How to manage a patient with hypotension?

Management of Hypotension (BP 90/59 mmHg)

For a patient with BP 90/59 mmHg, immediate management depends critically on whether symptoms or end-organ dysfunction are present—asymptomatic patients require observation and evaluation for underlying causes, while symptomatic patients need urgent bedside assessment with passive leg raise testing to guide fluid versus vasopressor therapy. 1, 2

Initial Assessment Algorithm

Determine Hemodynamic Stability

• Assess for symptoms and signs of end-organ dysfunction immediately: altered mental status, chest pain, dyspnea, oliguria, or syncope 1, 2
• Unstable patients displaying any end-organ dysfunction signs require treatment in a high-acuity care setting 1
• Stable, asymptomatic patients with isolated hypotension may be observed while investigating underlying causes 2

Perform Focused Clinical Evaluation

• Document orthostatic vital signs: measure BP after 5 minutes supine/seated, then at 1 and 3 minutes after standing to identify orthostatic hypotension (drop >20 mmHg systolic or >10 mmHg diastolic) 1, 3
• Measure heart rate response to standing to assess baroreflex integrity 3
• Look for specific causes: medication effects (antihypertensives, diuretics), dehydration, blood loss, sepsis, cardiac dysfunction, or endocrine disorders (adrenal insufficiency, hypothyroidism) 1, 4

Treatment Based on Clinical Presentation

For Symptomatic Hypotension (Lightheadedness, Dizziness, Syncope)

Step 1: Perform Passive Leg Raise (PLR) Test

• Elevate legs passively and observe for clinical improvement 1, 2
• A positive PLR test (improvement in symptoms/BP) strongly predicts fluid responsiveness with positive likelihood ratio of 11 and pooled specificity of 92% 1
• A negative PLR test (no improvement) has negative likelihood ratio of 0.13 and pooled sensitivity of 88%, indicating fluid will not help 1

Step 2: Treat Based on PLR Results

If PLR is positive (fluid-responsive):

• Administer intravenous crystalloid fluids as first-line therapy 1, 2
• Use 0.9% sodium chloride or balanced crystalloid solution 1
• Typical initial bolus: 500 mL lactated Ringer's or normal saline 1
• Reassess after fluid administration 1

If PLR is negative (not fluid-responsive):

• Vasopressor support is indicated when vascular tone correction is needed 1, 2
• For hypotension with tachycardia: phenylephrine 1-10 mcg/kg/min IV is preferred 1
• Avoid phenylephrine if bradycardia is present due to risk of reflex bradycardia 1
• For persistent hypotension: dopamine 5-15 mcg/kg/min IV 1, 5 or noradrenaline if severe (systolic BP <80 mmHg) 1
• For chronic persistent hypotension: oral ephedrine 25-50 mg orally, 3-4 times daily may be useful 1

For Asymptomatic Hypotension

• Observation is appropriate as isolated low BP without symptoms does not require immediate intervention 2
• Investigate underlying causes systematically 4, 6:
  • Review all medications, especially antihypertensives, diuretics, and vasodilators 1
  • Assess for orthostatic hypotension with formal standing BP measurements 1, 3
  • Consider endocrine causes: adrenal insufficiency (check cortisol, ACTH), hypothyroidism, hypoaldosteronism (check renin, aldosterone, potassium) 4
  • Evaluate for autonomic dysfunction, especially in diabetics or elderly patients 4, 3
  • Rule out chronic conditions: heart failure, severe valvular disease, chronic blood loss 7

Critical Management Caveats

When to Escalate Care Immediately

Transfer to higher acuity setting if hypotension is accompanied by: 1, 2

• Altered mental status or confusion 1
• Chest pain or acute dyspnea 1
• Oliguria or signs of renal hypoperfusion 1
• Persistent symptoms despite initial fluid or vasopressor interventions 1, 2

Common Pitfalls to Avoid

• Do not reflexively give IV fluids without assessing fluid responsiveness—approximately 50% of hypotensive patients are not fluid-responsive and require vasopressor/inotropic support instead 1, 2
• Do not assume all hypotension requires treatment—asymptomatic chronic hypotension may be constitutional and benign 2, 6
• Do not use phenylephrine in bradycardic patients as it causes reflex bradycardia, especially in preload-independent states 1
• Do not abruptly discontinue vasopressors—wean gradually while expanding blood volume to prevent rebound hypotension 5

Special Populations

Elderly or frail patients:

• Test for orthostatic hypotension before intensifying any BP-lowering medications 1
• Pursue non-pharmacological approaches first for orthostatic hypotension (adequate hydration, compression stockings, physical countermaneuvers) 1, 3
• Switch medications that worsen orthostatic hypotension rather than simply reducing doses 1

Patients on chronic antihypertensives:

• Consider holding or reducing BP medications if symptomatic 1
• Do not abruptly discontinue all antihypertensives in elderly patients, as this may cause rebound hypertension 1