopan HClFenoldopan HCl 0.1-0.3 ug/kg/min0.1-0.3 ug/kg/min <5 minutes<5 minutes 30-60 minutes30-60 minutes

Nicardipine HClNicardipine HCl 5-15 mg/h, titrasi dosis 5-15 mg/h, titrasi dosis 2,5 mg/h setiap 10 menit2,5 mg/h setiap 10 menit


Esmolol HClEsmolol HCl 250-500 ug/kg/min IV 250-500 ug/kg/min IV bolus, then 50-100 bolus, then 50-100 ug/kg/min by infusion; ug/kg/min by infusion; may repeat bolus after 5 may repeat bolus after 5 minutes or increase minutes or increase infusion to 300 ug/mininfusion to 300 ug/min


Chobanian AV et al, The JNC 7 report, JAMA 2003;389-2560-70

NicardipineNicardipine Dihydropyridine calcium channel blockerDihydropyridine calcium channel blocker

Coronary and cerebral arterial vasodilation Coronary and cerebral arterial vasodilation No negative inotropic or cromotropic effectsNo negative inotropic or cromotropic effects Reduces SVR, little to no effect on HR/COReduces SVR, little to no effect on HR/CO

Onset: 5-15 minOnset: 5-15 min Duration of action: 15 min-6 hoursDuration of action: 15 min-6 hours Adverse effects: Adverse effects:

Tachycardia (+/-Tachycardia (+/-))

Adapted from: Chobanian AV, et al. Hypertension. 2003;42:1206-1252. Rynn KO et al. J Pharm Pract. 2005;18:363-376.

Ca++ plus Calmodulin

Myosin Kinase

Ca++ plus Calmodulin

Actin-Myosin Interaction Contraction

Myosin Kinase

Ca++ Ca++

Blocking effect of CCB

Ca++ Ca++

Calcium Channel Blocker Mechanism

Comparison between Calcium Comparison between Calcium AntagonistAntagonist

DrugDrug Coronary Coronary VasodilationVasodilation

SuppressionSuppressionof Cardiac of Cardiac

ContractilityContractility

SuppressionSuppressionof SA Nodeof SA Node

SuppressionSuppressionof AV Nodeof AV Node

VerapamilVerapamil(phenylalkylamine)(phenylalkylamine) ++++++++ ++++++++ ++++++++++ ++++++++++

DiltiazemDiltiazem(benzothiazepin)(benzothiazepin) ++++++ ++++ ++++++++++ ++++++++

NicardipineNicardipine(dihydropyridine )(dihydropyridine ) ++++++++++ 00 ++ 00

Kerins DM. Goodman Gilman’s.10th ed.2001:843-70

NICARDIPINE TRIALSNICARDIPINE TRIALS

Efficacy Nicardipine on Hypertensive Efficacy Nicardipine on Hypertensive EmergencyEmergency

Drugs 2006 (66) 13

Efficacy Nicardipine on CerebrovascularEfficacy Nicardipine on Cerebrovascular

Efficacy Nicardipine on PregnancyEfficacy Nicardipine on Pregnancy

Efficacy Nicardipine on Emergence From Efficacy Nicardipine on Emergence From TIVATIVA

Indikasi :Indikasi : Hipertensi EmergensiHipertensi Emergensi

Hipertensi akut saat pembedahan Hipertensi akut saat pembedahan

BoxBox : : @ 10 ampul@ 10 ampul

HNAHNA : Rp 1 : Rp 1770,000 (per ampul) /0,000 (per ampul) /

Rp 1,Rp 1,7700,000 (per box)00,000 (per box)

Preparasi BlistraPreparasi BlistraBlistra injeksi dilarutkan mencapai konsentrasi 0.01% - Blistra injeksi dilarutkan mencapai konsentrasi 0.01% -

0.02% (0.1 mg/ml – 0.2 mg/ml)0.02% (0.1 mg/ml – 0.2 mg/ml)

Pengenceran Blistra dapat menggunakan tabel berikut Pengenceran Blistra dapat menggunakan tabel berikut (menggunakan infus drip) :(menggunakan infus drip) :

Contoh Blistra dalam konsentrasi 0.02%Contoh Blistra dalam konsentrasi 0.02%

Dosis BLISTRAUntuk Hipertensi Emergensi : 0.5-6 µg/kgBB/menitUntuk Hipertensi Akut Saat Operasi : 2-10 µg/kgBB/menit

Sodium Chloride / NaCl

Dextrose 5%

Glucose 5%

Potacol – R

Ringer Asetat

KN 1A / 1B / 4A

Except :

Sodium Bicarbonat & RL100 20 (2 ampul)

250 50 (5 ampul)500 100 (10 ampul)

Sediaan Pelarut yg Digunakan (mL)

Jumlah Blistra yg ditambahkan (mL)

Flowrate (tetes/menit) {0.02%}

Dose x BB x Sediaan PelarutBlistra yg digunakan x 1000

Contoh : Pasien dengan BB 85 kg diterapi Blistradosis 2 mcg/kg/menit dengan infus makrodrip 100 mL. Berapa tetes per menit laju infus ?

0.5 1 2 3 4 5 6 7 8 9 1040 2 4 8 12 16 20 24 28 32 36 4050 2.5 5 10 15 20 25 30 35 40 45 5060 3 6 12 18 24 30 36 42 48 54 6070 3.5 7 14 21 28 35 42 49 56 63 7080 4 8 16 24 32 40 48 56 64 72 8090 4.5 9 18 27 36 45 54 63 72 81 90100 5 10 20 30 40 50 60 70 80 90 100

Flow rate dalam

(tetes/menit

Dosis (mcg/kgBB/menit)BB (kg)

x 60 : 3

2 x 85 x 10020 x 1000

x 60:3 = 17 tts/menit

Preparasi BlistraPreparasi BlistraBlistra injeksi dilarutkan mencapai konsentrasi 0.01% - Blistra injeksi dilarutkan mencapai konsentrasi 0.01% -

0.02% (0.1 mg/ml – 0.2 mg/ml)0.02% (0.1 mg/ml – 0.2 mg/ml)

Pengenceran Blistra dapat menggunakan tabel berikut Pengenceran Blistra dapat menggunakan tabel berikut (menggunakan syringe pump) :(menggunakan syringe pump) :

Dosis BLISTRAUntuk Hipertensi Emergensi : 0.5 µg/kgBB/menit sampai target

tekanan darah tercapaiUntuk Hipertensi Akut Saat Operasi : 2-10 µg/kgBB/menit

Sodium Chloride / NaCl

Dextrose 5%

Glucose 5%

Potacol – R

Ringer Asetat

KN 1A / 1B / 4A

Except :

Sodium Bicarbonat & RL50 10 (1 ampul)

Sediaan Pelarut yg Digunakan (mL)

Jumlah Blistra yg ditambahkan (mL)

Flowrate (mL/Jam) {0.02%}

0.5 1 2 3 4 5 6 7 8 9 1040 6 12 24 36 48 60 72 84 96 108 12050 7.5 15 30 45 60 75 90 105 120 135 15060 9 18 36 54 72 90 108 126 144 162 18070 10.5 21 42 63 84 105 126 147 168 189 21080 12 24 48 72 96 120 144 168 192 216 24090 13.5 27 54 81 108 135 162 189 216 243 270100 15 30 60 90 120 150 180 210 240 270 300

Flow rate dalam

(ml/jam)

Dosis (mcg/kgBB/menit)BB (kg)

Dose x BB x Sediaan PelarutBlistra yg digunakan x 1000

Contoh : Pasien dengan BB 85 kg diterapi Blistradosis 2 mcg/kg/menit dengan syringe pump 50 mL. Berapa tetes per menit laju infus ?

pump

x 60

2 x 85 x 5010 x 1000

x 60 = 51 mL/jam

Terima KasihTerima Kasih

PT Pharos Menyediakan Preparat PT Pharos Menyediakan Preparat Lengkap untuk Manajemen Hipertensi Lengkap untuk Manajemen Hipertensi

BLISTRA

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