Orthostatic hypotension

What is the pathophysiology of orthostatic hypotension?

1) Impaired autonomic reflexes and/or 2) Reduced intravascular volume Medications: -Antihypertensives (ARBs, ACEi) -Vasodilators -Diuretics -Narcotics -Antipsychotic medications -Antidepressants -Alcohol consumption Neurologic: -Diabetic autonomic polyneuropathy -Parkinson disease -Polyneuropathies -Guillain-Barre syndrome

How does orthostatic hypotension present clinically?

Dizziness, weakness, light-headedness, visual, syncope with changes in position. Syncope (may be recurrent), change in mental status (due to hypoperfusion). +/- weak pulse, cool extremities, tachycardia, hypotension and tachypnea.

What is the pharmacologic treatment of orthostatic hypotension?

Fludrocortisone Midodrine may be added on if additional therapy is needed or if unable to take fludrocortisone. -Midodrine is a vasopressor/antihypotensive agent

What is the workup for orthostatic hypotension?

Includes: BMP, CBC and ECG to look for other causes.

What is orthostatic hypotension?

Marked reduction of blood pressure from supine to upright position (ex: supine to standing).

What is the non-pharmacologic treatment of orthostatic hypotension?

Remove offending medications whenever possible. Increase salt and fluid intake. Gradual exercise. Elastic stockings. Usage of caffeine. Maintain the head of the bed elevated, gradual changes in position. Usually tried before pharmacologic treatment.

What is an operative source of orthostatic hypotension?

Side effect of epidural analgesia.

How is orthostatic hypotension managed?

Treat underlying disease, remove offending medications (if possible) and support blood pressure.

How is orthostatic hypotension diagnosed?

Within 2-5 minutes of quiet standing (after a 5 minute period of being supine), there is EITHER a: -Fall in the systolic blood pressure of 20 mmHg or greater AND/OR -Fall of the diastolic blood pressure 10 mmHg or greater with changes in position. The pulse rate normally rises on standing. The absence of an increase in heart rate as compensation for the fall in blood pressure is associated with autonomic dysfunction. If secondary to hypovolemia, it may be accompanied with an increase of pulse rate >15 beats per minute.