SUN-174 EFFICACY AND SAFETY OF INTRAVENOUS LABETALOL FOR HYPERTENSIVE CRISIS IN CHILDREN

Abstract

Hypertensive crisis is uncommon in children. American Association of Pediatrics acknowledges the lack of robust evidence-based management guidelines for the same. Most data on the choice of drugs is extrapolated from adults and small case series in children. The objectives of this study were to determine the efficacy and safety of IV labetalol as a first-line agent or an add on drug compared to IV nitroprusside/nitroglycerine in the management of hypertensive crisis in children. A retrospective chart review of 56 consecutive children (age 1 month to ≤ 12 years) with hypertensive crisis admitted to pediatric intensive care unit (PICU) during a 10-year period (July 2009- 2019) was done. Data with respect to baseline demographics, clinical presentation, etiological workup, treatment details, and blood pressure (BP) trends were recorded. The choice of antihypertensive agents was left to the clinician's discretion. The proportion of patients, attaining target BP (95th percentile) in >12 to ≤ 48 hours after admission was taken as primary endpoint. The secondary endpoints were PICU needs, morbidity, and mortality. The median age of the children was 7 years (range 1-12). Hypertensive crisis comprised < 1 % of PICU admissions. Most crisis presented as hypertensive emergency (89%) and had renal etiology as the leading cause (61%). The proportion of children attaining the primary endpoint was significantly more in the group receiving labetalol (n=23) as compared to those not receiving labetalol (n=33) (62% vs. 29%, p < 0.0001). The proportion of children having precipitous fall in BP before 12 hours, leading to hypotension was similar in both treatment groups (13% vs 15%). The PICU needs for ventilation (0% vs 27%, p < 0.0001), renal replacement therapy (0% vs 9%, p = 0.003) and raised intracranial pressure (ICP) (0% vs 9%, p = 0.003) were significantly less in the labetalol group. The central nervous system (CNS) morbidity was also significantly reduced in the labetalol group (41% vs. 9%, p < 0.0001). One child compared to three died in the labetalol and non-labetalol group respectively (4.3% vs. 9%, p = 0.2). The data were also analyzed for practice variations between two periods of five years each (2009-2013 and 2014-2019). There latter cohort showed significantly more use of labetalol (74% for 2014-2019 vs. 26% for 2009-2013, p < 0.0001). Labetalol, when used alone or as an add on drug was more efficacious than IV nitroprusside/nitroglycerine in attaining the primary endpoint. There was a lesser need for ventilation and renal replacement therapy with labetalol. The CNS morbidity at discharge was also lesser. The propensity to hypotension was however similar in both groups. There is only one study looking at the safety and efficacy of labetalol in children with hypertensive crisis up to ≤ 24 months of age. Ours is the only study to the best of our knowledge in children up to 12 years of age. However, our study suffers from the inherent problems of a retrospective analysis. In conclusion, our study shows that labetalol is safe and efficacious in hypertensive crisis in children up to ≤ 12 years of age.