What is the treatment for hypotension?

Treatment of Hypotension

The treatment of hypotension should be targeted at the underlying cause, with immediate intervention for symptomatic patients that includes fluid resuscitation for hypovolemia, vasopressors for vasodilatory states, and inotropic support for cardiac dysfunction. 1

Initial Assessment and Diagnosis

• Determine the etiology of hypotension through:

  • Bedside assessment to define the cause 1
  • Evaluation for fluid responsiveness using passive leg raise (PLR) test 1
  • Ultrasound when available to help ascertain shock etiology 1

• Signs of hypotension requiring treatment:

  • Systolic BP <90 mmHg or MAP <70 mmHg
  • Symptoms including dizziness, lightheadedness, weakness, fatigue, decreased urine output 1
  • Evidence of end-organ hypoperfusion (altered mental status, oliguria, elevated lactate) 1

Treatment Algorithm Based on Etiology

1. Hypovolemic Hypotension

• First-line treatment: Intravenous fluid resuscitation

  • Initial normal saline fluid bolus (10-20 ml/kg; maximum 1,000 ml) 1
  • Consider colloid solutions in patients with capillary leak and hypoalbuminemia 1
  • Use PLR test to predict fluid responsiveness (positive likelihood ratio = 11) 1

• Important caveat: Only ~50% of patients with suspected hypovolemia actually respond to fluid bolus 1

2. Distributive Shock (Sepsis, Anaphylaxis)

• First-line vasopressor: Norepinephrine after adequate fluid resuscitation 1
• Second-line options:
  • Add vasopressin (up to 0.03 UI/min) if hypotension persists 1
  • Consider epinephrine as a single agent if myocardial depression is present 1

3. Cardiogenic Shock

• First-line treatment: Inotropes (dobutamine, dopamine, phosphodiesterase III inhibitors) 1
• For persistent hypotension with tachycardia: Add norepinephrine 1
• For bradycardia: Consider dopamine 1
• For afterload dependent states (aortic stenosis, mitral stenosis): Phenylephrine or vasopressin 1

4. Orthostatic Hypotension

• Non-pharmacological interventions:

  • Increased salt intake (6-10g daily) 2
  • Physical counter-pressure maneuvers (leg crossing, squatting, muscle tensing) 2
  • Compression garments providing 30-40 mmHg pressure 2
  • Acute water ingestion (500ml, 30 minutes before anticipated orthostatic stress) 2

• Pharmacological treatments:

  • First-line: Midodrine (5-20mg three times daily) 2, 3
  • Alternative first-line: Fludrocortisone (0.1-0.3mg daily) 2
  • For refractory cases: Droxidopa (100-600mg TID) 2
  • For postprandial hypotension: Octreotide 2

Monitoring and Titration

• Target a MAP of 65 mmHg in most patients 1
• Complement blood pressure targets with other markers of perfusion:
  • Lactate clearance
  • Mixed or central venous oxygen saturations
  • Urine output
  • Mental status 1
• Use arterial monitoring for precise titration of vasoactive drugs 1
• Monitor for supine hypertension with medications (BP>200 mmHg systolic with midodrine) 3

Special Considerations

• Elderly patients: Higher risk of orthostatic hypotension (20% prevalence); require slower titration and monitoring for falls 2, 4
• Cardiac patients: Monitor closely for supine hypertension 2
• Postoperative patients: Consider PLR test before fluid administration; if negative, focus on vascular tone and chronotropy/inotropy 1
• Phenylephrine: Best used when hypotension is accompanied by tachycardia due to potential reflex bradycardia 1

Common Pitfalls to Avoid

• Assuming all hypotension is due to hypovolemia (only ~54% of suspected cases respond to fluid) 1
• Focusing on BP numbers rather than symptoms and end-organ perfusion 2
• Overlooking non-pharmacological measures for orthostatic hypotension 2
• Administering vasopressors too close to bedtime in orthostatic hypotension 2
• Failure to discontinue contributing medications 2

Remember that treatment should continue only for patients who report significant symptomatic improvement, particularly with medications like midodrine 3.