What are the treatment options for hypotension (low blood pressure)?

From the Guidelines

Treatment for hypotension should prioritize a bedside assessment to define the cause and then treat accordingly, with a focus on fluid responsiveness and the use of passive leg raise (PLR) test to guide management, as supported by a recent meta-analysis 1. The most appropriate management for hypotensive, haemodynamically unstable patients is to perform a bedside assessment to define the cause and then treat accordingly.

Key Considerations

• The PLR test should be considered for patients with postoperative hypotension to detect whether inadequate preload is contributing to hypotension 1.
• If the PLR test does not correct hypotension, further management should focus on vascular tone and chronotropy/inotropy 1.
• 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 1.
• Hypotension should be treated immediately in the symptomatic patient, with intravenous fluid being appropriate in many instances for a positive PLR test, and vasopressor or inotropic support indicated if preload augmentation is not needed 1.

Treatment Approach

• For acute hypotension, intravenous fluids like normal saline or lactated Ringer's solution are typically administered at 500-1000mL boluses to restore blood volume.
• Vasopressor medications may be necessary in severe cases, with norepinephrine being a common choice.
• The side-effect profile of drugs used in the treatment of hypotension must be taken into account, with phenylephrine being best used in situations where the hypotension is accompanied by tachycardia 1.

Additional Considerations

• Patient transfer to a higher level of care may be required in order to deliver appropriate therapies, dependent on local facilities and available resources 1.
• Lifestyle modifications and medications like fludrocortisone or midodrine may be prescribed for persistent orthostatic hypotension, as supported by other studies 1.

From the FDA Drug Label

Restoration of Blood Pressure in Acute Hypotensive States 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 Average Dosage: Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution. Give this solution by intravenous infusion. After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs

Treatment for Hypotension:

• The treatment for hypotension involves correcting blood volume depletion as fully as possible before administering any vasopressor.
• Norepinephrine (IV) can be administered to restore blood pressure in acute hypotensive states, with an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, and then adjusting the rate of flow to maintain a low normal blood pressure.
• Dopamine (IV) can also be used to treat hypotension, but if hypotension persists, it should be discontinued and a more potent vasoconstrictor agent such as norepinephrine should be administered 2, 2, 3.

From the Research

Treatment Options for Hypotension

• The treatment for hypotension can vary depending on the underlying cause, with options including fluid resuscitation, medication, and lifestyle changes 4, 5, 6, 7, 8.
• Fluid resuscitation is a common treatment approach, with options including normal saline, lactated Ringer's solution, and other crystalloids 6, 7, 8.
• The choice of fluid can depend on the specific patient population and the underlying cause of hypotension, with some studies suggesting that lactated Ringer's solution may be associated with improved outcomes in certain cases 6.

Fluid Resuscitation

• Normal saline and lactated Ringer's solution are two commonly used fluids for resuscitation in hypotensive patients 6, 7, 8.
• Some studies have compared the effects of these two fluids, with mixed results 6, 7, 8.
• A study published in 2022 found that lactated Ringer's solution was associated with improved survival in patients with sepsis-induced hypotension 6.
• Another study published in 2019 found no difference in quality of recovery between patients receiving normal saline and those receiving lactated Ringer's solution 7.

Specific Patient Populations

• Patients with orthostatic hypotension and postural tachycardia syndrome may benefit from oral salt replacement and intravenous hydration 4.
• Patients with sepsis-induced hypotension may benefit from lactated Ringer's solution as the initial fluid for resuscitation 6.
• Patients with acute pancreatitis may not have a significant difference in outcome based on the type of fluid resuscitation used 8.

Clinical Practice

• Monitoring and management of hypotension in the intensive care unit (ICU) can be challenging and variable 5.
• A survey of ICU personnel found that hypotension is often underdiagnosed and preventable, and that most ICUs do not have a specific hypotension treatment guideline or protocol 5.
• The use of balanced crystalloids, dobutamine, norepinephrine, and Trendelenburg position are common treatments for hypotension in the ICU 5.