Ensure adequate tissue perfusion (maintain SvO2 >70 with use of blood or dobutamine)
Address the underlying problem (i.e., antibiotic for infection, stent or CABG (coronary artery bypass graft surgery) for infarction, steroids for adrenal insufficiency, etc...)The best way to determine if a person will benefit from fluids is by doing a passive leg raise followed by measuring the output from the heart. Medication
Chronic hypotension sometimes requires the use of medications. Some medications that are commonly used include Fludrocortisone, Erythropoietin, and Sympathomimetics such as Midodrine and Noradrenaline and precursor (L-DOPS). Fludrocortisone is the first-line therapy (in the absence of heart failure) for patients with chronic hypotension or resistant orthostatic hypotension. It works by increasing the intravascular volume. Midodrine is a therapy used for severe orthostatic hypotension, and works by increasing peripheral vascular resistance. Noradrenaline and its precursor L-DOPS are used for primary autonomic dysfunction by increasing vascular tone. Erythropoietin is given to patients with neurogenic orthostatic hypotension and it works through increasing vascular volume and viscosity. Pediatrics
The definition of hypotension changes in the pediatric population depending on the childs age as seen in the table below. The clinical history provided by the caretaker is the most important part in determining the cause of hypotension in pediatric patients. Symptoms for children with hypotension include increased sleepiness, not using the restroom as much (or at all), having difficulty breathing or breathing rapidly, or syncope. The treatment for hypotension in pediatric patients is similar to the treatment in adults by following the four first steps listed above (see Treatment).
Syndromes
Orthostatic hypotension
Orthostatic hypotension, also called postural hypotension, is a common form of low blood pressure. It occurs after a change in body position, typically when a person stands up from either a seated or lying position. It is usually transient and represents a delay in the normal compensatory ability of the autonomic nervous system. It is commonly seen in hypovolemia and as a result of various medications. In addition to blood pressure-lowering medications, many psychiatric medications, in particular antidepressants, can have this side effect. Simple blood pressure and heart rate measurements while lying, seated, and standing (with a two-minute delay in between each position change) can confirm the presence of orthostatic hypotension. Taking these measurements is known as orthostatic vitals. Orthostatic hypotension is indicated if there is a drop of 20 mmHg in systolic pressure (and a 10 mmHg drop in diastolic pressure in some facilities) and a 20 beats per minute increase in heart rate. Vasovagal syncope
Vasovagal syncope is a form of dysautonomia characterized by an inappropriate drop in blood pressure while in the upright position. Vasovagal syncope occurs as a result of increased activity of the vagus nerve, the mainstay of the parasympathetic nervous system. Patients will feel sudden, unprovoked lightheadedness, sweating, changes in vision, and finally a loss of consciousness. Consciousness will often return rapidly once patient is lying down and the blood pressure returns to normal. Other
Another, but rarer form, is postprandial hypotension, a drastic decline in blood pressure that occurs 30 to 75 minutes after eating substantial meals.