From the Guidelines
If a patient remains hypotensive after receiving a 500mL IV normal saline bolus and has anorexia, the next step should be to administer norepinephrine as the first-line vasopressor, as recommended by the most recent guidelines 1. The patient's persistent hypotension despite initial fluid resuscitation indicates the need for vasopressor support to maintain adequate blood pressure and perfusion of vital organs.
- Key considerations in this scenario include:
- Continuing fluid resuscitation with additional IV fluids, such as crystalloids, to ensure adequate intravascular volume
- Initiating norepinephrine at a dose of 0.05-0.5 mcg/kg/min, titrated to a mean arterial pressure goal of >65 mmHg, as suggested by the guidelines 1
- Investigating the underlying cause of hypotension and anorexia, which may include sepsis, adrenal insufficiency, or gastrointestinal fluid losses
- Monitoring vital signs, urine output, and laboratory parameters, such as lactate levels and electrolytes, to assess the patient's response to treatment and guide further management
- The use of vasopressin can be considered if hypotension persists despite the use of norepinephrine, as indicated by the guidelines 1.
- It is essential to prioritize the patient's morbidity, mortality, and quality of life in this scenario, and to make decisions based on the most recent and highest-quality evidence available, such as the study published in Critical Care Medicine 1.
From the FDA Drug Label
Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement Occasionally much larger or even enormous daily doses (as high as 68 mg base or 17 vials) may be necessary if the patient remains hypotensive, but occult blood volume depletion should always be suspected and corrected when present.
If the patient remains hypotensive after giving 500mL IV NS bolus, and has anorexia, the next step would be to:
- Suspect and correct occult blood volume depletion
- Consider administering norepinephrine (LEVOPHED), while also giving more fluid, as the patient may still be hypovolemic despite the initial bolus 2
- Monitor central venous pressure to guide further fluid management and vasopressor therapy.
From the Research
Patient Assessment and Management
If a patient remains hypotensive after receiving a 500mL IV NS bolus and has anorexia, the following steps can be considered:
- Evaluate the patient's fluid and electrolyte status, as anorexia nervosa can lead to plasma volume depletion and hypovolemic hyponatremia 3
- Assess for signs of hemoconcentration, which may be masked by malnutrition, and evaluate for underlying anemia 3
- Consider the potential for refeeding syndrome, which can occur in patients with anorexia nervosa who are being renourished, and monitor for electrolyte disturbances such as hypophosphatemia, hypokalemia, hypocalcemia, and hypomagnesemia 4
Laboratory Evaluation
- Complete blood count (CBC) to evaluate for anemia, leukopenia, and thrombocytopenia, which are common complications of anorexia nervosa 5
- Electrolyte panel to monitor for electrolyte disturbances, which can occur in patients with anorexia nervosa, particularly during refeeding 4
- Liver function tests (LFTs) to evaluate for hepatic dysfunction, which can occur in patients with anorexia nervosa 4
Management Considerations
- Aggressive electrolyte monitoring and repletion may be necessary to manage electrolyte disturbances 4
- A multidisciplinary approach to care, involving medical and psychiatric disciplines, may be necessary to manage the complex medical and psychiatric complications of anorexia nervosa 4
- Nutritional support should be begun slowly and carefully to avoid refeeding syndrome 4