What is the immediate treatment for a patient presenting with hypotension?

From the Guidelines

The immediate treatment for a patient presenting with hypotension involves rapid assessment and fluid resuscitation with crystalloid fluids, such as normal saline, and if hypotension persists, norepinephrine should be the first-line choice for vasopressor therapy, as recommended by the most recent guidelines 1.

Key Considerations

• The initial step in managing hypotension is to ensure adequate fluid resuscitation, typically with intravenous (IV) crystalloid fluids such as normal saline, administering 500-1000 mL as a bolus over 15-30 minutes, and reassessing the patient's response 1.
• If hypotension persists despite adequate fluid resuscitation, vasopressor medications may be necessary, with norepinephrine being the preferred first-line agent, initiated at a dose of 0.1-0.5 mcg/kg/min and titrated to maintain a mean arterial pressure (MAP) of at least 65 mmHg 1.
• Simultaneously, it is crucial to identify and treat the underlying cause of hypotension, which could include sepsis, hemorrhage, cardiac dysfunction, or medication effects, as the treatment approach may vary based on the etiology 1.
• Continuous monitoring of vital signs, urine output, and mental status is essential to gauge treatment effectiveness, as hypotension requires urgent intervention to prevent organ dysfunction and failure if prolonged 1.

Additional Measures

• In cases where hypotension is associated with anaphylaxis, epinephrine (adrenaline) must be delivered immediately at a dose of 0.01 mg/kg (1mg/mL dilution, to a maximum total dose of 0.5 mL) intra-muscularly into the lateral thigh muscle, and this can be repeated every 5–15 min if necessary 1.
• For patients receiving beta-blockers, glucagon 1–5 mg i.v. infusion over 5 min and followed by an infusion (5–15 mg/min) titrated to clinical response may be useful for treating refractory cardiovascular effects 1.
• Vasopressin can be added when hypotension persists despite using norepinephrine, highlighting the importance of a stepwise approach in managing refractory hypotension 1.

From the FDA Drug Label

1 INDICATIONS & USAGE Norepinephrine Bitartrate Injection, USP is indicated to raise blood pressure in adult patients with severe, acute hypotension.

The immediate treatment for a patient presenting with hypotension is to administer norepinephrine (IV) to raise blood pressure, as indicated in the drug label 2.

• Key considerations:
  • Address hypovolemia prior to initiating norepinephrine bitartrate injection, if possible.
  • Monitor for changes to the skin of the extremities in susceptible patients.
  • Avoid norepinephrine bitartrate injection in patients with mesenteric or peripheral vascular thrombosis.
• Alternative treatment: If hypotension persists with dopamine (IV) infusion, dopamine should be discontinued and a more potent vasoconstrictor agent such as norepinephrine should be administered 3.

From the Research

Immediate Treatment for Hypotension

The immediate treatment for a patient presenting with hypotension depends on the underlying cause of the condition.

• For hypotension caused by hemorrhagic shock, studies have investigated the use of different fluid resuscitation strategies, including hypertonic saline and lactated Ringer's solution 4, 5.
• In the setting of trauma, prehospital interventions for hypotension have been described, with most casualties not receiving prehospital blood or fluid intervention 6.
• For sepsis-induced hypotension, initial fluid resuscitation with lactated Ringer's solution compared with 0.9% saline may be associated with improved clinical outcomes 7.
• Limited resuscitation with hypertonic saline, hypertonic sodium acetate, and lactated Ringer's solutions has been studied in a model of uncontrolled hemorrhage from a vascular injury, with varying results 8.

Fluid Resuscitation Strategies

Different fluid resuscitation strategies have been compared in various studies, including:

• Hypertonic saline versus lactated Ringer's solution in dogs subjected to hemorrhagic shock 4
• Hypertonic saline versus isotonic fluid resuscitation in a large animal model combining hemorrhagic shock with head injury 5
• Lactated Ringer's solution versus 0.9% saline for initial fluid resuscitation in patients with sepsis-induced hypotension 7
• Hypertonic sodium acetate-dextran solution versus lactated Ringer's solution and hypertonic saline-dextran solution in a model of uncontrolled hemorrhage from a vascular injury 8

Key Findings

Key findings from these studies include:

• Hypertonic saline may be effective in reducing intracranial pressure and improving outcomes in patients with hemorrhagic shock and head injury 4, 5
• Lactated Ringer's solution may be associated with improved survival and more hospital-free days in patients with sepsis-induced hypotension 7
• Limited resuscitation with any fluid may be associated with significant mucosal acidosis, and the choice of fluid should be carefully considered 8