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<< Symptomatic Hypotension: ED Stabilization And The Emerging Role Of Sonography

Risk Management Pitfalls For Hypotension

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Risk Management Pitfalls For Hypotension

Risk Management Pitfalls For Hypotension

1. Assuming that an ashen, lethargic patient is not hypotensive because he has a good blood pressure of 120/80 mmHg.

Treating the number rather than the patient can cause you to miss the hypotensive state. Treat the patient; this patient is hypotensive. The BP is well below baseline and he looks terrible for now. It might get worse. Cardiac dysfunction and tissue ischemia can persist despite normalization of BP, heart rate, and CVP.

2. Inadequate workup of the underlying etiology.

Establishing adequate urine output with fluid boluses won't stop bleeding from a gastric ulcer or ruptured aorta. Giving antibiotics for a fever won't be effective if a gangrenous gallbladder remains undiagnosed.

3. Inadequate fluid loading.

Look for low CVP signs, evaluate urine output, and monitor cardiac output response to fluid administration. Tissue perfusion is your goal and cardiac output is usually the key to achieving this. A hyperdynamic heart is attempting to compensate for a low ventricular volume.

4. Delaying ventilator assistance.

Improved ventilation and oxygen delivery to the lungs and ultimately the organs puts less demand on the heart and reduces the oxygen debt.

5. Overaggressive resuscitation without factoring in the wishes of the patient or family. 

respectful and cost-effective treatment plan may hinge on getting these important pieces of information.

6. Discontinuing monitoring after a "good blood pressure" is reached.

The BP is a single and imperfect parameter in assessing the patient's volume and circulatory state. Multiple tools may be necessary to assess tissue perfusion and changes in cardiac output. In some patients, there is an improvement in the blood pressure, a normalized pulse rate, and no more postural dizziness after fluid administration for self-limited diarrheal illness. Another patient may have an improvement in the BP to120/80 but still feel weak and short of breath because the LVEF is 20%, or the pericardial effusion remains undiagnosed, or the tissue oxygen debt state remains unpaid.

7. Allowing slow tests to guide management.

Do not wait for the creatinine and D- dimer to come back before getting the CT; do not wait for the CXR to see if the mediastinum is wide or if the heart is large.

8. Discounting the possibility of orthostatic hypotension as the primary etiology in the elderly patient with supine hypertensive readings..

9. Ignoring the role and use of bedside sonography in hypotension resuscitation.

The rote use of fluid then vasopressors and inotropic agents may not help and can worsen some clinical processes. Hypotension is not a disease or even a syndrome to be fixed. It is a sign that something is going wrong. You just have to figure it out quickly and carefully. Goaldirected sonography accurately addresses many dangerous and time sensitive clinical questions.

10. Not re-evaluating hemodynamic profiles.

RV, LV function, and preload status can change even when you do the right things.
 
Publication Information
Authors

Anthony J. Weekes; Ryan J. Zapata; Antonio Napolitano

Publication Date

November 1, 2007

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