Paradoxical hypertension

Abstract

A host of physiologic factors contribute to the maintenance of blood pressure. Of these, intravascular volume is perhaps the most important. Thus, when confronted with low or elevated blood pressure, clinicians rightly consider reduced or elevated intravascular volume, respectively. Volume expansion is usually a correct response to hypotension; similarly, volume expansion in the context of hypertension is counter intuitive. As with any clinical heuristic, however, there are exceptions to this association. Scattered reports of paradoxical hypertension in patients with hypovolemia have appeared over the years. Although the physiology underpinning these cases is not clear, central or hormonal mechanisms have been suggested. Although this scenario is obviously rare, it is important to recognize. Despite their apparent hypertension, such patients actually require volume expansion, and pharmacologic lowering of blood pressure could be hazardous. In the current volume of The Journal, DePiero et al report a large series of children with severe diabetic ketoacidosis (DKA), who at some point during their therapy exhibited significant hypertension. Although the mechanism is also not certain, there is good evidence that central factors play a role in these children; specifically, the children had more severe acidosis and evidence of CNS involvement. The management of severe DKA is a clinical challenge, in which a dizzying array of interconnected physiologic perturbations can be present. Before intervening to address hypertension in a child with DKA, it is incumbent on clinicians to be aware of this phenomenon and not worsen the situation with an ill-advised therapy. Article page 156 ▸ Hypertension during Diabetic Ketoacidosis in ChildrenThe Journal of PediatricsVol. 223PreviewTo characterize hemodynamic alterations occurring during diabetic ketoacidosis (DKA) in a large cohort of children and to identify clinical and biochemical factors associated with hypertension. Full-Text PDF