How to correct hypotension?

Correction of Hypotension

First, correct hypotension by identifying the underlying cause, then administer intravenous fluids for hypovolemia, followed by vasopressors if fluid-refractory, with a goal of maintaining mean arterial pressure ≥65 mmHg. 1

Identify the Cause of Hypotension

Hypotension (systolic BP <90 mmHg or MAP <70 mmHg) requires urgent evaluation to determine the underlying cause:

1. Hypovolemia: Signs include tachycardia, dry mucous membranes, decreased skin turgor, oliguria
2. Cardiogenic: Signs include jugular venous distention, pulmonary edema, S3 gallop
3. Distributive: Signs include warm extremities (sepsis), anaphylaxis, neurogenic shock
4. Obstructive: Signs include distended neck veins, muffled heart sounds (tamponade), hypoxemia (pulmonary embolism)

Step-by-Step Management Algorithm

Step 1: Fluid Resuscitation

• First-line treatment for most hypotensive patients is IV fluid resuscitation 2, 1
• Administer crystalloid fluid bolus (10-20 mL/kg; maximum 1,000 mL) of isotonic solution 1
• For patients with acute ischemic stroke, use 0.9% saline rather than hypotonic solutions 2
• Assess fluid responsiveness (using passive leg raise test, IVC ultrasound, or pulse pressure variation)
• If fluid responsive, continue with fluid administration (250-500 mL over 30-60 minutes) 1

Step 2: Vasopressors (if hypotension persists after adequate fluid resuscitation)

• Norepinephrine is first-line vasopressor for most causes of hypotension 1, 3

  • Initial dose: 8-12 mcg/min (2-3 mL/min of standard dilution)
  • Maintenance: 2-4 mcg/min (0.5-1 mL/min)
  • Target: Systolic BP 80-100 mmHg or MAP ≥65 mmHg 3
  • Administer through central line when possible to avoid extravasation 3

• Phenylephrine: Alternative for hypotension with tachycardia

  • Dosing range: 0.5-2.0 mcg/kg/min IV 1

• Epinephrine or Dopamine: For bradycardic hypotension

  • Epinephrine: 0.05-2 mcg/kg/min IV
  • Dopamine: 5-10 mcg/kg/min 1

Step 3: Additional Interventions Based on Cause

For Cardiogenic Shock:

• Intra-aortic balloon counterpulsation for patients who don't respond to pharmacologic therapy 2
• Avoid beta-blockers or calcium channel antagonists in low-output states 2
• Consider dobutamine for myocardial depression 1

For Septic Shock:

• Early antimicrobial therapy
• Source control
• Consider higher MAP targets (80-85 mmHg) in patients with chronic hypertension 2

For Neurogenic Shock:

• Maintain euvolemia
• Consider vasopressors with both alpha and beta activity

Special Considerations

Hypertrophic Cardiomyopathy

• Avoid factors that trigger dynamic outflow obstructions 2:
  • Positive inotropic agents
  • Tachycardia
  • Reduced preload
• For hypotension, prioritize IV fluids and use alpha-agonists (phenylephrine, vasopressin) rather than beta-agonists 2

Acute Ischemic Stroke

• Arterial hypotension is rare during acute ischemic stroke and suggests another cause 2
• Maintain euvolemia with isotonic fluids 2
• If vasopressors are needed, use them cautiously to avoid excessive hypertension 2

Elderly Patients

• Higher risk of orthostatic hypotension (20% prevalence) 1
• Require slower titration and monitoring for falls

Monitoring During Treatment

• Continuous blood pressure monitoring (arterial line if available)
• Assess perfusion markers: lactate clearance, mixed/central venous oxygen saturations, urine output, mental status 1
• Monitor for fluid overload (pulmonary edema, peripheral edema)
• Central venous pressure monitoring may help detect occult hypovolemia 3

Common Pitfalls to Avoid

1. Administering vasopressors without adequate fluid resuscitation
2. Assuming all hypotension is due to hypovolemia
3. Focusing only on BP numbers rather than signs of end-organ perfusion
4. Abrupt withdrawal of vasopressors (reduce gradually) 3
5. Administering vasopressors through peripheral IVs (risk of extravasation and tissue necrosis)
6. Treating hypertension too aggressively, which can lead to hypotension 1

By following this algorithmic approach to hypotension management, you can effectively restore adequate tissue perfusion and minimize end-organ damage.