ASSESSMENT OF THE PATIENT WITH A LOW BLOOD PRESSURE

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ASSESSMENT OF THE PATIENT WITH A LOW BLOOD
PRESSURE

• Peter E. Morris, MD, FACP, FCCP
• Pulmonary Critical Care Medicine
• Wake Forest University School of Medicine
• Winston Salem, NC

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• Division of Pulmonary Critical Care Medicine
• 22 Faculty
• 14 MDs
• Division Research Interests
• Obstructive Lung Disease
• Critical Care
• Environmental Lung Disease
• Center on Human Genomics

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ASSESSMENT OF THE PATIENT WITH A LOW BLOOD
PRESSURE
What is an abnormal blood pressure? HYPOVOLEMIA H
YPOTENSION SHOCK ADEQUATE PERFUSION
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BLOOD PRESSURE GOAL MAP vs Systolic? MAP 60-70
mmHg Systolic gt90
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CEREBRAL PERFUSION PRESSURE (CPP)
MAP-ICP CPP

• 65-5 60 mmHG
• lt60 ? risk of brain ischemia
• and neuronal damage

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Relative CBF
Normal
Hypertensive
(Autoregulation)
50
100
150
200
MAP
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SHOCK

• Cardiogenic
• Neurologic
• Distributive
• Hypovolemic

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SHOCK

• Preshock known as warm shock or compensated
  shock
• homeostatic mechanisms rapidly compensate for
  diminished perfusion
• Despite a 10 percent reduction in total effective
  blood volume, a previously healthy adult may be
  asymptomatic
• Tachycardia, peripheral vasoconstriction, modest
  decrement in systemic blood pressure

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SHOCK

• Shock During this stage, regulatory mechanisms
  are overwhelmed - signs and symptoms of organ
  dysfunction appear tachycardia, tachypnea,
  metabolic acidosis, oliguria, cool and clammy
  skin.
• A 20 to 25 percent reduction in effective blood
  volume

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• REASONS FOR SHOCK
• Hemorrhage
• Myocardial dysfunction (cardiomyopathy,
  ischemia, pharmacologic, toxic,
  valvular)
• Circulatory obstruction (pulmonary embolus,
  cardiac tamponade,
  pneumothorax) (contd)

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REASONS FOR SHOCK

• Hypovolemia (gastrointestinal GI, insensible
  losses, third-space fluid
  sequestration)
• Central sympathetic disruption (Drug overdose)
• Arteriovenous fistula
• (contd)

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REASONS FOR SHOCK

• Vascular Endothelial Cell Dysfunction/Disruption
• Sepsis (bacterial, viral, fungal)
• Anaphylaxis
• Dyshemoglobinemia (carbon monoxide,
  methemoglobinemia)
• Cellular poisons (cyanide sulfur, iron, lithium)
• Traumatic or massive tissue destruction
• Heat shock, Hypothermia

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Age Variation Compensatory reflexes may be more
prominently demonstrated in young adults.
Considerable variability exists at extremes of
age. Most notably, younger individuals are able
to maintain normal blood pressure until vascular
and cardiac decompensation is imminent.
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FOR MOST ACUTELY HYPOTENSIVE PTS
if PULMONARY EDEMA (-) then FLUID CHALLENGE
IS AN APPROPRIATE FIRST RESPONSE
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• BOLUS OF FLUID?
• FLUID CHALLENGE?
• CONSIDER

• HOW MUCH?
• HOW FAST?
• LENGTH OF TUBING
• DIAMETER OF CATHETER
• LENGTH OF CATHETER
• PRESSURE BAGS

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DEHYDRATION LOW URINE OUTPUT HYPOTENSION
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DURING RESUSCITATION REMEMBER TO MONITOR MENTAL
STATUS VITAL SIGNS (MAP - O2 SATS) URINE
OUTPUT SKIN PERFUSION (LACTATE)
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Early Goal-Directed Therapy for Septic Shock

• Standard
• CVP ?8-12 mm Hg
• Vasopressors for SBP ?90 mm Hg
• Maintain UOP ?0.5 mL/kg/hr
• MAP ?65 mm Hg
• Goal-directed
• Above, plus
• Patients monitored with CVP and SVO2
• If SVO2 lt70
• RBCs until Hct ?30
• If SVO2 still lt70, add dobutamine to dose of 20
  µg/kg/min

• Randomized, non-blinded trial of traditional vs
  early goal-directed therapy (EGT)
• Septic shock unresponsive to 20 mL/kg
  crystalloids, or
• Lactate ?4 mmol/L

Rivers E, et al. N Engl J Med 20013451368-77.
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EGT Pts Received More Fluids, RBCs and Dobutamine
Fluids in mL
Patients Receiving Treatment ()
6000
5000
4000
3000
2000
1000
0
Pressors
First 6 hours
Rivers E, et al. N Engl J Med 20013451368-77.
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Early Goal-Directed Therapy for Septic Shock

• EGT in patients with severe sepsis produced the
  following
• 42 ? in relative risk of in-hospital and 28-day
  mortality (P0.009, P0.01)
• 33 ? in relative risk of death at 60 days
  (P0.03)
• NNT to prevent 1 event (death) 6-8

Mortality ()
Aggressive resuscitation begun in emergency
department. Rivers E, et al. N Engl J Med
20013451368-77.
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ADRENAL FUNCTION
Schroeder S. Wichers M. Klingmuller D. Hofer M.
Lehmann LE. von Spiegel T. Hering R. Putensen C.
Hoeft A. Stuber F. The hypothalamic-pituitary-ad
renal axis of patients with severe sepsis
altered response to corticotropin-releasing
hormone. Critical Care Medicine. 29(2)310-6,
2001 Feb.
Shenker Y and Skatrud JB Adrenal Insufficiency
in Critically Ill Patients Am. J. Respir.
Crit. Care Med., Volume 163, Number 7, June
2001, 1520-1523
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Annane D et al. Effect of Treatment With Low
Doses of Hydrocortisone and Fludrocortisone on
Mortality in Patients With Septic ShockJAMA 2002
288 862-871
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114 pts
150 pts
115 pts
150 pts
P 0.03
Annane D et al. Effect of Treatment With Low
Doses of Hydrocortisone and Fludrocortisone on
Mortality in Patients With Septic ShockJAMA 2002
288 862-871