Hyper/Hypotension

Intern Boot Camp

7/5/2017
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Blood Pressure Management is Complicated
 Blood Pressure Measurements
• Hypotensive – systolic <90 mmHg or diastolic <60 mmHg
• “Normal” – systolic <120 mmHg and diastolic <80 mmHg
• Prehypertension – systolic 120-139 mmHg or diastolic 80-80 mmHg
• Hypertension
• Stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg
• Stage 2: systolic ≥160 mmHg or diastolic ≥100 mmHg
• Hypertensive urgency – SBP >180/120 without evidence of end-organ damage
• Hypertensive emergency – SBP >180/120 with end-organ damage
 Hypotension
• Systolic <90 mmHg or diastolic <60 mmHg
• Etiology – volume depletion, sepsis, anaphylaxis, drug reactions, cardiac
conditions, neurological disorders, obstruction, steroid withdrawal, etc.
• Need to identify the cause of the hypotension to know how to treat
• Remember, a patient with a high baseline blood pressure can be
hypotensive with a seemingly normal blood pressure
 Causes of Hypotension
• #1 – Hemorrhage
• #2 – Hemorrhage
• #3 – Hemorrhage
 Shock
Parameter I II III IV
Blood Loss (%) <15 15-30 30-40 >40
Pulse (bpm) <100 100-120 121-140 >140
Blood Pressure Normal Normal Decreased Decreased
RR (breaths/minute) 14-20 20-30 30-40 >35
UOP (mL/h) >30 20-30 5-15 Negligible
CNS Symptoms Normal Anxious Confused Lethargic
 “Doctor, SBP is in the 80s…”
• Need objective measurements – pulse, respiratory rate, UOP, hemoglobin
• Need to know the history – past medical/surgical history, home
medications, allergies
• Need to know the hospital course – baseline blood pressure, hospital
medications, surgeries, mental status, intra-op resuscitation
• Need to think about possible sources of infection or hemorrhage
• Need to evaluate the patient - temptation to give a 1L bolus to everybody
 Resuscitative Fluids
• Crystalloids
• Normal saline
• Ringer’s lactate
• Colloids
• Albumin
Hypotension
 Classification of Hypertension
• “Normal” – systolic <120 mmHg and diastolic <80 mmHg
• Prehypertension – systolic 120-139 mmHg or diastolic 80-80 mmHg
• Hypertension
• Stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg
• Stage 2: systolic ≥160 mmHg or diastolic ≥100 mmHg
• Hypertensive urgency – SBP >180/120 without evidence of end-organ damage
• Hypertensive emergency – SBP >180/120 with end-organ damage
 Causes of Hypertension in Hospitalized
Patients
• Pain, anxiety, agitation
• Bladder distention
• Medications
• Drug withdrawal (legal and illicit drugs)
• Undiagnosed hypertension or poorly-controlled hypertension
• Hypervolemia
• Increased intracranial pressure (Cushing’s triad)
Treatment Options in Hospitalized Patients
• Surgical patients often cannot be restarted on their home meds
• If available, order medications in the same class as their home meds
• Commonly used IV medications – Metoprolol, Enalaprilat, Hydralazine
• Other IV medications – Esmolol, Nicardipine, Labetalol
• Restart home medications slowly when patients are able to tolerate diets
 “Doctor, SBP is in the 200s…”
• Need objective measurements – pulse, respiratory rate, UOP, “pain”
• Need to know the history – past medical/surgical history, home
medications, allergies
• Need to know the hospital course – baseline blood pressure, hospital
medications, surgeries, mental status, intra-op resuscitation
• Goal is to look for signs of end-organ dysfunction while trying to treat the
underlying problem
Questions?