What is the algorithm to treat hypotension (low blood pressure)?

From the Guidelines

The treatment of hypotension should be based on the presumed underlying cause, including vasodilation, hypovolaemia, bradycardia, and low cardiac output, as recommended by the perioperative quality initiative (POQi) international consensus statement 1. To address hypotension, the following steps can be taken:

• Ensure adequate intravenous access and initiate fluid resuscitation with crystalloids, such as normal saline or lactated Ringer's solution, typically starting with a 500-1000 mL bolus in adults.
• If hypotension persists despite fluid administration, consider using vasopressors, with norepinephrine being a common first-line agent, starting at 0.01-0.1 mcg/kg/min and titrating to maintain a mean arterial pressure (MAP) of at least 65 mmHg 1.
• Alternatively, phenylephrine (40-60 mcg/min) or vasopressin (0.01-0.04 units/min) may be used, taking into account the side-effect profile of these drugs, such as reflex bradycardia with phenylephrine 1.
• For cardiogenic shock, dobutamine (2-20 mcg/kg/min) can be added to improve cardiac output, and in cases of adrenal insufficiency, hydrocortisone 100 mg IV every 8 hours should be administered.
• Continuous hemodynamic monitoring is essential during treatment, including blood pressure, heart rate, urine output, and mental status, to restore adequate tissue perfusion by increasing vascular tone, improving cardiac contractility, and ensuring sufficient intravascular volume 1. It is also important to consider the concept of permissive hypotension and restrictive volume resuscitation in certain patient populations, such as those without traumatic brain injury (TBI) or spinal injury, as supported by the European guideline on management of major bleeding and coagulopathy following trauma 1. However, this approach may need to be tailored to individual patient needs, taking into account factors such as chronic arterial hypertension and the potential for damage control resuscitation 1. Ultimately, the goal of hypotension treatment is to improve patient outcomes by addressing the underlying cause and restoring adequate tissue perfusion, while minimizing potential harms associated with aggressive fluid resuscitation or vasopressor use 1.

From the FDA Drug Label

Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs

The algorithm to treat hypotension involves:

• Correcting blood volume depletion as fully as possible before administering a vasopressor
• Administering norepinephrine (IV), such as LEVOPHED, at an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute
• Adjusting the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic)
• Monitoring the patient's response and adjusting the dosage as needed, with an average maintenance dose ranging from 0.5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base) 2

From the Research

Algorithm to Treat Hypotension

• The treatment of hypotension, particularly in patients with sepsis-induced hypotension, involves fluid resuscitation as a crucial step 3, 4, 5, 6, 7.
• The choice of fluid for resuscitation has been a topic of research, with studies comparing the outcomes of using lactated Ringer's solution versus 0.9% saline 3, 7.
• A study published in 2025 found that initial fluid resuscitation with lactated Ringer's solution, compared with 0.9% saline, might be associated with improved survival in patients with sepsis-induced hypotension 3.
• Another study from 2017 recommended crystalloids as the initial fluid solution of choice in the resuscitation of patients with severe sepsis and septic shock, suggesting that balanced crystalloids may improve patient-centered outcomes 4.
• Systematic reviews and meta-analyses have compared the efficacy and safety of balanced crystalloids with normal saline in critically ill patients, with mixed results regarding mortality, acute kidney injury, and the need for renal replacement therapy 5, 6.
• A retrospective analysis from 2023 found no significant difference in mortality rates, hospital length of stay, ICU admission, mechanical ventilation, oxygen therapy, and renal replacement therapy between sepsis patients receiving lactated Ringer's and normal saline as the predominant resuscitation fluid 7.

Key Findings

• Lactated Ringer's solution may be associated with improved survival compared to 0.9% saline in patients with sepsis-induced hypotension 3.
• Balanced crystalloids are recommended as the preferred solution for resuscitation in patients with severe sepsis and septic shock, potentially improving patient-centered outcomes 4.
• The choice between balanced crystalloids and normal saline may depend on specific patient populations, such as those with traumatic brain injury 5.
• Further large-scale prospective studies are needed to confirm or refute the current findings and solidify guidelines on the use of balanced crystalloids in fluid resuscitation 6, 7.