Hypotension and CV Shock

Suggested approach and Clinical Pearls

• Hypotension is considered as a deviation of >20% below usual blood pressure
• Shock is a failure to provide a perfusing blood pressure resulting in end-organ dysfunction (may be high or low-cardiac output state, with variable blood pressure)
• Consider the circulation based on pre-load, afterload, rhythm, rate, systolic and diastolic myocardial function (on both ventricles)
• If there are signs of micro-circulatory insufficiency (capillary refill >3 seconds (nose, ears, digits), mottled knees, UO <0.5mL/kg/hr), then hypotension is consistent with shock state
• Cardiac output (flow) depends on pressure and vascular resistance
  • Increasing blood pressure in a low cardiac output state through vasoconstriction will compromise the patient
• Jugular venous pressure can indicate level of intravascular volume status
  • Consider pre-existing right heart failure in this assessment
• To assess fluid responsiveness, consider a 'passive leg raise'
  
  • Raise legs to 45 degrees with the body horizontal for one minute.  Reassess BP for increase of the pulse pressure (difference between SBP and DBP) by 10% to demonstrate fluid responsiveness.