What does hypotension with a blood pressure of 78/49 and a mean arterial pressure (MAP) of 48 indicate and how is it treated?

From the Guidelines

Hypotension with a blood pressure of 78/49 and a mean arterial pressure (MAP) of 48 indicates severe hypotension and inadequate perfusion, requiring immediate attention and treatment.

Treatment Approach

• The primary goal is to restore a mean arterial pressure (MAP) of 65 mmHg as soon as possible, as recommended by the Surviving Sepsis Campaign guidelines 1.
• Fluid therapy should be initiated promptly to improve microvascular blood flow and increase cardiac output, with crystalloid solutions being the first choice due to their well-tolerated and cost-effective nature 1.
• Vasopressor therapy may be necessary if fluid resuscitation alone is insufficient to achieve the target MAP, with norepinephrine being the first-line vasopressor agent 1.
• The choice of vasopressor and fluid management should be guided by clinical endpoints, such as mean arterial pressure, skin color, capillary refill, mental status, and urinary output, rather than a predetermined protocol 1.
• Central venous access and monitoring of central venous pressure may be helpful in guiding fluid management, but simpler non-invasive devices, such as tissue perfusion monitors, may also be useful 1.

Key Considerations

• Early recognition and prompt treatment of sepsis and septic shock are crucial to improving patient outcomes 1.
• Individualized treatment approaches should be tailored to the specific needs and clinical response of each patient, rather than relying on a one-size-fits-all protocol 1.
• Repeated measurements of clinical endpoints, such as mean arterial pressure and urinary output, should be used to guide fluid and vasopressor management 1.

From the Research

Hypotension Indication

• A blood pressure of 78/49 and a mean arterial pressure (MAP) of 48 indicates hypotension, which is a condition where the blood pressure is lower than normal 2, 3, 4, 5.
• According to the study by 2, a MAP of less than 70 mmHg can be used as a sensitive indicator of hypotension.
• The study by 3 suggests that a MAP target of at least 65 mmHg is recommended, and higher in older patients and in patients with chronic hypertension or atherosclerosis.
• However, the study by 5 found that a MAP of 72 to 82 mmHg may be necessary to avoid acute kidney insufficiency in patients with septic shock and initial renal function impairment.

Treatment of Hypotension

• The treatment of hypotension depends on the underlying cause and severity of the condition 6, 4.
• According to the study by 6, controlled hypotension can be achieved using various pharmacological agents, including inhalation anaesthetics, sodium nitroprusside, nitroglycerin, and calcium channel antagonists.
• The study by 4 suggests that the lowest tolerable intraoperative blood pressure should be defined according to the individual patient's preoperative blood pressure and risk profile.
• The use of vasopressors, such as norepinephrine or epinephrine, may be necessary to increase blood pressure in patients with severe hypotension 3.
• However, the study by 3 found that higher blood pressure targets were associated with a greater risk of new-onset supraventricular cardiac arrhythmia.

Key Considerations

• The management of hypotension requires careful consideration of the individual patient's risk factors, underlying medical conditions, and the potential consequences of hypotension 4, 5.
• The study by 5 highlights the importance of maintaining adequate renal perfusion pressure to prevent acute kidney insufficiency.
• The use of MAP as a guide for blood pressure management is recommended, as it is a more reliable indicator of organ perfusion than systolic blood pressure alone 2, 3, 4, 5.