Tag: transfusion

Hypotension

Hypotension

Sam speaks to Intensivists Dr Jonathan Casement and Dr Rob Everitt about differentiating and managing hypotension.

Differential

  • Life threatening
    • Acute haemorrhage
      • On the floor and four more
    • Sepsis
    • Arrhythmia/cardiac
    • Drugs (including transfusion reaction)
    • Anaphylaxis
  • Dehydration (beware the accuracy of this diagnosis)
  • Epidural anaesthesia
  • Heart failure
  • Pregnancy
  • Syncope/postural
  • Neurological
    • Positional
    • PD
    • Diabetes

Approach

  • Eyeball the patient / ABCDEF
  • Calling a code
    • 777 (or your local hospital emergency number)
    • This is Sam, medical house officer I need the adult resus team to attend North Shore Hospital, ward 10, room E3.
  • History
    • Why are they in hospital?
    • Post-op?
    • Onset, timing & trend of hypotension
    • Postural
    • Medications
    • Associated symptoms
      • Pain is very concerning
    • ROS
  • Vitals + Examination
    • End-of-bed-o-gram is probably the most important
    • Peripheries for perfusion and pulse
    • Manual BP
      • Both arms
      • Cuff size
    • Urine output
    • Drain output
  • Consider investigations
    • Keep in mind these may be of limited value
    • ABG (lactate, glucose, Hb)
    • ECG
  • Management
    • Fluid challenge only if hypovolaemic
      • 250 – 500 mL stat
    • Rehydrate gradually
    • Transfusion
      • Target Hb >70
      • Use one unit then reassess
    • Avoid transfusion outside daylight hours
    • Catheterise and measure fluid balance
    • Fix the underlying cause
    • Have a low threshold to escalate to a senior
    • Clear observation and escalation plan if cause is unclear
  • Document
    • Review past notes
    • Basics (date/time/name/reason for review)
    • Positives and pertinent negatives
    • Impression and differential with justification.
    • Have you eliminated life threatening conditions?
    • Beware an impression of dehydration.
    • Are they actually hypovolaemic?
    • Why would they be dehydrated on the ward?
    • Clear and specific plan
    • Monitoring
    • Consider discussion with senior and escalation, especially if called back to patient again