What is the treatment for hypotension?

Treatment for Hypotension

The first-line treatment for hypotension is intravenous fluid resuscitation with an initial normal saline fluid bolus (10-20 mL/kg; maximum 1,000 mL), followed by vasopressor therapy if hypotension persists after adequate fluid administration. 1

Assessment and Diagnosis

Before initiating treatment, determine the etiology of hypotension through:

1. Bedside assessment to identify:

   • Systolic BP <90 mmHg or MAP <70 mmHg
   • Symptoms: dizziness, lightheadedness, weakness, fatigue
   • Signs of end-organ hypoperfusion: altered mental status, oliguria, elevated lactate

2. Fluid responsiveness evaluation:

   • Passive leg raise (PLR) test (positive likelihood ratio = 11) 2
   • Ultrasound assessment when available

Treatment Algorithm

Step 1: Fluid Resuscitation

• Administer IV normal saline bolus (10-20 mL/kg; maximum 1,000 mL) 1
• Consider colloid solutions in patients with capillary leak and hypoalbuminemia 1
• For trauma patients without TBI, use restricted volume replacement with target systolic BP 80-90 mmHg (MAP 50-60 mmHg) until major bleeding is controlled 2
• For patients with severe TBI, maintain MAP ≥80 mmHg 2

Step 2: Vasopressor Therapy (if hypotension persists after fluid resuscitation)

Based on shock type:

Distributive Shock (sepsis, anaphylaxis)

• First-line: Norepinephrine 1, 3
• Second-line: Add vasopressin (up to 0.03 UI/min) 1

Cardiogenic Shock

• With myocardial depression: Dobutamine, dopamine, or phosphodiesterase III inhibitors 1, 4
• With persistent hypotension and tachycardia: Add norepinephrine 1
• With bradycardia: Consider dopamine 1, 4
• For afterload-dependent states (aortic/mitral stenosis): Phenylephrine or vasopressin 1

Hypovolemic Shock

• Continue fluid resuscitation if patient remains fluid responsive
• Add vasopressors if hypotension persists despite adequate volume 1

Step 3: Target Blood Pressure

• Target MAP of 65 mmHg in most patients 1
• Monitor other perfusion markers: lactate clearance, venous oxygen saturations, urine output, mental status 1
• Use arterial monitoring for precise titration of vasoactive drugs in severe cases 1

Special Considerations

Orthostatic Hypotension

1. Non-pharmacological interventions 1, 5:

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

2. Pharmacological treatment 1, 6, 7:

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

Perioperative Hypotension

• Perform structured bedside assessment to determine etiology, select appropriate treatment, and consider changing monitoring intensity 2
• Use PLR test to guide fluid administration; if negative, focus on vascular tone and chronotropy/inotropy 2

Common Pitfalls to Avoid

1. Assuming all hypotension is due to hypovolemia 1

   • Only ~50% of postoperative hypotensive patients respond to fluid boluses 2

2. Delaying vasopressor initiation in life-threatening hypotension 1

   • Start vasopressors early in severe hypotension while continuing fluid resuscitation

3. Focusing only on BP numbers rather than symptoms and end-organ perfusion 1

4. Administering vasopressors without adequate fluid resuscitation 1

5. Failure to discontinue contributing medications 1, 7

   • Review and adjust medications that may cause or worsen hypotension

6. Combining two RAS blockers (ACE inhibitor and ARB) in hypertension management 2

   • This can lead to excessive hypotension

By following this structured approach to hypotension management, clinicians can effectively restore adequate tissue perfusion and prevent end-organ damage while addressing the underlying cause of hypotension.