Table 3.
Management of hypertensive crises induced by catecholamine secreting tumors in children (8, 10, 11, 14).
| Drug | Mechanism | Dosage | Side effects | Contraindications |
|---|---|---|---|---|
| FIRST LINE TREATMENT | ||||
| Urapidil | Selective α1-adrenergic receptor antagonist - central serotoninergic 1A receptor agonist | Initial 0.5–4.0 mg/kg per hour Maintenance 0.2–2.0 mg/kg per hour | Hypotension, tachycardia, dizziness, central sedation, nausea and nasal congestion | Athero-venous shunt, stenosis of the aortic isthmus |
| Phentolamine | Competitive non selective α1/α2 adrenergic receptor antagonist | Bolus 0.1-5 mg/Kg | Hypotension, tachycardia, dizziness, central sedation, arrythmias and nasal congestion | // |
| Labetalol (in case of concomitant tachyarrhythmias, after adequate α-adrenergic blockade) | Combinate α1/β-adrenergic blocker (ratio 1:7) | 0.25–3 mg/kg/hour Titrate slowly Max: 3 mg/kg/hour | Orthostatic hypotension, dizziness | Asma, sinuses bradycardia, atrio-ventricular block, heart failure |
| Esmolol (in case of concomitant tachyarrhythmias, after adequate α-adrenergic blockade) | Selective β1-adrenergic blocker | Bolus of 500–600 μg/kg over 2 min. Maintenance 200 (50–250) μg/kg/min. Max 500 µg/Kg/min | Hypotension, bradycardia, risk of atrio-ventricular block | Asma, sinuses bradycardia, sick sinus syndrome, atrio-ventricular block, hypotension, heart failure, cardiogenic shock, pulmonary hypertension |
| SECOND LINE TREATMENT | ||||
| Sodium nitroprusside | Vasodilator (nitro-derivates) | Starting: 0.3–0.5 µg/kg/min. Titrate by 0.1 µg/kg/min every few minutes. Max: 10 µg/kg/min | Tachycardia, flushing, palpitations, and hypotension. Monitor for risk of cyanide and thiocyanate toxicity (so protect from light) |
Renal and/or hepatic failure, hypothyroidism, deficit of vitamin B12 |
| Nicardipine | Dihydropyridine calcium channel blocker | Starting: 0.5–1 µg/kg/min. Max: 4–5 µg/kg/min | Tachycardia, flushing, palpitations, and hypotension, edema, headache | Pathological hyperlipemia, nephrosis or acute pancreatic inflammation secondary to hyperlipemia |
| OTHER TREATMENTS | ||||
| Magnesium sulphate | Vasodilator, inhibits catecholamine release from adrenal medulla and sympathetic paraganglia | Loading dose: 40–60 mg/kg over 10 minutes. Maintenance: 15–30 mg/kg/hour | Neuromuscular paralysis | Use with caution in those with neuromuscular disease (risk of paralysis) |
| Dexmedetomidine | Central α2-agonist | Loading dose: 0.5–1 µg/kg/dose over 10 minutes. Maintenance: 0.2–0.5 µg/kg/hour | Respiratory depression, bradycardia, xerostomia | In those with reduced respiratory drive |