What would be an appropriate intervention to manage hypotension in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease (CKD), Pulmonary Embolism (PE), and Coronary Artery Disease (CAD)?

From the Guidelines

I strongly recommend performing a passive leg raise (PLR) test to assess fluid responsiveness in this patient with a blood pressure of 98/41 and a mean arterial pressure (MAP) of 60, given her complex medical history of COPD, CKD, PE, and CAD. The patient's hypotension requires immediate attention to prevent organ hypoperfusion, particularly given her history of CKD. According to the perioperative quality initiative consensus statement on postoperative blood pressure, risk and outcomes for elective surgery 1, a PLR test can help determine if the patient will respond to fluid administration, with a positive likelihood ratio of 11 and a pooled specificity of 92%. If the PLR test is positive, indicating fluid responsiveness, administering a 500 mL intravenous bolus of lactated Ringer’s solution would be an appropriate next step, as suggested by the study 1. However, if the PLR test does not correct hypotension, further management should focus on vascular tone and chronotropy/inotropy, potentially requiring vasopressor or inotropic support. Given the patient's history of CAD, norepinephrine would be a preferred vasopressor option, as it provides both alpha and beta adrenergic effects, increasing vascular tone while maintaining cardiac output. The dose of norepinephrine should be titrated to maintain a MAP of at least 65 mmHg, with careful monitoring of urine output, respiratory status, and cardiac function to avoid volume overload and other potential complications. Key considerations in managing this patient's hypotension include:

• Careful fluid administration to avoid volume overload, given her history of COPD and CKD
• Monitoring of cardiac function and potential adjustment of vasopressor or inotropic support as needed
• Close attention to the patient's respiratory status, given her history of COPD and PE
• Consideration of transfer to a higher level of care if necessary to deliver appropriate therapies, dependent on local facilities and available resources.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. An infusion of LEVOPHED should be given into a large vein (see PRECAUTIONS) 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 Average Dosage: Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution. Each mL of this dilution contains 4 mcg of the base of LEVOPHED Give this solution by intravenous infusion. 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 patient's blood pressure is 98/41 with a mean arterial pressure (MAP) of 60. Norepinephrine (IV) can be considered to help boost the patient's blood pressure. The average initial dose is 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, which can be adjusted to maintain a low normal blood pressure. However, it is essential to correct blood volume depletion as fully as possible before administering any vasopressor.

• Key considerations:
  • The patient has a history of COPD, CKD, PE, and CAD, which may impact the treatment approach.
  • Norepinephrine (IV) should be used with caution in patients with hypertension and cardiac disease.
  • The patient's fluid status should be closely monitored, and blood volume replacement should be considered as needed.
  • The dosage of Norepinephrine (IV) should be titrated according to the patient's response, and the infusion rate should be adjusted to maintain a low normal blood pressure 2.
  • Contraindications for Norepinephrine (IV) include hypotension from blood volume deficits, mesenteric or peripheral vascular thrombosis, and cyclopropane and halothane anesthesia 2.

From the Research

Patient's Condition

The patient, Rey Rueda, has a blood pressure (BP) of 98/41 and a mean arterial pressure (MAP) of 60. The patient's history includes COPD, CKD, PE, and CAD.

Treatment Options

To boost the patient's BP, several treatment options can be considered:

• Norepinephrine: A study published in 2020 3 found that early initiation of norepinephrine in patients with septic shock was associated with decreased short-term mortality and shorter time to achieved target MAP.
• Phenylephrine: A study published in 2006 4 found that administration of phenylephrine increased cardiac and systemic vascular resistance indexes with minimal effect on heart rate, and may be useful for increasing mean arterial pressure without increasing heart rate.
• Epinephrine: A study published in 2018 5 found that reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes.
• Dobutamine: A study published in 2006 4 found that administration of dobutamine increased oxygen delivery and heart rate, and may be useful for increasing cardiac output.

Comparison of Vasopressors

A study published in 2012 6 compared the effects of norepinephrine, epinephrine, and phenylephrine on septic myocardial dysfunction. The study found that norepinephrine and epinephrine improved mean arterial pressure, cardiac output, and preload recruitable stroke work, while phenylephrine exhibited deleterious effects on systolodiastolic function and ventriculoarterial coupling. A study published in 2023 7 compared the effects of norepinephrine and phenylephrine on intraoperative hypotension in adult patients undergoing major noncardiac surgery. The study found that there was no significant difference in acute kidney injury, 30-day mortality, myocardial injury after noncardiac surgery, hospital length of stay, and rehospitalisation within 30 days between the two groups.

Key Points

• Norepinephrine may be a suitable option for increasing BP in patients with septic shock 3.
• Phenylephrine may be useful for increasing mean arterial pressure without increasing heart rate 4.
• Epinephrine may not be associated with improved outcomes in cardiac arrest patients 5.
• Dobutamine may be useful for increasing cardiac output 4.
• Norepinephrine and epinephrine may improve myocardial function in septic shock, while phenylephrine may exhibit deleterious effects 6.