What is the Dangle Protocol for patients at risk of orthostatic (low blood pressure) hypotension?

Dangle Protocol for Patients at Risk of Orthostatic Hypotension

The dangle protocol involves having patients sit at the edge of the bed with legs hanging down for 3 minutes before standing to prevent significant blood pressure drops and associated symptoms in those at risk for orthostatic hypotension. 1

Definition and Significance

Orthostatic hypotension is defined as:

• A decrease in systolic blood pressure ≥20 mmHg
• OR a decrease in diastolic blood pressure ≥10 mmHg
• Within 3 minutes of standing from a supine position 2, 3

This condition is associated with:

• Increased cardiovascular risk
• Higher fall risk
• Up to 50% increase in all-cause mortality 3
• Symptoms due to organ hypoperfusion including dizziness, lightheadedness, visual disturbances, and "coat hanger" neck/shoulder pain 3

Implementing the Dangle Protocol

Step-by-Step Procedure

1. Start with patient in supine position for at least 5 minutes
2. Assist patient to sitting position at edge of bed with legs hanging down ("dangling")
3. Maintain this position for 3 minutes to allow cardiovascular adjustment
4. Monitor vital signs and symptoms during this transition
5. If tolerated, proceed to standing position
6. If symptoms develop, return patient to supine position immediately 1

Assessment During Dangling

• Monitor blood pressure and heart rate before, during, and after position change
• Observe for symptoms of orthostatic intolerance:
  • Dizziness
  • Lightheadedness
  • Visual changes
  • Pallor
  • Diaphoresis
  • Nausea 3, 4

High-Risk Populations

The dangle protocol is particularly important for:

• Elderly patients (prevalence of orthostatic hypotension is 20% in older adults) 3
• Patients with diabetes mellitus (due to cardiovascular autonomic neuropathy) 2, 1
• Patients with cardiovascular disease 1
• Those with age-related vagal dysfunction 1
• Patients on medications that can cause or worsen orthostatic hypotension 5
• Postoperative patients (especially geriatric patients at risk for delirium) 6

Enhancing the Protocol

Additional Non-Pharmacological Strategies

• Encourage active leg and foot movement during dangling to promote venous return 1
• Teach physical counter-pressure maneuvers (leg crossing, lower body muscle tensing) 6
• Consider compression garments (thigh-high or abdominal) for high-risk patients 6
• Ensure adequate hydration status before position changes 6, 4
• For patients with severe symptoms, consider head elevation of 10° during sleep 6

Medication Considerations

• Review medications that may worsen orthostatic hypotension:
  • Beta-blockers
  • Alpha-blockers
  • Diuretics
  • Sedatives 6
• For patients with persistent symptomatic orthostatic hypotension despite non-pharmacological measures, consider:
  • Midodrine (5-20 mg three times daily) 6
  • Fludrocortisone (0.1-0.3 mg daily) 6

Special Considerations for Diabetic Patients

Patients with diabetes require particular attention due to:

• Higher prevalence of cardiovascular autonomic neuropathy (CAN) 2
• Orthostatic hypotension suggesting advanced CAN 2
• Increased mortality risk when orthostatic hypotension is present 2
• Reduced exercise capacity and blood pressure response to position changes 2

For diabetic patients, orthostatic hypotension should be assessed routinely even without symptoms, particularly after age 50 2.

Monitoring Protocol Effectiveness

• Success is measured by symptom improvement rather than normalization of blood pressure 6
• Document tolerance to position changes
• If symptoms persist despite proper implementation of the dangle protocol, consider more comprehensive evaluation for neurogenic vs. non-neurogenic causes of orthostatic hypotension 3

The dangle protocol is a simple yet effective intervention that can significantly reduce the risk of falls and other adverse events associated with orthostatic hypotension when moving patients from supine to standing positions.