Caroline Bredthauer, BA
Medical Student
New York Medical College
New York, New York, United States
Ashley Rosenberg, BA
Medical Student
New York Medical Student
Valhalla, New York, United States
Tasfia Bushra, BS
Medical Student
New York Medical College
Valhalla, New York, United States
Jun Beom Ku, MD
Resident
New York Medical College (Metropolitan)
New York, New York, United States
Eric L. Altschuler, MD, PhD
Associate Chief, Director of Clinical Research
Metropolitan Hospital
New York, New York, United States
CVA
Case Description:
A 68-yo female with PMHx HTN, HFpEF, DM2, ESRD on HD presented to the ED with multifocal pneumonia. Hospital course was complicated by acute right PCA ischemic stroke, s/p Tenecteplase, with hemorrhagic conversion. On admission to acute inpatient rehabilitation (AIR), BP lability was noted with daily episodes of both hyper- and hypotension (e.g., minimum BP 86/50, maximum BP 222/67 on AIR Day 2 (AIRD2)). Her initial hypertensive regimen included labetalol 400 mg twice daily and nifedipine 90 mg daily. She lost 19% of the time allotted to her for PT, and 20% of the time allotted to her for OT, secondary to either hypo- or hypertension during her hospitalization. After stabilization of BP with the additions of furosemide 200 mg TIW (AIRD9) and hydralazine 50 mg TID (AIRD10) on Nephrology’s recommendations, the patient was able to complete 100% of PT and OT sessions during the last three days of AIR.
Discussions:
Persistently labile BPs were a barrier to the patient’s therapy earlier in her hospitalization. Optimization of her BP regimen prevented her from missing additional therapy. The patient was ultimately able to meet goals of therapy, including graduating from supervised to independent bed mobility and ambulating 150 feet with a straight cane while supervised. Extremely high (and extremely low) BP is a relative contraindication to therapy. Adding furosemide and hydralazine, two medications with anti-hypertensive properties, was an effective strategy to prevent extreme hypertension from interfering with the patient’s therapy.
Conclusions:
Labile BPs can prevent patients from completing daily therapy in an AIR setting. Stabilization of BP extremes, such that extreme hypertension is prevented without exacerbating hypotension, is critical to maximize patient therapy time. Future studies of recognition and treatment of very high and extremely labile BP, especially in dialysis patients, early in an AIR stay may be warranted.
