Psychosocial Experiences That Support Positive Self-Concept in Children with Cleft Lip and Palate Adopted From China.

OBJECTIVE: Existing psychosocial research offers little information on the unique challenges and strengths of children adopted from China with cleft lip and/or palate (CL/P). The present study aimed to understand biopsychosocial factors that support positive self-concept in this population. DESIGN: Qualitative, semistructured interviews were conducted with children and their parents. Interpretive phenomenological analysis of transcribed interviews was utilized for data analysis. SETTING: Participants were recruited in an outpatient, pediatric multidisciplinary cleft clinic during a standard team visit. PATIENTS, PARTICIPANTS: Participants were ages 8 to 12 years with a diagnosis of isolated cleft lip-palate who were internationally adopted from China before the age of 2 years and English-speaking. Participants also included English-speaking parents. RESULTS: Themes reflecting data from the child and parent subsamples include: (1) child's characteristics, (2) family strengths, (3) adoption identity, (4) cultural identity, (5) coping with a cleft, and (6) social factors. Additional 2 to 3 subthemes were identified for the parent and child subsamples within each broader theme. CONCLUSIONS: Findings from this sample suggested factors supporting positive self-concept included pride and self-efficacy in activities, family support, instilment of family values, strategies for coping with a cleft, family belonging, cultural exposure, and normalization of differences. Medical providers can support patients and families by providing education on surgeries, CL/P sequelae and outcomes, and pediatric medical stress. Mental health providers can screen for social and emotional challenges and provide psychoeducation on racial/ethnic socialization, identity development, and coping.

A rational approach to fluid therapy in sepsis.

Aggressive fluid resuscitation to achieve a central venous pressure (CVP) greater than 8 mm Hg has been promoted as the standard of care, in the management of patients with severe sepsis and septic shock. However recent clinical trials have demonstrated that this approach does not improve the outcome of patients with severe sepsis and septic shock. Pathophysiologically, sepsis is characterized by vasoplegia with loss of arterial tone, venodilation with sequestration of blood in the unstressed blood compartment and changes in ventricular function with reduced compliance and reduced preload responsiveness. These data suggest that sepsis is primarily not a volume-depleted state and recent evidence demonstrates that most septic patients are poorly responsive to fluids. Furthermore, almost all of the administered fluid is sequestered in the tissues, resulting in severe oedema in vital organs and, thereby, increasing the risk of organ dysfunction. These data suggest that a physiologic, haemodynamically guided conservative approach to fluid therapy in patients with sepsis would be prudent and would likely reduce the morbidity and improve the outcome of this disease.

The demise of early goal-directed therapy for severe sepsis and septic shock.

A protocol for the quantitative resuscitation of severe sepsis and septic shock known as early goal-directed therapy (EGDT) was published in 2001. Despite serious limitations, this study became widely adopted around the world and formed the basis of the Surviving Sepsis Campaign 6 h resuscitation bundle. Subsequently, a large number of observational before-and-after studies were published which demonstrated that EGDT reduced mortality. However, during this time period, there has been a substantial reduction in the mortality from sepsis in many Western nations that appears unrelated to EGDT. Recently, the Protocolized Care for Early Septic Shock (ProCESS) and The Australasian Resuscitation in Sepsis Evaluation (ARISE) trials failed to demonstrate any outcome benefit from EGDT. These two large, multicenter, randomized controlled studies raise serious questions regarding the validity of the original EGDT study and the scientific rigor of the uncontrolled, largely retrospective before-after clinical studies. Furthermore, accruing data suggest an association between the amount of fluid administered in the first 72 h and the mortality of patients with severe sepsis. Patients in all arms of the ProCESS and ARISE trials received substantial and nearly equivalent amounts of fluid. It is proposed that a more conservative fluid strategy and the earlier use of norepinephrine in patients with septic shock may be associated with further improvements in the outcome of patients with sepsis.

The effect of copper-oxide-treated soft and hard surfaces on the incidence of healthcare-associated infections: a two-phase study.

BACKGROUND: Copper-oxide-impregnated linens and hard surfaces within the hospital environment have emerged as a novel technology to reduce environmental contamination and thereby potentially reduce the risk of healthcare-associated infections (HCAIs). METHODS: This was a two-phase study. Phase 1 was a prospective, cluster-randomized, cross-over clinical trial in which one pod (eight beds) of our general ICU (GICU) utilized copper-oxide-impregnated linens whereas the other pod (eight beds) used standard hospital linens. Phase 2 was a two-year before-after study, following the relocation of three ICUs into a new ICU tower in which all the hard surfaces were treated with copper oxide (in addition to copper-impregnated linens). HCAIs were recorded using the National Healthcare Safety Network definitions. FINDINGS: A total of 1282 patients were enrolled in phase 1. There was no difference in the rate of HCAI between the patients who received standard compared with copper oxide linen. In phase 2 there was a significant reduction in the number of infections due to Clostridioides difficile (2.4 per 1000 vs 0.7 per 1000 patient-days; incidence rate ratio: 3.3; 95% confidence interval: 1.4-8.7; P = 0.002) but no difference in the rate of central-line-associated bloodstream infections nor of catheter-associated urinary tract infections. CONCLUSION: Copper-oxide-impregnated linens alone had no effect on the rate of HCAI. Our data suggest that copper-oxide-treated hard surfaces reduced the rate of infections due to C. difficile; however, important confounders cannot be excluded.

[Corticosteroid insufficiency in the critically ill. Pathomechanisms and recommendations for diagnosis and treatment]. / Kortikosteroidinsuffizienz bei kritisch Kranken. Pathomechanismen und Empfehlungen zur Diagnose und Behandlung.

Critically ill patients with severe systemic inflammation can develop critical illness-related corticosteroid insufficiency (CIRCI), which is associated with a poor outcome. A task force of the American College of Critical Care Medicine compiled recommendations for diagnosis and treatment of this clinical entity thereby focusing on patients with septic shock and acute respiratory distress syndrome (ARDS). The results of large scale multi-centre trials gave partially conflicting results arguing against the broad use of corticosteroids in stress doses. However, the task force recommended treatment with stress-dose corticosteroids in patients with septic shock who respond poorly to fluid resuscitation and vasopressor therapy and in patients with early ARDS (<14 days after onset). The dose of corticosteroids should be reduced in a step-wise manner. Corticosteroids at stress doses are currently under investigation in other target populations of critically ill patients potentially suffering from CIRCI. Preliminary data suggest that patients with vasodilatory shock after cardiac surgery and patients with liver cirrhosis and sepsis can benefit from corticosteroids. Critical illness-related corticosteroid insufficiency can also occur in patients with trauma, traumatic brain injury, acute pancreatitis and burn injuries, but data from clinical trials on these target groups are insufficient at present. The therapeutic use of corticosteroids in stress doses reduces the incidence of post-traumatic stress disorder (PTSD) after intensive care treatment.

The clinical characteristics and hospital and post-hospital survival of patients with the obesity hypoventilation syndrome: analysis of a large cohort.

OBJECTIVE: The worldwide prevalence of obesity has reached epidemic proportions. Obesity hypoventilation syndrome (OHS) is a common yet largely undiagnosed and mistreated condition that likely carries a high mortality. The aim of this study was to determine the clinical characteristics, hospital outcome, outcome following hospital discharge and predictors of death in a large cohort of patients hospitalized with OHS. OHS is an important condition as many patients with this syndrome are misdiagnosed and receive inappropriate treatment. METHODS: We reviewed the electronic medical records of patients with unequivocal OHS admitted to a 525-bed tertiary-care teaching hospital over a 5-year period. Demographic and clinical data as well as hospital disposition were recorded. In order to determine the patients' post-discharge status, we linked our database to the database of death certificates of the State Registrar of Vital Records. RESULTS: We identified 600 patients who met the inclusion criteria for this study. The patients' mean age was 58 ± 15 years with a mean body mass index of 48.2 ± 8.3 kg m-2; 64% were women. Thirty-seven percent had a history of diabetes and 43% had been misdiagnosed as having chronic obstructive pulmonary disease, while none had been previously diagnosed with OHS. The most common admission diagnoses were respiratory failure, heart failure and sepsis. Ninety (15%) patients died during the index hospitalization. The patients' age, S-creatinine, respiratory failure, sepsis and admission to the ICU were independent predictors of hospital mortality. The hospital survivors were followed for a mean of 1,174 ± 501 d (3.2 ± 1.3 years) from the index hospitalization. On follow-up, 98 of the 510 (19%) hospital survivors died, with an overall cumulative mortality of 31.3%. The patients' age, S-creatinine and admission to the ICU were independent predictors of post-hospital mortality. CONCLUSION: Obesity hypoventilation syndrome is a common disease that is frequently misdiagnosed and mistreated and carries a 3-year morality, which is significantly worse than that for most cancers combined. Considering the high mortality of this disease, all patients with a body mass index > 35 kg m-2 should be screened for OHS; those patients with both early and established OHS should be referred to a pulmonary and/or sleep specialist for evaluation for non-invasive positive pressure ventilation, to a dietician for dietary counseling and lifestyle modification and to a bariatric surgeon for evaluation for bariatric surgery.

A case series of hospitalized patients with elevated digoxin levels.

PURPOSE: Although there is renewed enthusiasm for the use of digoxin in patients with heart failure, current dosing guidelines are based on a nomogram published in 1974. We studied the incidence of and risk factors for elevated digoxin levels in patients admitted to a community hospital, and compared their dosage regimens to published guidelines. SUBJECTS AND METHODS: We reviewed the charts of all patients who had serum digoxin levels greater than 2.4 ng/mL during a 6-month period. We collected demographic and clinical data, indications for digoxin use, digoxin dosage, concurrent medications, laboratory data, and clinical and electrocardiographic features of digoxin toxicity. RESULTS: Of the 1,433 patients with digoxin assays, 115 (8%) patients had elevated levels. Of the 82 patients with complete records and correctly timed digoxin levels, 59 (72%) had electrocardiographic or clinical features of digoxin toxicity. Patients with serum digoxin levels >2.4 ng/mL were slightly older (78 +/- 8 versus 73 +/- 9 years of age; P = 0.12) and had greater serum creatinine levels (3.1 +/- 7.3 versus 1.4 +/- 0.3 mg/dL; P = 0.01) than those with levels < or =2.4 ng/mL. Forty-seven patients had elevated digoxin levels on admission, including 21 patients admitted for digoxin toxicity. Impaired or worsening renal function contributed to high levels in 37 patients, and a drug interaction was a contributory factor in 10 cases. Twenty (43%) of these patients were taking the recommended maintenance dose based on the scheme employed in the Digitalis Investigation Group study. Thirty-five patients developed high digoxin levels while in hospital. In 26 patients, this followed a loading dose of digoxin for the control of rapid atrial fibrillation. Impaired renal function was implicated in all of these patients. Despite the elevated digoxin level, rate control was achieved in only 11 patients of these patients. CONCLUSIONS: Elevated digoxin levels and clinical toxicity remains a common adverse drug reaction. Elderly patients, particularly those with impaired renal function and low body weights, are at the greatest risk. As published digoxin nomograms often result in toxicity, clinical variables need to be monitored. In patients with congestive heart failure and normal sinus rhythm the potential benefit of digoxin is small; thus, patients should receive a dose that minimizes the risk of toxicity. For patients with new onset atrial fibrillation, other agents may be preferable for rate control.

The obese patient in the ICU.

Data from recent surveys indicate that a staggering 34.9% of US adults are overweight. Obese adults are at in increased risk for many chronic medical conditions, and this increases the likelihood of admission to an ICU. The critically ill obese patient presents the ICU team with many unique problems. Obesity may result in significant alterations of pulmonary and cardiac function, as well as the handling of many drugs. An appreciation of these and other changes is essential in the management of the obese ICU patient. The purpose of this article is to review some of the basic concepts related to the treatment of obese patients in the ICU.

Gastric intramucosal pH. A better predictor of multiorgan dysfunction syndrome and death than oxygen-derived variables in patients with sepsis.

OBJECTIVE: To determine the value of tonometrically measured gastric intramucosal pH (pHi) and accepted indices of systemic oxygenation in predicting multiorgan dysfunction syndrome (MODS) and death in critically ill patients with sepsis. DESIGN: Prospective, noninterventional study. SETTING: Multidisciplinary ICU of a tertiary care, teaching hospital. PATIENTS: Thirty critically ill ventilated patients with pulmonary artery catheters and nasogastric tonometers in place. MEASUREMENTS AND MAIN RESULTS: The pHi, arterial lactate concentration, arterial and mixed venous pH, APACHE II score, and oxygen-derived variables, including oxygen delivery (Do2) and oxygen consumption (Vo2) were determined within 24 h of the onset of sepsis. The patients were then followed until death or discharge from the ICU. The development of organ system dysfunction during the ICU stay was recorded. Fifteen patients developed MODS of whom 12 died. An additional three patients died. The pHi and arterial and mixed venous pH were significantly lower in those patients who developed MODS and in those patients who died. The Vo2 and Do2, however, were higher in these patients. Using stepwise discriminant analysis, only the pHi contributed to the prediction of both MODS and death. CONCLUSIONS: In patients with sepsis, indices of tissue oxygenation are better predictors of outcome than the hemodynamic and oxygen-derived variables obtained by invasive hemodynamic monitoring. These indices should be used to direct therapy.

Fever in the ICU.

Fever is a common problem in ICU patients. The presence of fever frequently results in the performance of diagnostic tests and procedures that significantly increase medical costs and expose the patient to unnecessary invasive diagnostic procedures and the inappropriate use of antibiotics. ICU patients frequently have multiple infectious and noninfectious causes of fever, necessitating a systematic and comprehensive diagnostic approach. Pneumonia, sinusitis, and blood stream infection are the most common infectious causes of fever. The urinary tract is unimportant in most ICU patients as a primary source of infection. Fever is a basic evolutionary response to infection, is an important host defense mechanism and, in the majority of patients, does not require treatment in itself. This article reviews the common infectious and noninfectious causes of fever in ICU patients and outlines a rational approach to the management of this problem.

Sublingual capnography: a clinical validation study.

OBJECTIVE: To compare sublingual PCO(2) (PslCO(2)) measurements with gastric intramucosal PCO(2) (PimCO(2)) as well as with the traditional indexes of tissue oxygenation in hemodynamically unstable ICU patients. DESIGN: A prospective, validation study. SETTING: The medical and coronary ICUs of a community teaching hospital. PATIENTS: Consecutive patients with severe sepsis, septic shock, or cardiogenic shock requiring pulmonary artery catheterization for hemodynamic management. INTERVENTIONS: During the first 24 h of ICU admission, the PslCO(2), PimCO(2), and blood lactate concentrations as well conventional hemodynamic and oxygenation parameters were recorded every 4 to 6 h. The PslCO(2)-PaCO(2) and PimCO(2)-PaCO(2) differences were used as indexes of tissue dysoxia. These variables were correlated with each other as well as with the traditional markers of tissue oxygenation. RESULTS: Seventy-six data sets were obtained on 22 patients. Fifteen patients had severe sepsis/septic shock, and 7 patients did not have sepsis. A patient with ischemic bowel who had a large PimCO(2)-PslCO(2) difference (60.2 mm Hg) was excluded. The initial PslCO(2) and PimCO(2) measurements were 43.5 +/- 10.4 mm Hg and 42.8 +/- 10.9 mm Hg, respectively (correlation coefficient [r] of 0.86; p < 0.001). The mean PslCO(2) and PimCO(2) for the entire data set were 48.0 +/- 13.4 mm Hg and 46.1 +/- 12.3 mm Hg, respectively (r = 0.78; p < 0.001). Ten patients died. The initial PslCO(2)-PaCO(2) difference was 9.2 +/- 5.0 mm Hg in the survivors and 17.8 +/- 11.5 mm Hg in the nonsurvivors (p = 0.04). The initial PimCO(2)-PaCO(2) difference was 8.4 +/- 4.8 mm Hg in the survivors and 16.1 +/- 13.7 mm Hg in the nonsurvivors (p = 0.08, not significant). The initial PslCO(2)-PaCO(2) difference correlated with the initial mixed venous-arterial CO(2) gradient (r = 0.66; p = 0.001), but correlated poorly with the initial blood lactate concentration (r = 0.38), mixed venous PO(2) (r = 0.05), and systemic oxygen delivery (r = - 0.39). CONCLUSION: In this study, sublingual capnometry yielded measurements that correlated well with those of gastric tonometry. PslCO(2) may serve as a technically simple and noninvasive clinical measurement of tissue dysoxia in critically ill and injured patients.

Pulmonary artery catheterization and esophageal doppler monitoring in the ICU.

The clinical assessment of cardiac performance and ventricular preload is notoriously unreliable in critically ill patients. Consequently, a number of technologies have been developed to provide the clinician with indexes of cardiovascular function to assist in therapeutic decision making. Foremost among these is the pulmonary artery catheter (PAC). Indeed, the PAC has largely shaped the practice of modern critical care. Yet, the information provided by the PAC is largely misunderstood, and its efficacy is never proven. Recently, continuous esophageal Doppler monitoring has emerged as an alternative to pulmonary artery catheterization. This paper evaluates the clinical utility of the PAC and esophageal Doppler monitoring in assessing the hemodynamic status of ICU patients.

Pressure-controlled ventilation in ARDS: a practical approach.

Patients with ARDS typically have functionally small lungs. A growing body of clinical and experimental evidence has demonstrated that mechanical ventilation that results in high transpulmonary pressure gradients and overdistention of lung units will potentiate the acute lung injury in patients with ARDS. A relative form of "lung rest" using low tidal volume mechanical ventilation that prevents alveolar overdistention has therefore been advocated. This may be achieved with low-volume, volume-cycled ventilation with a decelerating inspiratory flow or pressure-controlled ventilation (PCV). The goal of this article is to provide a simple and practical approach to the management of PCV in patients with ARDS. Implicit in our approach is the use of a ventilator with PCV software and waveform capabilities.

The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study.

CONTEXT: Aspiration of oropharyngeal material, with its high concentration of anaerobic bacteria, has been implicated in the pathogenesis of both ventilator-associated pneumonia (VAP) and aspiration pneumonitis (AP). Consequently, patients with these disorders are usually treated with antimicrobial agents with anaerobic activity. OBJECTIVE: To determine the incidence of anaerobic bacteria in patients with VAP and AP. DESIGN: Prospective, nonrandomized, interventional study. SETTING: University-affiliated community teaching hospital. PATIENTS AND INTERVENTIONS: We performed sequential blind protected specimen brush (PSB) sampling and mini-BAL in 143 patients with 185 episodes of suspected VAP and 25 patients with AP who required mechanical ventilation. Quantitative aerobic and anaerobic cultures were performed on all specimens. Pneumonia was considered to be present when either > 500 cfu/mL cultured from blind PSB sampling or > 5,000 cfu/mL cultured from mini-BAL were present. RESULTS: Using the predefined criteria, bacterial pneumonia was diagnosed in 63 of 185 suspected VAP episodes (34%) and 12 of 25 patients with AP (48%). At least one dose of an antibiotic was given in the 24 h prior to bacteriologic sampling in 106 suspected VAP episodes (57%) and in 12 patients with AP (48%). More than one pathogen was isolated from 11 VAP and four AP patients. Pseudomonas aeruginosa, Staphylococcus aureus, and enteric Gram-negative organisms were isolated most frequently from patients with VAP. In the patients with AP, enteric Gram-negative organisms were isolated in patients with GI disorders and Streptococcus pneumoniae and Haemophilus influenzae predominated in patients with "community-acquired" aspiration. Only one anaerobic organism was isolated from the entire group of patients; Veillonella paravula was isolated from a blind PSB specimen in a patient with suspected aspiration pneumonia. CONCLUSION: Despite painstaking effort, we were able to isolate only one anaerobic organism (nonpathogenic) from this group of patients. The spectrum of aerobes in patients with VAP was similar to that reported in the literature. The organisms found in patients with AP was a reflection of the organisms likely to colonize the oropharynx. The use of antibiotics with anaerobic coverage may not be necessary in patients with suspected VAP and AP. Furthermore, penicillin G and clindamycin may not be the antibiotics of choice in patients with AP.

The hemodynamic derangements in sepsis: implications for treatment strategies.

The incidence of the sepsis syndrome has increased dramatically in the last few decades. During this time, we have gained new insights into the pathophysiologic mechanisms leading to organ dysfunction in this syndrome. Yet, despite this increased knowledge and the use of novel therapeutic approaches, the mortality associated with the sepsis syndrome has remained between 30% and 40%. Appropriate antibiotic selection and hemodynamic support remain the cornerstone of treatment of patients with sepsis. Recent studies have failed to demonstrate a global oxygen debt in patients with sepsis. Furthermore, therapy aimed at increasing systemic oxygen delivery has failed to consistently improve patient outcome. The primary aim of the initial phase of resuscitation is to restore an adequate tissue perfusion pressure. Aggressive volume resuscitation is considered the best initial therapy for the cardiovascular instability of sepsis. Vasoactive agents are required in patients who remain hemodynamically unstable or have evidence of tissue hypoxia after adequate volume resuscitation.

A comparison of bronchodilator therapy delivered by nebulization and metered-dose inhaler in mechanically ventilated patients.

BACKGROUND: The optimal method of delivering bronchodilators in mechanically ventilated patients is unclear. The purpose of this study was to compare the pulmonary bioavailability of albuterol delivered by the nebulizer, the metered-dose inhaler (MDI) and spacer, and the right-angle MDI adaptor in ventilated patients using urinary analysis of drug levels. METHODS: Mechanically ventilated patients who had not received a bronchodilator in the previous 48 h and who had normal renal function were randomized to receive the following: (1) five puffs (450 microg) of albuterol delivered by the MDI with a small volume spacer; (2) five puffs of albuterol delivered by the MDI port on a right-angle adaptor; or (3) 2.5 mg albuterol delivered by a nebulizer. Urine was collected 6 h after the administration of the drug, and the amounts of albuterol and its sulfate conjugate were determined in the urine by a chromatographic assay. RESULTS: Thirty patients were studied, 10 in each group: their mean age and serum creatinine level were 62 years and 1.3 mg/dL, respectively. With the MDI and spacer, (mean +/- SD) 169+/-129 microg albuterol (38%) was recovered in the urine; with the nebulizer, 409+/-515 microg albuterol (16%) was recovered in the urine; and with the MDI port on the right-angle adaptor, 41+/-61 microg albuterol (9%) was recovered in the urine (p = 0.02 between groups). The level of albuterol in the urine was below the level of detection in four patients in whom the drug was delivered using the right-angle MDI adaptor. CONCLUSION: The three delivery systems varied markedly in their efficiency of drug delivery to the lung. As previous studies have confirmed, this study has demonstrated that using an MDI and spacer is an efficient method for delivering inhaled bronchodilators to the lung. The pulmonary bioavailability was poor with the right-angle MDI port. This port should not be used to deliver bronchodilators in mechanically ventilated patients.

A comparison of bronchoscopic vs blind protected specimen brush sampling in patients with suspected ventilator-associated pneumonia.

BACKGROUND: Pneumonia is a common complication in patients undergoing mechanical ventilation and increases ICU mortality. The clinical diagnosis of ventilator-associated, however, pneumonia is unreliable, and many consider bronchoscopic-directed protected specimen brush sampling and quantitative culture the diagnostic method of choice. Bronchoscopy, however, is expensive and not readily available in many ICUs. OBJECTIVE: To test the hypothesis that "blind" protected specimen brush (PSB) sampling may produce results similar to that of bronchoscopic-directed sampling. SETTING: The medical ICU of a university-affiliated teaching hospital. INTERVENTION: Patients with suspected ventilator-associated pneumonia (VAP) who had not received antibiotics for at least 48 h underwent "blind" and bronchoscopic-directed PSB sampling with quantitative culture. RESULTS: Fifty-five paired PSB specimens were obtained from 53 patients. There was an 85% quantitative agreement between the blind and bronchoscopic-directed specimens. The agreement was independent of the bronchopulmonary segment from which the bronchoscopic sampling was directed. CONCLUSION: The results of this study are consistent with the notion that blind PSB sampling and quantitative culture may prove to be a useful, cost-effective, and minimally invasive method of diagnosing VAP.

The diagnosis and management of hypertensive crises.

Severe hypertension is a common clinical problem in the United States, encountered in various clinical settings. Although various terms have been applied to severe hypertension, such as hypertensive crises, emergencies, or urgencies, they are all characterized by acute elevations in BP that may be associated with end-organ damage (hypertensive crisis). The immediate reduction of BP is only required in patients with acute end-organ damage. Hypertension associated with cerebral infarction or intracerebral hemorrhage only rarely requires treatment. While nitroprusside is commonly used to treat severe hypertension, it is an extremely toxic drug that should only be used in rare circumstances. Furthermore, the short-acting calcium channel blocker nifedipine is associated with significant morbidity and should be avoided. Today, a wide range of pharmacologic alternatives are available to the practitioner to control severe hypertension. This article reviews some of the current concepts and common misconceptions in the management of patients with acutely elevated BP.