How to manage hypotension?

From the Guidelines

Managing hypotension requires a multifaceted approach that prioritizes identifying and treating the underlying cause while supporting blood pressure, with the most recent and highest quality evidence suggesting that treatment should be tailored to the specific cause, whether hypovolemic, cardiogenic, distributive, or neurogenic shock. According to the most recent study 1, hypotensive symptoms may be due to over-diuresis, use of non-CV drugs with hemodynamic effects, autonomic dysfunction, or simultaneous administration of multiple HF medications, and all of these should be addressed before deciding to lower doses of evidence-based therapies.

Key Considerations

• Ensure adequate fluid resuscitation with intravenous crystalloids like normal saline or lactated Ringer's solution, typically starting with a 500-1000 mL bolus and reassessing, as suggested by older studies 1.
• If fluids are insufficient, vasopressors may be needed, with norepinephrine often being first-line for most causes of shock, while phenylephrine is useful for reflex tachycardia situations, and vasopressin can be added as a second agent.
• Position the patient supine with legs elevated to improve venous return, and discontinue or adjust medications that may be causing hypotension, such as antihypertensives or sedatives.
• Continuous monitoring of vital signs, urine output, and mental status is essential to assess response to treatment, with the goal of maintaining mean arterial pressure above 65 mmHg to ensure adequate organ perfusion.

Treatment Approaches

• For cardiogenic causes, inotropes like dobutamine may help, while midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension, as noted in studies 1.
• Nonpharmacologic measures, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, or using compressive garments over the legs and abdomen, can also be effective in managing orthostatic hypotension.
• Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical.

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 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

To manage hypotension, the following steps should be taken:

• Correct blood volume depletion as fully as possible before administering any vasopressor.
• Administer norepinephrine (IV), such as LEVOPHED, to help restore blood pressure in acute hypotensive states.
• Adjust the rate of flow to establish and maintain a low normal blood pressure, usually between 80 mm Hg to 100 mm Hg systolic.
• Monitor the patient's response and adjust the dosage as needed, with the average maintenance dose ranging from 0.5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base) 2.
• Norepinephrine (IV) is indicated for blood pressure control in certain acute hypotensive states, such as those caused by pheochromocytomectomy, sympathectomy, or septicemia 2.

From the Research

Managing Hypotension

To manage hypotension, several strategies can be employed, including:

• Maintaining the same drug dosage in cases of non-severe and asymptomatic hypotension, as recommended by European and US guidelines 3
• Decreasing blood pressure reducing drugs not indicated in heart failure with reduced ejection fraction (HFrEF) in instances of symptomatic or severe persistent hypotension 3
• Reducing the loop diuretic dose in the absence of associated signs of congestion 3
• Seeking the advice of a heart failure specialist unless the management of hypotension appears urgent 3

Drug-Induced Orthostatic Hypotension

Drug-induced orthostatic hypotension is a significant clinical problem that can be caused by various medications, including:

• Alpha 1-blockers, adrenergic blockers, and centrally acting drugs used to treat hypertension 4
• Phenothiazines, tricyclic antidepressants, and monoamine oxidase inhibitors used to treat psychiatric illnesses 4
• Dopamine agonists, antianginals, and antiarrhythmics used to treat cardiovascular conditions 4

Treatment of Orthostatic Hypotension

Several treatments are available for orthostatic hypotension, including:

• Midodrine, which has been shown to be effective in increasing standing systolic blood pressure and improving symptoms of orthostatic hypotension 5
• Oral vasopressors, such as ephedrine and yohimbine, which can be used in combination with other treatments to manage orthostatic hypotension 6
• Fludrocortisone, a mineralocorticoid that can help increase blood pressure 6
• Pressure support garments, which can help reduce the symptoms of orthostatic hypotension 6

Hypertensive Crisis

While hypotension is a significant clinical problem, hypertensive crisis is also a critical condition that requires prompt treatment, including:

• Reducing blood pressure rapidly in cases of hypertensive emergency, but not to normal values, to avoid hypoperfusion 7
• Using parenteral treatment, such as intravenous antihypertensives, to rapidly reduce blood pressure in cases of hypertensive emergency 7
• Admitting patients with hypertensive emergency to the hospital for close monitoring and treatment 7