What should I do for a patient with hypotension?

Management of Hypotension (BP 86/60)

For a patient with hypotension (BP 86/60), immediate fluid resuscitation with crystalloids should be initiated, followed by vasopressors if hypotension persists despite adequate fluid administration. 1

Initial Assessment and Management

Immediate Actions

• Establish IV access (large-bore if possible)
• Connect to continuous monitoring
• Elevate patient's legs (passive leg raise test)
• Administer oxygen if hypoxemic
• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours 1

Fluid Resuscitation

• First-line treatment: IV crystalloid fluids (preferably lactated Ringer's solution) 1, 2
• Initial bolus: 500-1000 mL rapidly in adults 3
• For children: 30 mL/kg in the first hour 3
• Monitor response to fluid administration
• A positive passive leg raise test strongly predicts fluid responsiveness (positive likelihood ratio = 11) 3, 1

Vasopressor Therapy

When to Start Vasopressors

• If hypotension persists despite initial fluid resuscitation
• Target mean arterial pressure (MAP) ≥ 65 mmHg 1

Vasopressor Selection

• First-line vasopressor: Norepinephrine 1, 4

  • Starting dose: 8-12 mcg/min
  • Dilute 4 mg in 1000 mL of 5% dextrose solution (4 mcg/mL)
  • Initial rate: 2-3 mL/min (8-12 mcg/min)
  • Titrate to maintain systolic BP 80-100 mmHg 4

• Alternative: Dopamine 3, 5

  • Dosing: 2-20 mcg/kg/min
  • For renal perfusion: 2-5 mcg/kg/min
  • For hemodynamic support: 5-20 mcg/kg/min
  • Administer through a large vein using an infusion pump 5

Special Considerations

Patient-Specific MAP Targets

• Standard target: MAP ≥ 65 mmHg 1
• Patients with chronic hypertension: Consider higher MAP target (75-85 mmHg) 1
• Elderly patients (>75 years): May benefit from lower MAP targets (60-65 mmHg) 1
• Trauma patients without TBI: Permissive hypotension (SBP 80-90 mmHg) until bleeding is controlled 3
• Trauma patients with TBI: Maintain normal blood pressure 3

Monitoring Parameters

• Continuous blood pressure monitoring
• Urine output (target >0.5 mL/kg/hr)
• Mental status
• Peripheral perfusion
• Serial lactate measurements 1

Potential Complications and Pitfalls

• Fluid overload: Monitor patients with underlying congestive heart failure or chronic renal disease for signs of volume overload 3
• Vasopressor extravasation: Administer vasopressors through a central line whenever possible to prevent tissue necrosis 4, 5
• Myocardial injury: Prolonged hypotension is associated with myocardial injury in trauma patients 6
• Inappropriate fluid administration: Only about 50% of hypotensive patients are fluid responsive; avoid excessive fluid administration in non-responders 3

Additional Interventions for Specific Causes

• For myocardial dysfunction: Add dobutamine (2.5-20 mcg/kg/min) 1
• For refractory distributive shock: Consider vasopressin (up to 0.03 U/min) as an adjunct to norepinephrine 1
• For suspected adrenal insufficiency: Consider hydrocortisone 200 mg IV 1

Remember that prompt recognition and treatment of hypotension is critical to prevent end-organ damage and improve patient outcomes.