What is the management approach for hypertensive related sepsis?

Management of Hypotension in Sepsis (Not Hypertensive Crisis)

The question appears to contain a terminology error—"hypertensive related sepsis" likely refers to hypotension/septic shock rather than hypertension with sepsis, as sepsis characteristically causes hypotension, not hypertension. I will address the management of septic shock with hypotension, which is the life-threatening emergency requiring immediate intervention.

Initial Fluid Resuscitation

Administer at least 30 mL/kg of intravenous crystalloid solution within the first 3 hours, targeting a mean arterial pressure (MAP) of 65 mmHg. 1

• Begin with a rapid bolus of at least 20 mL/kg of crystalloid solution for adults with sepsis and tissue hypoperfusion 2
• Some patients may require several liters during the first 24 hours to adequately resuscitate 2
• Monitor response to fluid loading by assessing: ≥10% increase in systolic/mean arterial pressure, ≥10% reduction in heart rate, improvement in mental state, peripheral perfusion, and/or urine output 2
• Stop fluid resuscitation if no improvement occurs or if crepitations develop, indicating fluid overload or impaired cardiac function 2

Vasopressor Initiation and Selection

Start norepinephrine as the first-line vasopressor as soon as hypotension persists despite initial fluid resuscitation, targeting MAP ≥65 mmHg. 2, 3

• Norepinephrine is the first-choice vasopressor recommended by the Surviving Sepsis Campaign 2
• Begin dosing at 0.02-0.05 μg/kg/min and titrate to achieve target MAP, with maximum dose of 0.1-0.2 μg/kg/min 3
• For patients with chronic hypertension, consider higher MAP targets of 70-75 mmHg 3
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring 2, 1

Vasopressor Escalation Protocol

If MAP target cannot be achieved with norepinephrine alone, add vasopressin at a fixed dose of 0.03 units/minute rather than increasing norepinephrine further. 2, 1

• Vasopressin acts on different vascular receptors (V1) than norepinephrine, providing complementary vasoconstriction 1
• Do not exceed 0.03-0.04 units/minute due to risk of cardiac, digital, and splanchnic ischemia 1
• Vasopressin should not be used as monotherapy 3

If hypotension persists despite norepinephrine plus vasopressin, add epinephrine as a third agent at 0.05-2 mcg/kg/min. 1, 4

• Epinephrine is FDA-approved for hypotension associated with septic shock 4
• Titrate in increments of 0.05-0.2 mcg/kg/min every 10-15 minutes to achieve desired MAP 4
• After hemodynamic stabilization, wean incrementally over 12-24 hours 4

Inotropic Support

Consider dobutamine infusion up to 20 μg/kg/min if there is evidence of persistent hypoperfusion despite adequate fluid loading and vasopressor support, particularly if myocardial dysfunction is present. 2, 1

• Titrate to endpoints reflecting tissue perfusion 2
• Reduce or discontinue if worsening hypotension or arrhythmias develop 2

Corticosteroid Therapy

Administer hydrocortisone 200 mg/day (50 mg IV every 6 hours) only if hemodynamic stability cannot be achieved despite adequate fluid resuscitation and vasopressor therapy. 2, 1

• Consider if patient remains refractory after 4 hours of norepinephrine or epinephrine at ≥0.25 mcg/kg/min 1
• Use continuous flow administration 2
• Taper when vasopressors are no longer required 2
• Do not use corticosteroids for sepsis without shock 2

Monitoring Tissue Perfusion

Continuously monitor tissue perfusion markers beyond blood pressure alone: lactate levels, urine output (target ≥0.5 mL/kg/h), mental status, and capillary refill. 2, 1

• Oliguria is defined as urine output ≤0.5 mL/kg/h for at least 2 hours despite adequate fluid resuscitation 2
• Monitor for signs of tissue hypoperfusion including decreased capillary refill, skin mottling, and peripheral cyanosis 2

Critical Pitfalls to Avoid

Do not use dopamine as a first-line vasopressor—it is associated with higher mortality and more arrhythmias compared to norepinephrine. 2, 3, 1

• Dopamine should only be considered in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia 2, 3
• Low-dose dopamine for "renal protection" is strongly contraindicated and offers no benefit 2, 1

Avoid phenylephrine except in specific circumstances—it may raise blood pressure while worsening tissue perfusion through excessive vasoconstriction. 3, 1

• Only use if norepinephrine causes serious arrhythmias, cardiac output is documented high with persistent hypotension, or as salvage therapy 2, 3

Do not delay antibiotic administration—door-to-antibiotic time is directly associated with mortality in sepsis. 5

• Patients without initial hypotension may experience delays in antibiotic administration, which increases mortality risk 5