Intravenous Medications for Children With Severe Hypertension and Symptoms or Signs of Target Organ Damage

First-line medications

Labetalol (combined alpha- and beta-adrenergic blocker)Labetalol (combined alpha- and beta-adrenergic blocker)

Infusion: 0.25–3 mg/kg/hour IV; Initiate at low end dose and gradually titrate as needed to control blood pressure

Bolus: 0.2–1 mg/kg IV every 10 to 20 minutes, increasing up to 40 mg/dose if needed

May cause bradycardia, wheezing

Relative contraindications for or caution should be used in patients with asthma or heart failure.

Nicardipine (calcium channel blocker)Nicardipine (calcium channel blocker)

Infusion: Initially 0.5–1 mcg/kg/minute IV (may give initial one-time bolus of 30 mcg/kg not to exceed 2 mg prior to infusion) titrate upward every 15 to 30 minutes to maximum 4 mcg/kg/minute

May cause reflex tachycardia

May raise cyclosporine/tacrolimus levelsMay raise cyclosporine/tacrolimus levels

Nicardipine is better for infants, children with lung disease, or children with significant asthma.Nicardipine is better for infants, children with lung disease, or children with significant asthma.

Second-line medications

Hydralazine (direct vasodilator)Hydralazine (direct vasodilator)

Bolus: 0.1–0.2 mg/kg up to 0.4 mg/kg per dose IV every 4 to 6 hours, maximum dose 20 mg (may be given IM but has an even slower onset of action)

Tachycardia, headache

Hydralazine is given only as a bolus because its longer onset of action time (4 hours) is not as helpful in emergency situations.Hydralazine is given only as a bolus because its longer onset of action time (4 hours) is not as helpful in emergency situations.

Response to this medication varies in effect and rate.

Sodium nitroprusside (direct vasodilator)Sodium nitroprusside (direct vasodilator)

Infusion: Starting 0.3 to 0.5 mcg/kg/minute IV increase every 3 to 5 minutes as needed to a maximum dose of 10 mcg/kg/minute (typical dose 3 to 4 mcg/kg/minute)

Cyanide toxicity with prolonged use (> 72 hours) or in renal failure

May increase intracranial pressure

This medication requires careful monitoring and titration.

Second- or third-line medications

Esmolol (beta-adrenergic blocker)Esmolol (beta-adrenergic blocker)

Infusion: 100–500 mcg/kg/minute IV

May cause profound bradycardia

Esmolol is very short-acting, so constant infusion is needed. Esmolol is very short-acting, so constant infusion is needed.

This medication is contraindicated if a pheochromocytoma is possible.

Enalaprilat (angiotensin-converting enzyme inhibitor)

Infants and children (bolus dosing): 5–10 mcg/kg/dose every 8–24 hours

Adolescents and adults (bolus dosing) 0.625–1.25 mg dose every 6 hours

Used in caution with suspected case of renovascular hypertension and acute or chronic kidney disease; contraindicated in pregnancy

Onset of action is in 15 minutes.