What are the maneuvers to increase pulse in a moribund patient with hypotension?

Management of Hypotension in a Moribund Patient

In a moribund patient with hypotension, immediately initiate rapid volume loading with crystalloid fluids (30 mL/kg) while simultaneously starting norepinephrine as the first-line vasopressor to maintain mean arterial pressure ≥65 mmHg, correct any rhythm disturbances, and consider intra-aortic balloon counterpulsation if hypotension persists despite these interventions. 1, 2, 3

Immediate Resuscitation Algorithm

Step 1: Rapid Volume Assessment and Fluid Challenge

• Administer rapid IV crystalloid infusion of 30 mL/kg body weight to patients without clinical evidence of volume overload 1, 3, 4
• This fluid challenge should be given quickly to assess volume responsiveness before concluding the patient has refractory shock 1, 2
• Do not delay vasopressor initiation in the presence of severe hypotension (systolic BP <80 mmHg), as brief episodes of hypotension significantly increase mortality even when lasting ≤10 minutes 5

Step 2: Vasopressor Therapy

• Start norepinephrine immediately as the first-line vasopressor at 0.05-0.2 mcg/kg/min, titrating to maintain MAP ≥65 mmHg 2, 3, 6
• Norepinephrine should be administered via central line when possible, though peripheral administration is acceptable while establishing central access 3
• Add vasopressin (up to 0.03 units/min) if norepinephrine alone fails to achieve target MAP, which may reduce overall norepinephrine requirements 3, 7
• Consider epinephrine (0.05-2 mcg/kg/min) as an alternative or additional agent when myocardial dysfunction is present or additional support is needed 2, 3, 6

Step 3: Correct Rhythm Disturbances

• Immediately correct any rhythm disturbances or conduction abnormalities causing hypotension, as these are reversible causes that must be addressed urgently 1
• Bradycardia or tachyarrhythmias can significantly worsen hemodynamic status and should be treated before concluding that shock is refractory 1

Step 4: Mechanical Circulatory Support

• Initiate intra-aortic balloon counterpulsation for patients who do not respond to fluid resuscitation and vasopressors, unless further support is futile due to patient wishes or contraindications 1
• This is particularly important in cardiogenic shock to improve coronary perfusion pressure 1

Critical Monitoring Requirements

Establish invasive arterial monitoring immediately in all moribund patients requiring vasopressors for continuous blood pressure assessment 1, 3

Monitor the following parameters continuously:

• ECG, blood pressure, oxygen saturation, and urine output 2
• Arterial blood gases and serum lactate as markers of tissue perfusion 2
• Clinical signs of perfusion: mental status, capillary refill, skin temperature 3

Context-Specific Considerations

If Cardiogenic Shock is Suspected:

• Add dobutamine (2.5-10 mcg/kg/min) if there is evidence of low cardiac output despite adequate preload and MAP 2, 3
• Perform echocardiography to evaluate for mechanical complications (ventricular septal rupture, papillary muscle rupture, tamponade) 1
• Consider emergency coronary revascularization, as this has been shown to decrease mortality in cardiogenic shock 1

Critical Pitfalls to Avoid:

• Never use morphine in a moribund patient, as it is specifically contraindicated in lethargic or moribund patients and can worsen hypotension 1
• Do not administer beta-blockers or calcium channel antagonists to patients in a low-output state due to pump failure 1
• Avoid using vasopressors as a substitute for adequate volume resuscitation in hypovolemic patients, though in moribund patients with imminent cerebral or coronary ischemia, they can be started concurrently 3
• Do not rely on tachycardia as an indicator of hypotension severity, as 35% of hypotensive trauma patients are not tachycardic, and absence of tachycardia should not provide false reassurance 8

Prognostic Context

While the term "moribund" suggests grave prognosis, recent data show 47% survival at 30 days in moribund surgical patients, indicating that aggressive resuscitation is not necessarily futile 9. However, even brief episodes of hypotension (≤10 minutes) significantly increase mortality in critically ill patients, making rapid intervention essential 5.

Oxygen and Airway Management

• Provide supplemental oxygen to maintain arterial saturation >90% 1, 2
• Consider endotracheal intubation if significant respiratory compromise is present, as this may be necessary to optimize oxygenation and reduce work of breathing 2