How to manage hypotension in a patient with cellulitis?

From the Guidelines

For a patient with cellulitis who is hypotensive, immediate management should focus on fluid resuscitation and vasopressors if needed, with the goal of maintaining a mean arterial pressure (MAP) of at least 65 mmHg, as recommended by the Surviving Sepsis Campaign guidelines 1. To achieve this, start with rapid intravenous crystalloid fluids, typically 30 mL/kg of normal saline or lactated Ringer's solution over the first hour.

• Key considerations include:
  • Monitoring the patient's response to fluid resuscitation closely
  • Initiating vasopressor therapy with norepinephrine as the first-line agent if hypotension persists, starting at 0.05-0.1 mcg/kg/minute and titrating to maintain the target MAP
  • Addressing the underlying cellulitis with appropriate antibiotics, such as vancomycin 15-20 mg/kg IV every 12 hours (for suspected MRSA) plus piperacillin-tazobactam 4.5g IV every 6 hours (for broad coverage), as suggested by guidelines for the management of skin and soft tissue infections 1
  • Obtaining blood cultures before starting antibiotics if possible, but not delaying treatment
  • Monitoring the patient closely with serial vital signs, urine output measurements, and laboratory tests to assess response to treatment and organ perfusion Hypotension in cellulitis may indicate progression to sepsis, where the inflammatory response to infection causes vasodilation and increased vascular permeability, leading to decreased effective circulating volume and hypotension.
• The management approach should prioritize the patient's hemodynamic stability and the treatment of the underlying infection, with adjustments made based on the patient's response to initial therapy and the results of diagnostic tests.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

To get the blood pressure up in a patient with cellulitis who is hypotensive, administer epinephrine intravenously. The suggested dosing infusion rate is 0.05 mcg/kg/min to 2 mcg/kg/min, and should be titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min 2.

From the Research

Management of Hypotension in Cellulitis

To manage hypotension in a patient with cellulitis, it is essential to consider the underlying cause of the hypotension, which in this case may be related to sepsis. The following steps can be taken:

• Administer fluid resuscitation to increase blood pressure. The choice of fluid is crucial, with studies suggesting that balanced crystalloids such as lactated Ringer's solution may be associated with improved outcomes compared to normal saline 3.
• The initial fluid resuscitation dose is also important, with a medium initial fluid volume dose of 20-30 mL/kg within the first hour potentially associated with reduced 28-day mortality 4.
• Consider the composition of the fluid, with balanced crystalloids potentially having a beneficial effect on mortality compared to saline, particularly when started in the emergency department 5.

Fluid Resuscitation

The goal of fluid resuscitation is to restore adequate blood pressure and perfusion of vital organs. The following points should be considered:

• Lactated Ringer's solution may be a better choice than normal saline for initial fluid resuscitation in patients with sepsis-induced hypotension, with potential benefits including improved survival and more hospital-free days 3.
• The use of balanced crystalloids compared to normal saline did not reduce mortality, risk of severe acute kidney injury, or renal replacement therapy use rate in critically ill patients in some studies 6.
• However, other studies suggest that balanced crystalloids may have a beneficial effect on mortality, particularly when started early in the treatment of sepsis 5.

Sepsis Management

In patients with sepsis, it is essential to follow established guidelines for management, including:

• Early recognition and treatment of sepsis, with administration of antibiotics and fluid resuscitation as needed.
• Consideration of the patient's individual needs and response to treatment, with adjustment of the treatment plan as necessary.
• Monitoring of the patient's vital signs, including blood pressure, and adjustment of treatment to maintain adequate perfusion of vital organs.