What is the approach to managing hypotension (low blood pressure)?

From the Guidelines

The approach to hypotension should begin with identifying and treating the underlying cause while simultaneously stabilizing the patient, with crystalloid as the initial fluid resuscitation fluid of choice, as recommended by the most recent study 1. The first step in managing hypotension is to ensure adequate fluid resuscitation with crystalloids like normal saline or lactated Ringer's at 20-30 mL/kg IV bolus, reassessing after each bolus.

• If hypotension persists despite fluid resuscitation, vasopressors should be initiated.
• Norepinephrine is the first-line agent due to its reliable increase in mean arterial pressure with minimal chronotropic effects, as supported by studies 1.
• For cardiogenic shock, adding dobutamine to improve cardiac output may be considered, while in septic shock, maintaining mean arterial pressure ≥65 mmHg is recommended 1.
• Vasopressin can be added as a second agent in refractory cases, as suggested by the study 1. Throughout treatment, continuously monitoring vital signs, urine output, mental status, and lactate levels to assess perfusion is crucial.
• The physiological goal is to restore adequate tissue perfusion by maintaining sufficient cardiac output and vascular tone, as prolonged hypotension leads to organ dysfunction through inadequate oxygen delivery to tissues.
• A passive leg raise (PLR) test can be useful in detecting whether inadequate preload is contributing to hypotension, and guiding further management, as discussed in the study 1.

From the FDA Drug Label

For blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions). As an adjunct in the treatment of cardiac arrest and profound hypotension. The approach to hypotension using norepinephrine (IV) involves its use for blood pressure control in certain acute hypotensive states. Key points include:

• Indications: certain acute hypotensive states
• Use: as an adjunct in the treatment of cardiac arrest and profound hypotension 2

From the Research

Hypotension Approach

• The management of patients with severe sepsis and septic shock involves the use of crystalloids as the initial fluid solution of choice in resuscitation, as recommended by current guidelines 3.
• Balanced crystalloids, such as lactated Ringer's solution, may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available 3, 4.
• Semi-synthetic colloids are not recommended, as they have been shown to decrease survival in patients with severe sepsis and septic shock 3.
• The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain and requires further research 3.
• Initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, may be associated with improved survival in patients with sepsis-induced hypotension 4.
• Point of care ultrasound (POCUS) can be a useful tool in assessing volume status and guiding fluid management, but should be used in conjunction with clinical judgment and physical examination, rather than as a replacement for it 5.

Fluid Resuscitation

• Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock 3.
• Lactated Ringer's solution may be a better choice than 0.9% saline for initial fluid resuscitation in patients with sepsis-induced hypotension, due to its potential to improve survival and reduce hospital-free days 4.
• The choice of fluid for resuscitation should be based on the individual patient's needs and clinical status, rather than a one-size-fits-all approach.

Volume Status Assessment

• Traditional non-invasive methods of volume assessment, such as skin turgor and jugular venous distension, have limitations and can be subjective 5.
• Invasive assessments of volume status, such as central venous pressure and pulmonary artery pressures, also have limitations and challenges 5.
• POCUS can be a useful tool in assessing volume status, but should be used in conjunction with clinical judgment and physical examination, rather than as a replacement for it 5.