Hypotension, treatment

Intravenous NTG should be initiated in all patients with an ACS who do not have a contraindication and who have persistent ischemic symptoms, heart failure, or uncontrolled high BP. The usual dose is 5 to 10 mcg/min by continuous infusion, titrated up to 200 mcg/min until relief of symptoms or limiting side effects (e.g., headache or hypotension). Treatment should be continued for approximately 24 hours after ischemia is relieved. 

The resuspended and formulated Fraction II precipitate normally contains some aggregated IgG and trace substances that can cause hypotensive reactions in patients, such as the enzyme prekail ikrein activator (186). These features restrict this type of product to intramuscular adininistration. Further processing is required if products suitable for intravenous adininistration are required. Processes used for this purpose include treatment at pH 4 with the enzyme pepsin [9001-75-6] being added if necessary (131,184), or further purification by ion-exchange chromatography (44). These and other methods have been fiiUy reviewed (45,185,187,188). Intravenous immunoglobulin products are usually suppHed in the freeze-dried state but a product stable in the solution state is also available (189). 

Normally, dietary tyramine is broken down in the gastrointestinal tract by MAO and is not absorbed. In the presence of MAOI, however, all of its potent sympathomimetic actions are seen. Other side effects of MAOI include excessive CNS stimulation, orthostatic hypotension, weight gain, and in rare cases hepatotoxicity. Because the monoamine oxidase inhibitors exhibit greater toxicity, yet no greater therapeutic response than other, newer agents, clinical use has been markedly curtailed. The primary use for MAOIs is in the treatment of atypical depressions, eg, those associated with increased appetite, phobic anxiety, hypersomnolence, and fatigues, but not melancholia (2). 

Nifedipine, verapamil, and diltiazem are all efficacious in the treatment of mild and moderate hypertension, but nifedipine is more efficacious than diltiazem and verapamil in the control of severe hypertension. Nifedipine does not cause significant reflex tachycardia or orthostatic hypotension. Nifedipine benefits the older and black patients and patients with low PRA. 

Glonidine. Clonidine decreases blood pressure, heart rate, cardiac output, stroke volume, and total peripheral resistance. It activates central a2 adrenoceptors ia the brainstem vasomotor center and produces a prolonged hypotensive response. Clonidine, most efficaciously used concomitantly with a diuretic in long-term treatment, decreases renin and aldosterone secretion. 

Figures 2 and 3 illustrate the constant release of pilocarpiae over the seven day treatment period. An initial burst of dmg iato the eye is seen ia the first few hours. This is temporary and the system drops to the rated value ia approximately six hours. The total amount of dmg released ia this transitory period is less than that normally given ia pilocarpiae ophthalmic solutions. The ocular hypotensive effect of these devices is hiUy developed within 2 hours of placement ia the conjunctival sac, and the hypotensive response is maintained throughout the therapy. This system replaces the need for eyedrops apphed four times per day to control iatraocular pressure.

An imidazole derivative which is also a hypotensive agent by virtue of adrenergic a-2-receptor blockade is imiloxan (75). Its synthe.sis begins by conversion of 2-cyanomethyl-1,4-benzodioxane (72) to its iminosMhylether with anhydrous HC in clhanol (73). Reaction of the latter with aminoacetaldehyde diethylacetal and subsequent acid treatment produces the imidazole ring (74). Alkylation of 74 with ethyl iodide mediated by sodium hydride completes the synthesis [251. 

In general, systemic treatment with ASON is well-tolerated and side effects are dose-dependent. Among those, thrombocytopenia, hypotension, fever, increasing liver enzymes, and complement activation were most frequently seen. 

Hypotension is defined as abnormally low blood pressure. In most cases, hypotension is adequately treated with general measures (e.g. physical exercise), dtug treatment is rarely required. Drugs used for the treatment of hypotension include a-adrenoceptor agonists and compounds which activate both a and (3 adrenoceptors. 

VMATs are irreversibly inhibited by the potent antihypertensive drug reserpine. The depressive effects of reserpine helped to formulate the original monoamine hypothesis of affective disorders. Reseipine also appears to interact with the transporters near the site of substrate recognition. Tetrabenazine, which is used in treatment of movement disorders, inhibits VMAT2 much more potently than VMAT1, consistent with the less hypotensive action of this agent. 

MAINTAINING ADEQUATE TISSUE PERFUSION. When a patient is in shock and experiencing ineffective tissue perfusion tiiere is a decrease in oxygen resulting in an inability of die body to nourish its cells at die capillary level. If die patient has marked hypotension die administration of a vasopressor (a drug diat raises die blood pressure because of its ability to constrict blood vessels) is required. The primary health care provider determines die cause of die hypotension and then selects the best mediod of treatment. Some hypotensive episodes require die use of a less potent vasopressor, such as metaraminol, whereas at other times a more potent vasopressor, such as dobutamine (Dobutrex), dopamine (Intropin), or norepinephrine (Levoplied) is necessary. 

The following isa suggested dosing schedule for the administration of midodrine shortly before arising in the morning, midday, and late afternoon (not after 6 00 fm). The nurse should continue drug therapy only in the patient whose orthostatic hypotension improves during the initial treatment. 

Mr. Cole is receiving dopamine for the treatment of severe hypotension. In planning the care for Mr. Cole, determine what would be the most important aspects of nursing management. Explain your answers. 

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