Hypotension - NYSORA

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Hypotension

Learning objectives

  • Discuss the perioperative management of patients with hypotension
  • Describe the management of hypotension

Definition and mechanism

  • Frequently used definitions are:
    • A systolic arterial pressure (SAP) < 80 mmHg
    • A MAP < 65 mmHg
    • A decrease of 10-60% in baseline MAP or SAP
  • Caused by excessive vasodilation or insufficient constriction of arterioles
  • Due to decreased sympathetic nervous system output or increased parasympathetic activity

Signs and symptoms

  • Cold, clammy skin
  • Decrease in skin coloration (pallor)
  • Rapid, shallow breathing
  • Weak and rapid pulse

Causes

  • Vasodilation
  • Intravascular hypovolemia
  • Anaphylaxis
  • Sepsis/SIRS
  • Anesthetic agent overdose or swap
  • Low cardiac output
  • High intrathoracic pressure
  • Impairment of sympathetic nervous system
  • Compromised baroreflex regulation

Risk factors

  • Older age
  • High ASA class
  • Male lex
  • Lower pre-induction SAP
  • General anesthesia with propofol
  • Combination of general and regional anesthesia
  • Duration of surgery
  • Emergency surgery
  • Antihypertensive medications (ACE inhibitors, A2 receptor antagonists, beta blockers or alpha-2 agonists)

Management

Hypotension, depth of anesthesia, 100% O2, cycle BP, HR, rhythm, ST changes, SaO2, etCO2, PAP, crystalloid, vasopressors, postive inotropic agents, trendelenburg, ephedrine, phenylephrine, vasoprin, norepinephrine, epinephrine, terlipressin, trachial deviation, JVD, air entry, CVP, PCWP, peripheral perfusion, blood loss, IVC compression

Postoperative complications

  • Myocardial injury
  • Myocardial infarction
  • Cardiogenic shock
  • Acute kidney injury
  • Delirium
  • Stroke
  • Death 

Suggested reading

  • Weinberg L, Li SY, Louis M, et al. Reported definitions of intraoperative hypotension in adults undergoing non-cardiac surgery under general anaesthesia: a review. BMC Anesthesiol. 2022;22(1):69.
  • Guarracino, F., Bertini, P. Perioperative hypotension: causes and remedies. J Anesth Analg Crit Care 2, 17 (2022).
  • Kouz K, Hoppe P, Briesenick L, Saugel B. Intraoperative hypotension: Pathophysiology, clinical relevance, and therapeutic approaches. Indian J Anaesth. 2020;64(2):90-96.
  • Lonjaret L, Lairez O, Minville V, Geeraerts T. Optimal perioperative management of arterial blood pressure. Integr Blood Press Control. 2014;7:49-59.

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