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Esmolol for the management of pediatric hypertension after cardiac operations
D B Wiest1, S S Garner, W E Uber
1Department of Pharmaceutical Sciences, Medical University of South Carolina, Charleston 29425, USA.
Insights
Esmolol effectively controlled postoperative hypertension in pediatric cardiac surgery patients. Higher doses were needed for aortic coarctation repair compared to other congenital heart defect repairs.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Postoperative hypertension is common in children following aortic coarctation repair and other congenital heart defect surgeries.
- Elevated catecholamines often contribute to hypertension post-coarctation repair, suggesting beta-blockers as a potential treatment.
- Nitroprusside has been a traditional treatment, but esmolol offers a potential alternative.
Purpose of the Study:
- To investigate the efficacy and disposition of esmolol for acute hypertension in pediatric patients after cardiac operations.
- To compare esmolol's effectiveness in patients with aortic coarctation repair versus other congenital heart defect repairs.
Main Methods:
- An open-label trial involving 20 pediatric patients (1 month to 12 years) with postoperative hypertension.
- Esmolol was administered and titrated to maintain blood pressure at or below the 90th percentile for age.
Main Results:
- Esmolol significantly reduced heart rate and blood pressure in pediatric patients post-cardiac surgery.
- A higher esmolol dosage and clearance were observed in patients after aortic coarctation repair.
- Esmolol dose correlated with the percentage reduction in systolic blood pressure and steady-state concentrations.
Conclusions:
- Esmolol effectively controlled hypertension in 19 out of 20 pediatric patients without adverse effects.
- Patients undergoing aortic coarctation repair required higher esmolol doses than those with other congenital heart defect repairs.
Objective:
Hypertension frequently occurs during the immediate postoperative period in children after repair of aortic coarctation but may also occur after repair of other congenital heart defects. Nitroprusside has often been used to control blood pressure in this setting. Because hypertension after coarctation repair is frequently associated with elevations in catecholamines, esmolol, a short-acting beta-blocking agent, may be an effective alternative. Therefore we undertook the first systematic investigation to determine the efficacy and disposition of esmolol in pediatric patients with acute hypertension after cardiac operations.
Methods:
Twenty patients aged 1 month to 12 years (median 25.6 months) with acute hypertension after cardiac operations received esmolol in an opened-labeled trial. Esmolol was titrated to a blood pressure less than or equal to the 90th percentile for age.
Results:
Ten patients had coarctation repair and the remaining patients underwent repair of other congenital heart defects. On final esmolol dose (mean +/- standard deviation dosage 700 +/- 232 microg/kg/min) there was a significant percent decrease in heart rate and systolic and diastolic blood pressures from postoperative values. Esmolol dose was significantly associated with percent reduction in systolic blood pressure. Final esmolol dose and total body clearance were significantly higher in patients after coarctation repair. There were significant associations between esmolol dose and esmolol blood concentrations at steady state.
Conclusions:
The dosage required to control hypertension in patients after repair of aortic coarctation was higher than patients who underwent repair of other congenital heart defects. Esmolol was effective in controlling blood pressure in 19 of 20 patients without adverse effects.