The Hypotensive Patient

Question 1

A 50yr old male with no significant past medical history is day 2 admission for a community acquired pneumonia (CURB-65 = 3). He is currently receiving IV Co-Amoxiclav and Clarithyromycin, and slow IV fluids (12 hourly).
His current observations are: HR 109, BP 91/65, RR 22, Saturation 95% OA, Temperature 37.9
His NEWS score is: 6

a) Why is his blood pressure low?
b) What further details would you like to know?

Answer 1

a) Sepsis - peripheral vasodilatation leading to a distributive shock (almost)

b) General appearance
- unwell, clammy, cyanosed, etc.

Airway.
- Patency, secretions, abnormal sounds, etc.

Breathing.

• Oxygen requirement
• do they need a blood gas?
• Abnormal sounds - wheeze (consider nebs), crackles (may be overloaded if bibasal)
• PMHx of COPD/Asthma or chest sepsis

Circulation.

• Baseline BP/ change from normal?
• Fluid status
• PMHx of CCF, or other CVD
• Medications that may influence fluid status (eg. furosemide, antihypertensives)
• Catheter required?

Disability.

• Any new confusion/ reduced GCS
• Glucose, pupils, neurology

Exposure.

• Abdo, calves (?PE), wounds, sores, etc.
• Do they need/ have they had cultures? (sepsis 6)

Question 2

How would you investigate/manage patient with chest sepsis?

Answer 2

Sepsis 6. (BUFALO)

• Blood cultures
• Urine output - catheter
• Fluids (NaCl bolus, then replacement/ maintenance)
• Antibiotics - broad-spec (eg. tazocin in chest sepsis)
• Lactate - VBG/ABG (>2 = pathological)
• Oxygen - 15L/min via NRB, titrate down

Bedside.

• Full A-E assessment and examination
• Sputum sample
• ECG - PE (sinus tachy, RBBB, S1Q3T3), sepsis-induced AF, etc.
• Consider urine dip

Bloods.
- IV access - bloods (FBC, CRP, U+Es, clotting, LFTs, glucose), ABG, blood cultures

Imaging.

• CXR
• ?CTPA (?PE)

Special tests.

Question 3

Sequential organ failure assessment (SOFA) score.

a) When should it be used?
b) Criteria

Answer 3

a) In patients with sepsis admitted to ITU, to calculate mortality risk
(NOT to diagnose sepsis, and not for ward level care)

b) - CV - MAP (or use of vasopressors)
- Resp - PaO2, FiO2, on ventilation (NIV or CPAP)
- Haem - platelet count
- Neuro - GCS
- Hepatic - Bilirubin
- Renal - Creatinine

Question 4

qSOFA score.

a) When should it be used?
b) Criteria
c) What is a ‘positive’ score?

Answer 4

a) Outside ITU, to determine mortality risk at the bedside for patients with sepsis

b) - GCS < 15
- RR: 22 or more
- Systolic BP: 100 or less

c) - 2 - 3 = high risk (3 - 14x increase in mortality)
- 1 or less = not high risk

Question 5

You are on call for medicine. It is 2am.

The nurse bleeps you, “ Hi Doctor, Mrs Smith in bed 10 has dropped her blood pressure, it is 85 systolic.”

Answer 5

• What’s the rest of their obs, what are they scoring?
• What is the trend of the BP?
• Why are they in hospital?
• Do they have IV access?
• Are there fluids running?

Go and see the patient

Question 6

67 year old patient admitted with ?urosepsis, on day 2 oral nitrofurantoin. BP 86/54 and bloods on admission show current AKI.
PMHx - HTN, T2DM
DHx - Ramipril 2.5 mg BD, metformin 1g BD

a) Management of this situation

Answer 6

a) - Sepsis 6
- Fluid bolus (consider fluid status) to bring BP up
- Consider switching to IV abx according to local policy (eg. IV tazocin; beware gentamicin due to AKI)
- Omit ramipril until BP and renal function improve
- Omit metformin until renal function improves

Question 7

Why can furosemide actually help to INCREASE blood pressure in overloaded patients?

Answer 7

Frank-Starling curve.

• In healthy patients, when preload (EDV) increases, stroke volume (SV) also increases
• In patients with reduced cardiac function and/or those who are very overloaded, SV begins to DECREASE beyond a critical threshold of preload
• Hence, in these patients actually offloading fluids with furosemide and reducing preload will increase SV