How do I manage a patient with hypotension?

From the Guidelines

Managing a patient with hypotension requires prompt assessment and intervention, starting with establishing adequate intravenous access and administering crystalloid fluids, such as normal saline, at 500-1000 mL boluses, reassessing after each bolus, as recommended by the most recent guidelines 1. The initial management of hypotension involves fluid resuscitation to restore adequate blood volume and perfusion pressure.

• Key steps include:
  • Administering crystalloid fluids, such as normal saline or lactated Ringer's, in boluses of 500-1000 mL and reassessing after each bolus.
  • Using a passive leg raise (PLR) test to assess fluid responsiveness, as suggested by a recent study 1.
  • If hypotension persists despite fluid resuscitation, considering the use of vasopressors, with norepinephrine being the first-line agent, starting at 0.05-0.1 mcg/kg/min and titrating to maintain a mean arterial pressure (MAP) of at least 65 mmHg.
  • Identifying and treating the underlying cause of hypotension, which may include sepsis, hemorrhage, cardiac dysfunction, anaphylaxis, or medication effects.
  • Continuously monitoring vital signs, urine output, mental status, and laboratory values.
  • Considering the use of inotropic agents, such as dobutamine, in patients with cardiogenic shock or those who are hypotensive and hypoperfused.
  • Avoiding the use of inotropic agents unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns, as recommended by guidelines 1. It is essential to prioritize the patient's morbidity, mortality, and quality of life when managing hypotension, and to base treatment decisions on the most recent and highest-quality evidence available 1.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

To manage a patient with hypotension, specifically septic shock associated hypotension, consider administering epinephrine (IV). The suggested dosing infusion rate is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve a desired mean arterial pressure (MAP). Dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min. After hemodynamic stabilization, wean incrementally over time 2.

• Key considerations:
  • Administer into a large vein, avoiding catheter tie-in technique and veins of the leg in elderly patients or those with occlusive vascular diseases.
  • Titrate to achieve desired blood pressure goal.
  • Wean incrementally over time after hemodynamic stabilization.

From the Research

Management of Hypotension

To manage a patient with hypotension, several strategies can be employed, including the administration of intravenous fluids. The choice of fluid can depend on various factors, including the underlying cause of hypotension and the patient's individual needs.

• Fluid Administration:

  • The optimal fluid for resuscitation in hypotensive patients, especially in trauma settings, is still a topic of debate 3.
  • Studies have shown varying results with the use of crystalloids (such as lactated Ringer's solution or normal saline) versus colloids (such as hetastarch or albumin) 4, 5, 6.
  • For example, in severe head injury, hypertonic saline may be superior to lactated Ringer's solution in managing intracranial pressure and reducing the need for interventions 4.
  • In dogs with isoflurane-induced hypotension, hetastarch was found to be more effective than lactated Ringer's solution in increasing systolic arterial blood pressure 5.
  • In hypotensive-prone dialysis patients, hydroxyethylstarch (HES) was effective in preserving blood volume and systolic blood pressure, comparable to albumin but superior to hypertonic saline 6.

• Comparison of Lactated Ringer's Solution and Normal Saline:

  • A recent crossover trial comparing hospital-wide use of lactated Ringer's solution versus normal saline found no significant difference in the incidence of death or readmission to the hospital within 90 days after the index admission 7.
  • This suggests that, for routine intravenous administration of fluids, lactated Ringer's solution may not be clinically superior to normal saline in a general hospital population.

• Clinical Considerations:

  • The management of hypotension should be tailored to the individual patient, considering factors such as the cause of hypotension, presence of head trauma, and renal function.
  • Continuous monitoring of blood pressure, intracranial pressure (in cases of head trauma), and other relevant parameters is crucial in guiding fluid management and adjusting treatment as necessary.