Management of Hypotension

Initial Assessment and Management

The first-line treatment for hypotension depends on its cause, with fluid resuscitation being the primary intervention for most forms, followed by vasopressors if fluid resuscitation fails to restore adequate blood pressure 1
Test for orthostatic hypotension before starting treatment by measuring blood pressure after 5 minutes of sitting/lying and then 1 and/or 3 minutes after standing 2
For mild hypotension, administer small boluses (5-10 mL/kg) of normal saline or balanced crystalloids 3
Consider patient positioning - elevate legs to improve venous return 3
If medication-induced, reduce or temporarily discontinue the causative medications 3

Crystalloids are the fluid of choice for initial resuscitation of hypotension 3
For significant hypotension, administer an initial fluid challenge of 30 mL/kg 3
Continue fluid administration as long as there is hemodynamic improvement based on dynamic or static variables 3
Consider albumin in addition to crystalloids when substantial amounts of crystalloids are required 3

Initiate vasopressor therapy if hypotension persists despite adequate fluid resuscitation 1, 3
Target a mean arterial pressure (MAP) of 65 mmHg 1, 3
Norepinephrine is the first-choice vasopressor for hypotension unresponsive to fluids 1, 3
For refractory hypotension, consider adding vasopressin (up to 0.03 U/min) or epinephrine to norepinephrine 1, 3
Dopamine should only be considered in highly selected patients with low risk of tachyarrhythmias or with relative bradycardia 1, 3

Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily, if not contraindicated 2
Implement physical counter-maneuvers, such as leg crossing, muscle tensing, squatting, and stooping 2
Use compression garments, including thigh-high and abdominal compression 2
Acute water ingestion of ≥480 mL can provide temporary relief, with peak effect occurring 30 minutes after consumption 2
Recommend smaller, more frequent meals to reduce post-prandial hypotension 2
Encourage physical activity and exercise to avoid deconditioning 2
Consider pharmacological treatment when non-pharmacological measures fail to adequately control symptoms 2
First-line medications include midodrine, fludrocortisone, and droxidopa 2

In cardiogenic shock, individualize MAP goals to balance hypoperfusion risk against potential negative impact on cardiac output 1
For acute heart failure, inotropes (dobutamine, dopamine, phosphodiesterase III inhibitors) are recommended as first-line agents 1
In persistently hypotensive cardiogenic shock with tachycardia, norepinephrine is advised 1
In patients with bradycardia, dopamine may be considered 1
In distributive shock (e.g., sepsis), norepinephrine is recommended as the initial vasoactive drug after appropriate fluid resuscitation 1
If hypotension persists, vasopressin (up to 0.03 UI/min) should be considered 1
For myocardial depression in septic shock, consider adding dobutamine to norepinephrine or using epinephrine as a single agent 1

Administration of vasoactive agents should always be targeted to effect and not based on a fixed dose 1
Monitor blood pressure using intra-arterial monitoring when using vasopressors 1
Complement MAP targets with other markers of perfusion, such as lactate, mixed or central venous oxygen saturations, urine output, skin perfusion, and mental status 1

Avoid delaying vasopressor use in cases of significant hypotension unresponsive to fluids 3
Avoid hydroxyethyl starches due to potential adverse effects 3
When using midodrine, avoid taking the last dose after 6 PM to prevent supine hypertension during sleep 2
Regular monitoring for adverse effects is essential, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone 2
For orthostatic hypotension, the therapeutic goal should be minimizing postural symptoms rather than restoring normotension 2