Management of Hypotension
In a hypotensive patient, immediately assess for reversible causes—hypovolemia, arrhythmias, drug-induced hypotension, and mechanical complications—while simultaneously initiating gentle volume loading if there is no evidence of congestion, followed by vasopressor support with norepinephrine if hypotension persists despite adequate filling. 1
Initial Assessment and Stabilization
Identify the Mechanism and Correct Reversible Causes
The first critical step is determining whether hypotension results from hypovolemia, cardiogenic shock, distributive shock, or obstructive causes 1.
Key reversible causes to address immediately: 1
- Hypovolemia: Assess for collapsible inferior vena cava, low jugular venous pressure, and poor tissue perfusion 1
- Arrhythmias: Bradycardia or tachyarrhythmias should be corrected or controlled 1
- Drug-induced hypotension: Review recent medications 1
- Mechanical complications: Rule out tamponade, valve dysfunction, or ventricular septal defect 1
Hemodynamic Monitoring
Establish continuous monitoring immediately: 1, 2
- Continuous cardiac monitoring and pulse oximetry 2
- Frequent blood pressure measurements (consider arterial line for accuracy) 2
- Obtain 12-lead ECG to evaluate for arrhythmias, ischemia, or conduction abnormalities 2
- Document neurological status including level of consciousness 2
Volume Management Strategy
When to Give Fluids
In patients with hypotension and normal perfusion without evidence of congestion (collapsible inferior vena cava), gentle volume loading should be attempted after ruling out mechanical complications. 1
Critical caveat for RV infarction: Volume overload should be avoided as it might worsen hemodynamics 1. In patients with RV infarction presenting with high jugular venous pressure and poor tissue perfusion, fluid administration can be detrimental 1.
Fluid Responsiveness Assessment
Perform a passive leg raise (PLR) test before administering additional fluids, as this strongly predicts fluid responsiveness with a positive likelihood ratio of 11 and pooled specificity of 92% 2. If PLR does not correct hypotension, focus on vasopressor and inotropic support rather than additional fluids 2.
Approximately 50% of hypotensive patients are fluid-responsive, making aggressive fluid resuscitation the initial step 2. However, if the patient shows signs of congestion or volume overload, diuretics—not fluids—are indicated 1.
Vasopressor and Inotropic Support
First-Line Vasopressor Therapy
Initiate norepinephrine as the first-line vasopressor after appropriate fluid resuscitation in distributive shock, targeting mean arterial pressure ≥65 mmHg. 2 Norepinephrine is also the preferred vasopressor when mean arterial pressure needs pharmacologic support in cardiogenic shock with persistent hypotension and tachycardia 1, 3.
Important FDA warning: Norepinephrine should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed 4. Continuous administration to maintain blood pressure without volume replacement may cause severe peripheral vasoconstriction, decreased renal perfusion, tissue hypoxia, and lactate acidosis 4.
Inotropic Support for Cardiogenic Shock
For cardiogenic shock, use dobutamine as the first-line inotrope, adding norepinephrine if hypotension persists with tachycardia. 2 In patients with heart failure and adequate blood pressure (SBP >90 mmHg) but severe reduction in cardiac output resulting in compromised vital organ perfusion, treatment with dobutamine or levosimendan may be considered 1.
Inotropic agents are not recommended unless the patient is symptomatically hypotensive or hypoperfused due to safety concerns. 1 Short-term intravenous infusion may be considered in patients with systolic blood pressure <90 mmHg and signs of peripheral hypoperfusion to maintain end-organ function 1.
Alternative Vasopressor Options
Dopamine may be considered if signs of renal hypoperfusion are present, starting at 2.5–5.0 μg/kg/min 1. However, dopamine requires close monitoring as hypoxia, hypercapnia, and acidosis reduce its effectiveness and increase adverse effects 5. If hypotension persists despite dopamine, switch to norepinephrine 1, 5.
A vasopressor (norepinephrine preferably) may be considered in patients with cardiogenic shock despite treatment with another inotrope to increase blood pressure and vital organ perfusion. 1
Special Consideration: Adrenal Insufficiency
When to Suspect Adrenal Insufficiency
Adrenal insufficiency must be considered in any patient with unexplained hypotension, especially if refractory to fluids and vasopressors. 6, 7 This is particularly critical because hypotension refractory to fluids and requiring vasopressors is the most common presentation of adrenal insufficiency in the ICU 7.
High-risk scenarios include: 6
- Any patient taking ≥20 mg/day prednisone or equivalent for at least 3 weeks who develops unexplained hypotension 6
- Hypotension requiring high-dose vasopressors or multiple vasopressor agents that remains refractory to treatment 6
- Unexplained collapse with gastrointestinal symptoms (vomiting or diarrhea) 6
Key clinical features: 6
- Hyponatremia is present in 90% of newly diagnosed adrenal insufficiency cases 6
- The absence of hyperkalemia cannot rule out the diagnosis—it occurs in only ~50% of cases 6
- Do not rely on electrolyte abnormalities alone to make or exclude the diagnosis 6
Emergency Management of Suspected Adrenal Crisis
If unstable with suspected adrenal crisis, give 100 mg IV hydrocortisone immediately—do NOT delay for testing. 6 Treatment of suspected acute adrenal insufficiency should NEVER be delayed by diagnostic procedures, as mortality is high if untreated 6.
Concurrent management: 6
- Infuse 0.9% saline at 1 L/hour (at least 2L total) 6
- Draw blood for cortisol and ACTH before treatment if possible, but do not delay treatment 6
If the diagnosis is uncertain and you still need to perform ACTH stimulation testing later, use dexamethasone 4 mg IV instead of hydrocortisone, as dexamethasone does not interfere with cortisol assays 6.
Diagnostic Approach When Stable
Paired measurement of early morning (8 AM) serum cortisol and plasma ACTH is the first-line diagnostic test. 6 Serum cortisol <250 nmol/L (<9 μg/dL) with elevated ACTH in the presence of acute illness is diagnostic of primary adrenal insufficiency 6.
The ACTH stimulation test is the gold standard for confirming adrenal insufficiency when initial results are indeterminate, with a peak cortisol <500 nmol/L (<18 μg/dL) being diagnostic 6. However, never wait for diagnostic test results to treat suspected adrenal crisis 6.
Specific Clinical Scenarios
Hypotension in Acute Myocardial Infarction
Bradycardia-hypotension syndrome (warm hypotension with bradycardia, venodilatation, normal jugular venous pressure, decreased tissue perfusion) usually occurs in inferior infarction and responds to atropine or pacing 1.
Hypovolemia presents with venoconstriction, low jugular venous pressure, and poor tissue perfusion, responding to fluid infusion 1.
Right ventricular infarction presents with high jugular venous pressure, poor tissue perfusion or shock, bradycardia, and hypotension—avoid volume overload in these patients 1.
Hypotension in Acute Stroke
In acute ischemic stroke, hypotension should be avoided; although there is no evidence for a precise target, systolic pressure <140 mmHg could be detrimental. 1 If necessary, fluids and vasoconstrictors may be used to raise blood pressure 1.
For patients with intracerebral hemorrhage presenting within 6 hours with systolic blood pressure >150 mmHg, blood pressure should be reduced if immediate surgery is not planned. 1
In subarachnoid hemorrhage with an unsecured aneurysm, maintain systolic blood pressure <160 mmHg but avoid hypotension (systolic <110 mmHg). 1
Post-Carotid Artery Stenting
For neurologically intact patients with persistent hypotension after carotid artery stenting, an additional period of in-hospital observation may be required. 1 The oral adrenergic agent ephedrine (25 to 50 mg orally, 3 or 4 times daily) may be useful in managing persistent hypotension 1.
Monitoring Treatment Response
Target mean arterial pressure ≥65 mmHg in distributive shock, and monitor serial markers of systemic and organ perfusion including lactate, mixed or central venous oxygen saturations, urine output, skin perfusion, and mental status 2.
For cardiogenic shock, target cardiac index >2.0 L/min/m² with pulmonary capillary wedge pressure <20 mmHg. 3
Transfer Considerations
Transfer immediately to a tertiary care center with ICU/CCU capabilities for patients in cardiogenic shock or requiring advanced hemodynamic support. 2 If the pulse is truly non-recordable, initiate high-quality CPR immediately following ACLS protocols 2.