Management of Hypotension Post Plasma Exchange

Initial Assessment and Fluid Responsiveness Testing

The British Journal of Anaesthesia recommends performing bedside hemodynamic assessment to determine the underlying cause of hypotension before initiating treatment, and using passive leg raise (PLR) testing to predict fluid responsiveness, with a positive likelihood ratio of 11 and specificity of 92% 1, 2
Approximately 50% of hypotensive patients post-procedure will respond to fluid administration, while the remaining patients require vasopressor or inotropic support rather than volume expansion, according to the British Journal of Anaesthesia 1, 2
Non-invasive cardiac output monitors or portable ultrasound devices can be used to identify whether the hypotension is due to inadequate preload, reduced vascular tone, or myocardial dysfunction, as suggested by the British Journal of Anaesthesia 1, 2

The Critical Care society recommends initiating crystalloid fluid resuscitation with 0.9% sodium chloride or balanced crystalloid solution if PLR testing is positive, and administering fluid boluses judiciously to achieve target blood pressure while avoiding excessive volume administration 3, 4
Colloids should be avoided due to adverse effects on hemostasis and lack of demonstrated superiority over crystalloids, according to the Critical Care society 3, 4

The Critical Care society recommends initiating noradrenaline (norepinephrine) as the first-line vasopressor if fluid resuscitation fails to achieve target blood pressure or PLR testing is negative, with a Grade 1C recommendation 3, 4, 5
Noradrenaline should be administered in addition to fluids, not as a replacement for appropriate volume resuscitation, as suggested by the Critical Care society 3, 4
Phenylephrine should be avoided in bradycardic patients as it can cause reflex bradycardia, especially in preload-independent states, according to the British Journal of Anaesthesia 1, 2

The Critical Care society recommends administering dobutamine if myocardial dysfunction is identified as the cause of hypotension, with a Grade 1C recommendation 3, 4
Inotropic agents are indicated when hypotension results from reduced cardiac contractility rather than inadequate preload or vascular tone, as suggested by the Critical Care society 3, 4, 5

The British Journal of Anaesthesia recommends monitoring for symptomatic hypotension requiring immediate treatment, and transferring to a higher level of care if hypotension persists despite initial interventions or if the patient requires multiple vasoactive agents 1, 2
The Stroke society recommends documenting clinical neurological examination and hemodynamic parameters before and after plasma exchange procedures 6
For persistent hypotension despite initial therapy, the British Journal of Anaesthesia suggests reassessing fluid status and cardiac function using available monitoring tools, and considering adding additional vasopressor support if single-agent therapy is insufficient 1, 2, 3, 4

Target a mean arterial pressure of 65 mmHg or systolic blood pressure of 80-100 mmHg during initial resuscitation, according to the Critical Care guideline 7

The American College of Critical Care recommends initiating norepinephrine as the first-line vasopressor if fluid resuscitation fails to achieve target blood pressure, with an initial infusion rate of 2-3 mL per minute (8-12 mcg per minute) 7