How to manage hypotension with BP 90/80?

Management of Hypotension with BP 90/80

Initial fluid resuscitation should be the first-line treatment for hypotension with BP 90/80, followed by norepinephrine if fluid therapy fails to achieve target blood pressure. 1

Initial Assessment and Management

Determine Severity and Context

• BP 90/80 represents moderate hypotension that requires prompt intervention
• Assess for signs of inadequate tissue perfusion (altered mental status, decreased urine output, cool extremities)
• Consider patient age: elderly patients may have baseline hypertension, making 90/80 relatively more severe 2

First-Line Treatment: Fluid Resuscitation

• Begin with restricted volume replacement using crystalloid solutions 1
• Preferred fluids:
  • 0.9% sodium chloride or balanced crystalloid solution (Grade 1B) 1
  • Avoid hypotonic solutions like Ringer's lactate, especially in patients with head trauma 1
  • Restrict colloids due to adverse effects on hemostasis (Grade 1C) 1

Second-Line Treatment: Vasopressors

When to Add Vasopressors

• Add norepinephrine when fluid resuscitation fails to achieve target blood pressure 1
• Specifically indicated when systolic BP remains <80 mmHg despite adequate fluid resuscitation 1

Norepinephrine Administration

• Dilute norepinephrine in 5% dextrose solution (4 mg in 1000 mL) 3
• Initial dose: 2-3 mL/min (8-12 mcg/min) 3
• Adjust to maintain systolic BP 80-100 mmHg 3
• Average maintenance dose: 0.5-1 mL/min (2-4 mcg/min) 3
• Administer through a central venous catheter when possible 3
• Target BP: 80-90 mmHg systolic in patients without traumatic brain injury 1

Special Considerations

• In myocardial dysfunction, add dobutamine (Grade 1C) 1
• For elderly patients (≥85 years), consider higher BP targets and more cautious vasopressor use 1
• In pregnant patients with hypotension, phenylephrine (0.6 μg/kg/min) or norepinephrine (0.05 μg/kg/min) can be used 4

Monitoring and Titration

• Continuously monitor BP, heart rate, urine output, and mental status
• Check for orthostatic hypotension before starting or intensifying BP medications 1
• Titrate vasopressors according to patient response 3
• Gradually reduce vasopressors once adequate BP and tissue perfusion are maintained 3

Potential Pitfalls and Caveats

1. Avoid excessive fluid administration - Restricted volume replacement is preferred to prevent complications 1

2. Watch for orthostatic hypotension - Test for orthostatic changes before intensifying treatment, especially in elderly patients 1

3. Consider patient-specific factors:

   • In elderly patients, BP 90/80 may represent more severe hypotension than in younger patients 2
   • Patients with chronic hypertension may require higher BP targets 3
   • Patients with autonomic dysfunction may have paradoxical responses to treatments 5, 6

4. Avoid abrupt withdrawal of vasopressors - Taper gradually to prevent rebound hypotension 3

5. Monitor for volume depletion - Always correct blood volume depletion before or concurrently with vasopressor administration 3

By following this algorithmic approach to managing hypotension with BP 90/80, you can effectively restore adequate tissue perfusion while minimizing complications associated with both hypotension and its treatment.