{"id":12821,"date":"2023-04-21T17:56:40","date_gmt":"2023-04-21T17:56:40","guid":{"rendered":"https:\/\/www.roshreview.com\/blog\/?p=12821"},"modified":"2023-05-01T15:46:36","modified_gmt":"2023-05-01T15:46:36","slug":"my-foolproof-guide-for-treating-hypotension-on-rounds","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/my-foolproof-guide-for-treating-hypotension-on-rounds\/","title":{"rendered":"My Foolproof Guide for Treating Hypotension on Rounds"},"content":{"rendered":"\n<h6 class=\"wp-block-heading\">As an anesthesiologist, I treat many patients with hypotension. Sometimes, it\u2019s my fault, but in those cases, it&#8217;s expected and correctable with the right medication. Of course, outside of the OR, the workup of hypotension, whether chronic or acute, can present more of a problem. In those cases, the question becomes <em>why<\/em> is the patient hypotensive, and there are many possible reasons.<\/h6>\n\n\n\n<h6 class=\"wp-block-heading\">To help you treat different types of patients with low blood pressure in an efficient way, I\u2019ll share with you a framework spelled out to me by one of my favorite mentors. This approach focuses on five underlying factors\u2014and is so foolproof that you will not only be able to treat your hypotensive patient, but also do so <em>correctly<\/em>.<\/h6>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h4 class=\"wp-block-heading\">The 5 Components of the Framework<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">Let\u2019s begin with a review. Remember Physiology 101? It was there, so many years ago, that you learned:&nbsp;<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\">Pressure (P) = Flow (Q) * Resistance (R)<\/p>\n<\/blockquote>\n\n\n\n<p class=\"wp-block-paragraph\">In physiologic terms, that would be:&nbsp;<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\">MAP = CO * SVR<\/p>\n<\/blockquote>\n\n\n\n<p class=\"wp-block-paragraph\">And considering the cardiac output is the product of heart rate and stroke volume, we get:<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\">MAP = (Stroke volume * <strong>Heart Rate<\/strong>) * SVR.<\/p>\n<\/blockquote>\n\n\n\n<p class=\"wp-block-paragraph\">In its simplest terms, blood pressure only depends on those three things\u2014<strong>stroke volume, heart rate,<\/strong> and <strong>systemic vascular resistance (afterload)<\/strong>. But stroke volume and heart rate can actually be separated into a couple more determinant factors.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">What determines one\u2019s stroke volume? How does the heart know how much blood to eject? Well, of course, it depends on how much blood gets put into the heart\u2014<strong>preload<\/strong>. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">How much of that blood leaves the heart? As a corollary, what\u2019s the difference between a strong, young, athlete\u2019s heart, and the patient waiting for a VAD? <strong>Contractility.<\/strong><\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\">So, stroke volume is determined by the <strong>preload<\/strong>, or how much blood gets into the heart, and by <strong>contractility<\/strong>, or the ability of the heart muscle to contract.<\/p>\n<\/blockquote>\n\n\n\n<p class=\"wp-block-paragraph\">As for <strong>heart rate, <\/strong>let\u2019s say a patient has a rate of 110. Sinus tachycardia is going to get you a much higher blood pressure, all other things being equal, than the wonky, dyssynchronous contractions of atrial fibrillation. So in addition to the heart rate, we care about the <strong>rhythm.&nbsp;<\/strong><\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\">To summarize, the five components of our hypotension framework are<strong> rate, rhythm, preload, afterload, <\/strong>and <strong>contractility<\/strong>.<\/p>\n<\/blockquote>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h4 class=\"wp-block-heading\">Treating Each Component of Hypotension<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">Now let\u2019s talk about how the five components can become perturbed, and what you can do to correct them in each case.<\/p>\n\n\n\n<h5 class=\"wp-block-heading\">#1: Rate<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Increasing heart rate will typically increase cardiac output.<\/strong> This is true up until the point that diastolic filling is compromised because the heart is beating too fast and doesn\u2019t have enough time to fill. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A hypotensive patient with a heart rate in the 30s needs their heart rate jacked up. Reach for <strong>atropine<\/strong> or <strong>epinephrine<\/strong> for the immediate fix. Alternatively, if you have the resources, transcutaneous or intravenous pacing can get the heart moving at a more normal rate.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Hypotensive with an HR of 150? Too fast! Give some <strong>esmolol<\/strong> to slow things down and allow time for diastolic filling. Now, this is all assuming a sinus rhythm. But what if it\u2019s not?<\/p>\n\n\n\n<h5 class=\"wp-block-heading\">#2: Rhythm<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">Sinus rhythm is the rhythm of life! It\u2019s the way in which our perfect, embryologically designed heart prefers to beat\u2014<strong>but not every patient\u2019s heart behaves this way. <\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Rapid A-fib with hypotension? Sounds like it\u2019s time to try and <strong>cardiovert<\/strong> this patient back to a normal rhythm.<strong> Pharmacologic cardioversion<\/strong> is another option with tools like amiodarone or lidocaine.&nbsp;<\/p>\n\n\n\n<h5 class=\"wp-block-heading\">#3: Preload<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">This one can be hard to assess without an <strong>echo probe.<\/strong> But you might have the luxury of markers like <strong>CVP<\/strong>, or <strong>arterial line waveform variations.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Short of that, fall back on the <strong>physical exam. <\/strong>Does the patient look dry? Do they have a reason to be dry (e.g., overdiuresis, diarrhea, blood loss)? If so, give them fluid or blood products.&nbsp;<\/p>\n\n\n\n<h5 class=\"wp-block-heading\">#4: Afterload<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">A low SVR state will lead to low blood pressure. <strong>The way to fix this one is with medication, not fluid. <\/strong>That septic patient needs some norepinephrine after they have failed their fluid challenge, not another 4 liters of crystalloid.&nbsp;<\/p>\n\n\n\n<h5 class=\"wp-block-heading\">#5: Contractility<\/h5>\n\n\n\n<p class=\"wp-block-paragraph\">A bad heart is often the most difficult problem to correct. If you have a sense (based on history or symptomatology) that poor heart function is to blame for hypotension, your typical response is going to be <strong>inotropy (epinephrine, dobutamine).<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Those medications are not without their risks, but in a hypotensive patient, they are probably risks you are willing to take.&nbsp;<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h4 class=\"wp-block-heading\">The Patient Will Show You the Way&nbsp;<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">As usual, you have to let the patient\u2019s story be your guide. If they lost a liter of blood into their belly (and another liter onto the road), you can be pretty sure you\u2019ve got a preload problem.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">What if the patient with chest pain and EKG changes is hypotensive? Take a look at their heart, and bolster its ability with an inotrope.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>The real magic is in your \u201csick\u201d patient, who needs ICU-level care. <\/strong>They have low SVR from infection, their heart wasn\u2019t strong to start with, they are overloaded with fluid but intravascularly depleted, and they are having occasional arrhythmias. You might be facing many of these problems at once. Do what you can to support the patient and work through the disease process so that they can return to normal physiology ASAP.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">One more tool that has become a boon to answering the question, \u201cWhy is this patient hypotensive?,\u201d is <strong><a href=\"https:\/\/www.roshreview.com\/blog\/introducing-the-newest-qbank-for-the-abem-advanced-em-ultrasonography-examination\/\">point-of-care ultrasound<\/a>. <\/strong>With a simple peek at the heart through a basic transthoracic echo view, you can get a gross sense of your preload and contractility. You can quickly rule out a heart that\u2019s sick and needs some help pumping, or an empty heart that simply needs some volume added to the tank. Proficiency with this technology will amplify your clinical acumen.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h4 class=\"wp-block-heading\">Use it Anytime, Anywhere&nbsp;<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">The beautiful thing about this framework is that it can be applied to any hypotensive patient. Did someone pass out in the clinic with a blood pressure of 84\/40? Did you walk into an ICU patient\u2019s room and see 67\/40 on the monitor? Or maybe during a surgical procedure, the A-line unexpectedly reads 77\/52. <strong>No matter where you are, the framework and physiology are the same. <\/strong>Use it!<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h4 class=\"wp-block-heading\"><a href=\"https:\/\/pinterest.com\/pin\/create\/link\/?url=https%3A%2F%2Fwww.roshreview.com%2Fblog%2F4-tips-for-scheduling-your-pance-exam-date%2F&amp;description=4+Tips+for+Scheduling+Your+PANCE+Exam+Date\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/h4>\n\n\n\n<p class=\"wp-block-paragraph\"><em><em>Rosh Review is a&nbsp;<a href=\"https:\/\/www.roshreview.com\/\">board review<\/a>&nbsp;company providing Qbanks that boost your confidence for your boards and beyond.&nbsp;Get started with a&nbsp;<a href=\"http:\/\/app.roshreview.com\/trial\">Rosh Review free trial<\/a>&nbsp;to the Qbank of your choice (no credit card required!) and gain access to board-style practice questions,&nbsp;detailed explanations, beautiful medical images, and more.<\/em><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>As an anesthesiologist, I treat many patients with hypotension. Sometimes, it\u2019s my fault, but in those cases, it&#8217;s expected and correctable with the right medication. Of course, outside of the OR, the workup of hypotension, whether chronic or acute, can present more of a problem. In those cases, the question becomes why is the patient <a href=\"https:\/\/www.roshreview.com\/blog\/my-foolproof-guide-for-treating-hypotension-on-rounds\/\">read more&#8230;<\/a><\/p>\n","protected":false},"author":157,"featured_media":12839,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[1996,3815,2025,2027,2029,2007,3810,2010,2011,2013,2016,2017],"tags":[2848,3292,3380,3681],"coauthors":[3947],"class_list":["post-12821","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blogtype","category-child-and-adolescent-psychiatry","category-emergency-medicine","category-family-medicine","category-internal-medicine","category-md-do","category-med-peds","category-ob-gyn","category-pediatric-emergency-medicine","category-pediatrics","category-psychiatry","category-special-purpose-exam","tag-hypotension","tag-persistent-hypotension","tag-professional-practice","tag-treatment"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>My Foolproof Guide for Treating Hypotension - RoshReview.com<\/title>\n<meta name=\"description\" content=\"Treating hypotension on rounds can be especially difficult. 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