What are the treatments for hypotension?

Treatment of Hypotension

The first-line treatment for hypotension depends on its cause, with fluid resuscitation being the primary intervention for most forms, followed by vasopressors if fluid resuscitation fails to restore adequate blood pressure. 1

Initial Assessment and Management

• Test for orthostatic hypotension before starting treatment by measuring blood pressure after 5 minutes of sitting/lying and then 1 and/or 3 minutes after standing 2
• For mild hypotension, administer small boluses (5-10 mL/kg) of normal saline or balanced crystalloids 3
• Consider patient positioning - elevate legs to improve venous return 3
• If medication-induced, reduce or temporarily discontinue the causative medications 3

Fluid Resuscitation

• Crystalloids are the fluid of choice for initial resuscitation of hypotension 3
• For significant hypotension, administer an initial fluid challenge of 30 mL/kg 3
• Continue fluid administration as long as there is hemodynamic improvement based on dynamic or static variables 3
• Consider albumin in addition to crystalloids when substantial amounts of crystalloids are required 3

Vasopressor Therapy

• Initiate vasopressor therapy if hypotension persists despite adequate fluid resuscitation 1, 3
• Target a mean arterial pressure (MAP) of 65 mmHg 1, 3
• Norepinephrine is the first-choice vasopressor for hypotension unresponsive to fluids 1, 3
• For refractory hypotension, consider adding vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine 1, 3
• Dopamine should only be considered in highly selected patients with low risk of tachyarrhythmias or with relative bradycardia 1, 3

Management of Orthostatic Hypotension

Non-Pharmacological Approaches

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily, if not contraindicated 2
• Implement physical counter-maneuvers, such as leg crossing, muscle tensing, squatting, and stooping 2, 4
• Use compression garments, including thigh-high and abdominal compression 2
• Acute water ingestion of ≥480 mL can provide temporary relief, with peak effect occurring 30 minutes after consumption 2, 5, 6
• Recommend smaller, more frequent meals to reduce post-prandial hypotension 2
• Encourage physical activity and exercise to avoid deconditioning 2

Pharmacological Treatment for Orthostatic Hypotension

• Consider pharmacological treatment when non-pharmacological measures fail to adequately control symptoms 2
• First-line medications include:
  • Midodrine (alpha-1 agonist): Initial dose 2.5-5mg three times daily, can increase standing systolic BP by 15-30 mmHg for 2-3 hours 2, 7
  • Fludrocortisone (mineralocorticoid): Initial dose 0.05-0.1mg daily, works by increasing plasma volume 2
  • Droxidopa: Particularly effective for neurogenic orthostatic hypotension 2

Special Considerations

Cardiogenic Shock

• In cardiogenic shock, individualize MAP goals to balance hypoperfusion risk against potential negative impact on cardiac output 1
• For acute heart failure, inotropes (dobutamine, dopamine, phosphodiesterase III inhibitors) are recommended as first-line agents 1
• In persistently hypotensive cardiogenic shock with tachycardia, norepinephrine is advised 1
• In patients with bradycardia, dopamine may be considered 1

Distributive Shock

• In distributive shock (e.g., sepsis), norepinephrine is recommended as the initial vasoactive drug after appropriate fluid resuscitation 1
• If hypotension persists, vasopressin (up to 0.03 UI/min) should be considered 1
• For myocardial depression in septic shock, consider adding dobutamine to norepinephrine or using epinephrine as a single agent 1

Medication-Induced Hypotension

• For patients on beta-blockers with hypotension, consider glucagon (5-10 mg infused over several minutes followed by 1-5 mg/hour IV infusion) 3
• For patients with both hypertension and orthostatic hypotension, consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors 2

Monitoring and Weaning

• Administration of vasoactive agents should always be targeted to effect and not based on a fixed dose 1
• Monitor blood pressure using intra-arterial monitoring when using vasopressors 1
• Complement MAP targets with other markers of perfusion, such as lactate, mixed or central venous oxygen saturations, urine output, skin perfusion, and mental status 1

Pitfalls and Caveats

• Avoid delaying vasopressor use in cases of significant hypotension unresponsive to fluids 3
• Avoid hydroxyethyl starches due to potential adverse effects 3
• When using midodrine, avoid taking the last dose after 6 PM to prevent supine hypertension during sleep 2
• Regular monitoring for adverse effects is essential, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone 2
• For orthostatic hypotension, the therapeutic goal should be minimizing postural symptoms rather than restoring normotension 2