- Author: Wellman W Cheung, MD, FACS; Chief Editor: Edward David Kim, MD, FACS more...
The goals of pharmacotherapy are to reduce anxiety, morbidity, and prevent complications.
Whether a sedative should be given is determined based on a careful risk-benefit analysis. By binding to specific receptor sites, these agents appear to potentiate the effects of gamma-aminobutyrate (GABA) and to facilitate inhibitory GABA neurotransmission, as well as other inhibitory transmitters.
Midazolam has been studied as an anxiolytic and amnestic agent that does not affect voiding dynamics. It is a shorter-acting benzodiazepine sedative-hypnotic that is useful in patients requiring acute or short-term sedation. It is also useful for its amnestic effects. A systematic review found that midazolam (0.5-0.6 mg/kg orally 30-45 min before the procedure or 0.2 mg/kg intranasally before the procedure) was safe and effective in reducing distress.
Autonomic dysreflexia is a potentially life-threatening complication. Once it is identified, immediately drain the bladder and remove the catheter and stop the study. Having an open urethral catheterization setup for immediate access would be helpful. If blood pressure remains elevated, an antihypertensive agent with quick onset and short duration of action (eg, nifedipine or a nitrate) may be given, and blood pressure is monitored.
Antihypertensives are used to reduce arterial pressure. For acute reduction of arterial pressure, the potent vasodilator sodium nitroprusside is effective. An intravenous beta-blocker may be administered in incremental doses until a heart rate of 60-80 beats/min is attained.
When beta-blockers are contraindicated, such as in second- or third-degree atrioventricular block, consider using calcium channel blockers. Sublingual nifedipine successfully treats refractory hypertension.
Esmolol is an ultra–short-acting beta2-blocker. It is particularly useful in patients with labile arterial pressure, especially if surgery is planned, because it can be discontinued abruptly if necessary. This agent is normally used in conjunction with nitroprusside. It may be useful as a means to test beta-blocker safety and tolerance in patients with a history of obstructive pulmonary disease who are at possible risk of bronchospasm from beta-blockade. The elimination half-life of esmolol is 9 minutes.
Labetalol blocks alpha-, beta1-, and beta2-adrenergic receptor sites, decreasing blood pressure.
Propranolol is a class II antiarrhythmic nonselective beta-adrenergic receptor blocker. It has membrane-stabilizing activity and decreases the automaticity of contractions. Propranolol is not suitable for emergency treatment of hypertension. Do not administer propranolol intravenously in hypertensive emergencies.
Metoprolol is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. During IV administration, carefully monitor the blood pressure, heart rate, and electrocardiogram (ECG). When considering conversion from intravenous to oral dosage forms, use the ratio of 1 mg IV to 2.5 mg PO metoprolol.
Nitroprusside causes peripheral vasodilation by direct action on venous and arteriolar smooth muscle, thus reducing peripheral resistance. It is commonly given intravenously because of its rapid onset and short duration of action. It is easily titratable to reach the desired effect.
Nitroprusside is light sensitive; both bottle and tubing should be wrapped in aluminum foil. Before initiating nitroprusside, administer a beta-blocker to counteract the physiologic response of reflex tachycardia that occurs when nitroprusside is used alone. This physiologic response increases shear forces against the aortic wall, thus increasing arterial pressure. The objective is to keep the heart rate at 60-80 bpm.
Nifedipine is one of the more common channel blockers used for hypertension.
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