Management of Hypotension (BP 70/40)
For patients with hypotension (BP 70/40), immediate fluid resuscitation with 30 mL/kg of IV crystalloid fluid within the first 3 hours is recommended while simultaneously identifying and addressing the underlying cause. 1
Initial Assessment and Management
Immediate interventions:
- Establish IV access (large-bore if possible)
- Administer crystalloid fluid bolus (10-20 mL/kg initially)
- Elevate the patient's legs if hypotensive
- Apply oxygen if hypoxemic
- Connect to continuous monitoring 1
Assess for causes of hypotension:
- Hypovolemia (bleeding, dehydration)
- Cardiogenic (heart failure, arrhythmias)
- Distributive (sepsis, anaphylaxis)
- Obstructive (pulmonary embolism, tension pneumothorax)
- Medication-related (antihypertensives, sedatives)
Fluid Resuscitation
- Administer balanced crystalloids as first-line treatment for volume resuscitation 1
- Reassess hemodynamic status frequently during fluid administration
- Use dynamic measures to assess fluid responsiveness when available (e.g., pulse pressure variation, stroke volume variation) 1
- Consider passive leg raise (PLR) test to determine fluid responsiveness - a positive response strongly predicts fluid responsiveness (positive likelihood ratio = 11) 2
Vasopressor Therapy
If hypotension persists despite initial fluid resuscitation:
- Start vasopressors, targeting a mean arterial pressure (MAP) ≥ 65 mmHg 1
- Norepinephrine is the first-choice vasopressor (starting at 8-12 mcg/min) 1, 3
- Vasopressin (up to 0.03 U/min) can be used as an adjunct to norepinephrine 1
| Condition | Recommended Vasopressor |
|---|---|
| Distributive Shock | Norepinephrine (0.05-2 mcg/kg/min) |
| Cardiogenic Shock | Norepinephrine (0.05-2 mcg/kg/min) or dopamine |
| Afterload-Dependent States | Phenylephrine or vasopressin |
Special Considerations
Trauma Patients
- For trauma patients with uncontrolled hemorrhage, use a restricted volume replacement strategy with permissive hypotension (SBP 80-90 mmHg) until bleeding is controlled 1, 2
- This approach is contraindicated in patients with traumatic brain injury (TBI) or spinal injuries 2
Cardiac Dysfunction
- For myocardial dysfunction, add dobutamine to norepinephrine or use epinephrine as a single agent (initial dobutamine dose: 2.5-20 mcg/kg/min) 1
- Avoid excessive fluid administration in patients with cardiac dysfunction 1
Elderly Patients
- Elderly patients (>75 years) may benefit from lower MAP targets (60-65 mmHg) 1
- Patients with chronic hypertension may need higher MAP targets (75-85 mmHg) 1
Orthostatic Hypotension
- Test for orthostatic hypotension before starting or intensifying BP-lowering medication by measuring BP after 5 minutes of sitting/lying and then 1 and/or 3 minutes after standing 2
- For orthostatic hypotension, pursue non-pharmacological approaches as first-line treatment 2
Monitoring and Adjustments
Continuously monitor:
- Blood pressure
- Heart rate
- Urine output (target >0.5 mL/kg/hr)
- Mental status
- Peripheral perfusion
- Serial lactate measurements 1
Adjust therapy based on:
- Blood volume
- Cardiac contractility
- Urine flow
- Blood pressure
- Distribution of peripheral perfusion 1
Common Pitfalls to Avoid
- Delayed recognition and treatment of hypotension
- Inadequate fluid resuscitation before starting vasopressors
- Failure to identify and treat the underlying cause
- Excessive vasopressor use (may increase cardiac arrhythmias and myocardial oxygen demand)
- Permissive hypotension in patients with TBI or spinal injuries 1, 2
By following this structured approach to hypotension management, focusing on immediate fluid resuscitation while identifying and treating the underlying cause, you can effectively stabilize patients with hypotension and improve outcomes.