From the Guidelines
Hypotension in a non-infected patient is most commonly caused by hypovolemia, cardiovascular issues, medication effects, endocrine disorders, or neurological conditions, and should be managed by identifying and treating the underlying cause while providing supportive care, as supported by a recent study 1. The causes of hypotension can be broadly categorized into:
- Hypovolemia due to dehydration, blood loss, or excessive diuresis
- Cardiovascular issues such as heart failure, arrhythmias, or valvular disease
- Medication effects from antihypertensives, diuretics, beta-blockers, calcium channel blockers, or vasodilators
- Endocrine disorders like adrenal insufficiency, hypothyroidism, or hypoglycemia
- Neurological conditions such as autonomic dysfunction Other potential causes include anaphylaxis, pulmonary embolism, pericardial tamponade, tension pneumothorax, and severe anemia.
Management of Hypotension
Management should focus on identifying and treating the underlying cause while providing supportive care.
- For acute hypotension, intravenous fluids like normal saline at 500-1000mL bolus may be needed, as suggested by 1.
- A passive leg raise (PLR) test can be used to assess fluid responsiveness, and if the test is positive, intravenous fluid would be appropriate in many instances 1.
- If preload augmentation is not needed, vasopressor or inotropic support is indicated, with consideration of the side-effect profile of drugs used in the treatment of hypotension, such as phenylephrine, which can result in a reflex bradycardia, especially in the preload independent state 1.
- The choice of vasoactive drugs depends upon the aetiology and pathophysiology of the hypotensive episode, as discussed in 1.
Key Considerations
- Prompt identification and treatment of the underlying cause are essential to prevent end-organ damage.
- Hypotension occurs when there is inadequate vascular tone, decreased cardiac output, or reduced blood volume, leading to insufficient perfusion pressure to maintain adequate blood flow to vital organs.
- Non-invasive cardiac output monitors and portable ultrasound devices may help in identifying the root cause of hypotension and hence in choosing the most appropriate treatment, as suggested by 1.
From the FDA Drug Label
For blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions) The FDA drug label does not answer the question.
From the Research
Causes of Hypotension in Non-Infected Patients
- Hypotension can be caused by various factors, including significant underlying pathology 2
- Orthostatic hypotension (OH) is a common cause of hypotension, which can be non-neurogenic or neurogenic in origin 3
- Non-pharmacologic interventions are the first step in treating OH, and selecting appropriate medications can help with symptomatic relief 3
- Hypotension can also be caused by dehydration, blood loss, or certain medications 2
Evaluation and Management of Hypotension
- Expedited bedside evaluation with rapid initiation of treatment based on the underlying etiology is crucial in managing hypotension 2
- Serial reassessment of the patient's condition is essential to guide treatment and prevent organ injury 2
- Hemodynamic treatment should be applied early in patients with hypotension, and antibiotics should be administered promptly in cases of suspected infection 4
Fluid Resuscitation in Hypotension
- The choice of fluid for resuscitation in hypotension depends on various factors, including the underlying cause and the patient's condition 5, 6
- Lactated Ringer's solution and normal saline solution have similar effects on quality of recovery in stable emergency department patients 6
- However, lactated Ringer's solution may be associated with improved survival in patients with sepsis-induced hypotension compared to normal saline solution 5