How to manage hypotension?

Management of Hypotension

For patients with low blood pressure readings, management depends critically on whether symptoms and signs of inadequate organ perfusion are present—if systolic BP is <80 mmHg with altered mental status, cool extremities, decreased urine output, or tachycardia, this represents severe hypotension requiring urgent fluid resuscitation and potentially vasopressor support. 1

Initial Assessment and Risk Stratification

Evaluate for signs of inadequate organ perfusion rather than relying solely on BP numbers, particularly in elderly patients 1:

• Altered mental status
• Cool extremities
• Decreased urine output (<0.5 mL/kg/hr)
• Tachycardia
• Dizziness, lightheadedness, or syncope 2

Measure orthostatic vital signs before initiating or intensifying any treatment by having the patient sit or lie for 5 minutes, then measuring BP at 1 and/or 3 minutes after standing 3, 4. Orthostatic hypotension is defined as a decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing 4, 2.

Immediate Management of Severe Hypotension (Systolic BP <80 mmHg)

Administer intravenous fluid resuscitation as first-line treatment, particularly if dehydration is suspected 1:

• In acute liver failure or critical care settings, use colloid solutions (such as albumin) rather than crystalloid, with all solutions containing dextrose to maintain euglycemia 3
• For pediatric patients with hypotension, administer normal saline fluid bolus (10-20 mL/kg; maximum 1,000 mL) 3

If fluid resuscitation fails to maintain mean arterial pressure (MAP) of 50-60 mmHg, initiate vasopressor support 3, 1:

• Norepinephrine is the preferred first-line vasopressor for severe hypotension 1
• Alternative agents include epinephrine or dopamine (dopamine has been associated with increased systemic oxygen delivery in acute liver failure) 3
• Avoid vasopressin in acute liver failure settings 3

Consider pulmonary artery catheterization in hemodynamically unstable patients to ensure appropriate volume replacement has occurred before escalating to vasopressors 3.

Identify and Address Underlying Causes

Conduct a systematic medication review as this is the most common reversible cause 1, 4:

• Antihypertensive medications (ACE inhibitors, ARBs, calcium channel blockers, beta-blockers) 1
• Diuretics causing volume depletion 1
• Alpha-blockers (particularly prostate-specific agents) 3
• Sedatives that can reduce BP 3

Investigate cardiac causes, particularly in elderly patients 1:

• Heart failure with reduced cardiac output 1
• Bradyarrhythmias or heart block
• Valvular disease

Assess for volume depletion from 3:

• Decreased oral intake
• Gastrointestinal blood loss
• Excessive fluid losses

Screen for endocrine causes including adrenal insufficiency, particularly in patients with vasopressor-resistant hypotension 3.

Management of Orthostatic Hypotension

Non-Pharmacologic Interventions (First-Line for All Patients)

Implement non-pharmacologic approaches as first-line treatment, especially in patients with supine hypertension 3, 2:

• Increase fluid intake to 2-2.5 liters daily 2, 5
• Increase dietary sodium to 6-10 grams daily (unless contraindicated by heart failure) 2, 5
• Elevate head of bed 10-20 degrees to reduce nocturnal diuresis and supine hypertension 2, 5
• Use compression stockings (waist-high, 30-40 mmHg) 2, 5
• Physical countermaneuvers including leg crossing, squatting, or muscle tensing before standing 5
• Water bolus treatment: drinking 500 mL of water rapidly can increase BP within 5 minutes 5
• Avoid prolonged standing and rise slowly from supine/sitting positions 2

Adjust medication timing: switch BP-lowering medications that worsen orthostatic hypotension to alternative therapies rather than simply reducing dosage 3, 4.

Pharmacologic Treatment

For patients who do not respond adequately to non-pharmacologic measures, consider pharmacologic therapy 2, 5:

Midodrine (FDA-approved for symptomatic orthostatic hypotension) 6, 2:

• Starting dose: 2.5-5 mg three times daily 6, 2
• Maximum dose: 10 mg three times daily 6
• Take last dose 3-4 hours before bedtime to minimize supine hypertension 6
• Avoid if patient will be supine for extended periods 6
• Monitor for supine hypertension (can cause systolic BP >200 mmHg) 6
• Use with caution in patients with urinary retention, renal impairment (start at 2.5 mg), or hepatic impairment 6

Fludrocortisone 2, 5:

• Starting dose: 0.1 mg daily
• Increase gradually to 0.1-0.3 mg daily as needed
• Monitor for fluid retention and hypokalemia
• Carefully monitor for supine hypertension when used with midodrine 6, 5

Droxidopa (FDA-approved for neurogenic orthostatic hypotension) 4:

• Alternative to midodrine for neurogenic causes
• Avoid concomitant use with midodrine due to increased hypertension risk 6

Pyridostigmine 2, 5:

• Dose: 30-60 mg three times daily
• May be used as adjunct therapy
• Less likely to cause supine hypertension

Special Populations

Elderly and Frail Patients

When initiating BP-lowering treatment in patients aged ≥85 years or with moderate-to-severe frailty, use long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line agents, followed by low-dose diuretics if tolerated 3, 4:

• Avoid beta-blockers and alpha-blockers unless compelling indications exist 3, 4
• Consider deprescribing BP-lowering medications if BP drops with progressing frailty 3, 4

Dialysis Patients

For chronic hypotension in hemodialysis patients 3:

• Increase dialysis time to reduce ultrafiltration rate
• Consider transition to peritoneal dialysis, which may be better tolerated
• Adjust dialysate sodium concentration (though optimal concentration remains uncertain)

For peritoneal dialysis patients with hypotension 3:

• Reduce ultrafiltration volume by adjusting solutions (use less hypertonic glucose or change icodextrin to 1.5% glucose)
• Omit day dwell (in automated PD) or night dwell (in continuous ambulatory PD) in those with significant residual kidney function
• Liberalize salt intake if appropriate

Critical Pitfalls to Avoid

Do not rely solely on BP numbers in elderly patients—assess organ perfusion clinically 1. A BP of 83/52 may be well-tolerated in some elderly patients without symptoms.

Do not simply reduce antihypertensive doses in patients with orthostatic hypotension and supine hypertension—switch to alternative agents instead 3, 4.

Do not administer midodrine if patient will be supine for extended periods or within 3-4 hours of bedtime due to risk of severe supine hypertension 6.

Avoid excessive fluid boluses in patients with cardiac dysfunction or signs of volume overload (pulmonary edema), as this can precipitate cardiogenic shock 3.

Screen for adrenal insufficiency in vasopressor-resistant hypotension—these patients may respond to stress-dose hydrocortisone alone, avoiding high-dose lymphocytotoxic corticosteroids 3.