What is the immediate management of hypotension?

From the Guidelines

The immediate management of hypotension involves administering a fluid bolus of crystalloid as the initial fluid resuscitation fluid of choice, and if hypotension persists, norepinephrine should be the first-line choice. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of crystalloid as the initial fluid resuscitation fluid of choice 1. The study also highlights that if hypotension persists after fluid resuscitation, norepinephrine should be the first-line choice, and vasopressin can be added when hypotension persists despite using norepinephrine.

Key Considerations

• Ensure adequate intravenous access with two large-bore IVs (16-18 gauge) and administer a fluid bolus of 500-1000 mL of isotonic crystalloid (normal saline or lactated Ringer's) over 15-30 minutes, reassessing after each bolus.
• For persistent hypotension despite fluid resuscitation, vasopressors should be initiated, with norepinephrine (starting at 0.05-0.1 mcg/kg/min, titrated to effect) being the first-line agent for most causes of shock.
• Position the patient supine with legs elevated to improve venous return.
• Continuously monitor vital signs, urine output, and mental status.
• Simultaneously, investigate the cause through focused history, physical examination, ECG, point-of-care ultrasound, and laboratory tests including lactate, blood counts, and blood cultures if infection is suspected.

Special Considerations

• The concept of permissive hypotension and restrictive volume resuscitation may be applicable in certain situations, such as trauma patients without TBI and/or spinal injury, but this approach should be used with caution and careful consideration of the individual patient's needs 1.
• In patients with TBI and/or spinal injury, an adequate perfusion pressure is crucial to ensure tissue oxygenation of the injured central nervous system, and therefore, the concept of permissive hypotension and restrictive volume resuscitation is contraindicated.
• A PLR test can be useful in detecting whether inadequate preload is contributing to hypotension, and if the PLR test does not correct hypotension, further management should focus on vascular tone and chronotropy/inotropy 1.

From the FDA Drug Label

To prevent sloughing and necrosis in areas in which extravasation has taken place, the area should be infiltrated as soon as possible with 10 mL to 15 mL of saline solution containing from 5 mg to 10 mg of an adrenergic blocking agent. When discontinuing the infusion, gradually reduce the Norepinephrine Bitartrate Injection infusion rate while expanding blood volume with intravenous fluids. If hypotension occurs, the infusion rate should be rapidly increased until adequate blood pressure is obtained If hypotension persists, dopamine HCl should be discontinued and a more potent vasoconstrictor agent such as norepinephrine should be administered. The immediate management of hypotension involves:

• Addressing hypovolemia: Prior to initiating vasoconstrictor therapy, ensure that hypovolemia is fully corrected with either whole blood or plasma as indicated 2.
• Administering vasoconstrictors: Use medications like norepinephrine or dopamine to increase blood pressure 2 3.
• Monitoring and adjusting infusion rates: Gradually reduce the infusion rate of vasoconstrictors when discontinuing, and expand blood volume with intravenous fluids to prevent marked hypotension 2 3.
• Using adrenergic blocking agents: In cases of extravasation, infiltrate the area with saline solution containing an adrenergic blocking agent to prevent necrosis 2.

From the Research

Immediate Management of Hypotension

The immediate management of hypotension involves several key steps, including:

• Fluid resuscitation to restore blood volume and blood pressure
• Identification and treatment of the underlying cause of hypotension
• Monitoring of vital signs and adjustment of treatment as needed

Fluid Resuscitation

Fluid resuscitation is a critical component of hypotension management. The choice of fluid depends on the underlying cause of hypotension and the patient's individual needs. Options include:

• Lactated Ringer's solution 4
• Normal saline 5, 4
• Hypertonic saline 6, 7
• Hetastarch solution 5

Treatment of Underlying Cause

Treatment of the underlying cause of hypotension is essential to prevent further complications. This may involve:

• Control of bleeding in cases of hemorrhagic shock 5
• Treatment of sepsis or infection 4
• Management of cardiac or respiratory issues

Monitoring and Adjustment

Close monitoring of vital signs and adjustment of treatment as needed is crucial in managing hypotension. This includes:

• Monitoring of blood pressure and heart rate
• Assessment of urine output and mental status
• Adjustment of fluid resuscitation and other treatments as needed to achieve desired blood pressure goals 4, 7