How to manage a patient with severe hypotension?

Management of Severe Hypotension (BP 89/28)

For a patient with severe hypotension (BP 89/28), initiate immediate fluid resuscitation with 0.9% sodium chloride or balanced crystalloid solution, followed by noradrenaline if target blood pressure is not achieved with fluids alone. 1

Initial Assessment and Management

• Evaluate for potential causes of severe hypotension, including hemorrhage, trauma, sepsis, or cardiac dysfunction 1
• Begin crystalloid fluid therapy immediately using either 0.9% sodium chloride or a balanced crystalloid solution 1
• Avoid hypotonic solutions such as Ringer's lactate, especially in patients with head trauma 1
• Restrict colloid use due to potential adverse effects on hemostasis 1
• Monitor response to fluid resuscitation closely 1

Vasopressor Therapy

• If fluid resuscitation fails to achieve target blood pressure (systolic BP <80 mmHg), administer noradrenaline as the first-line vasopressor 1
• For septic shock-associated hypotension, epinephrine can be administered at 0.05-2 mcg/kg/min, titrated to achieve desired mean arterial pressure 2
• Add dobutamine in the presence of myocardial dysfunction 1
• Consider low-dose arginine vasopressin (bolus of 4 IU followed by 0.04 IU/min) in hemorrhagic shock, which has been shown to decrease blood product requirements 1

Special Considerations

Traumatic Hemorrhage

• In early stages of resuscitation for trauma patients, use a restricted volume replacement strategy and permissive hypotension (target systolic BP 80-90 mmHg) until bleeding is controlled 1
• Only add vasopressors if systolic BP remains <80 mmHg despite fluid resuscitation 1
• Be aware that the pathophysiology of acute blood loss consists of two phases: initial vasoconstriction followed by vasodilation 1

Cerebral Perfusion

• For patients with traumatic brain injury, maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion 1
• A single episode of hypotension (systolic BP <90 mmHg) during the early phase of traumatic brain injury worsens neurological outcome 1
• Avoid hypotensive hypnotic agents for sedation in patients with brain injury 1

Intracerebral Hemorrhage

• In patients with intracerebral hemorrhage and severe hypertension, gradual BP reduction is recommended, avoiding excessive lowering 1
• For patients with subarachnoid hemorrhage and unsecured aneurysm, frequent BP monitoring and control with short-acting medications is recommended 1

Monitoring and Follow-up

• Continuously monitor vital signs, including heart rate, blood pressure, and oxygen saturation 1
• Assess for orthostatic hypotension before starting or intensifying BP-lowering medication by measuring BP after 5 minutes of lying down and then 1-3 minutes after standing 1
• Single hematocrit measurements should not be used as an isolated marker for bleeding 1
• Document neurological status regularly, particularly in patients with head trauma or at risk of cerebral hypoperfusion 1

Pitfalls and Caveats

• Excessive BP reduction may compromise cerebral perfusion and induce ischemia, especially in patients with elevated intracranial pressure 1
• Avoid using vasopressors without adequate fluid resuscitation, as this may potentiate vasoconstriction and further reduce organ perfusion 1
• Be cautious with permissive hypotension in elderly patients and those with chronic arterial hypertension, as it may be contraindicated 1
• Consider that orthostatic hypotension increases with advancing age and is commonly associated with neurodegenerative diseases, diabetes, hypertension, and kidney failure 3, 4
• In frail or elderly patients, consider screening for frailty and adjust treatment accordingly, potentially using long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line agents 1