Hypotension Causes: Three Unusual Cases of Very Low Blood Pressure In the Hospital.

Hypotension causes physicians to pause.  I get paged everyday about nonsensical issues that can wait for my daily rounds.  But hypotension is different.  Hypotension causes physicians to react quickly.  What are the most common admitting causes of low blood pressure in my hospitalist practice?   Infection, gastrointestinal bleeding and other forms of volume depletion would have to have to lead the way.

The most common hypotension causing infections encountered by hospitalists are probably pneumonias and urinary tract infections.  When bacteria from either process enter the blood stream, they can cause an inflammatory chain reaction leading to hypotension, hemodynamic collapse and eventual rapid death.   When dealing with sepsis and shock, time is critical.  Minutes can mean the difference between life and death.  That's why if you suspect septic shock in your differential diagnosis, your first two goals should always by volume resuscitation and administering first doses of antibiotics as soon as possible.

The nationwide Surviving Sepsis campaign has lead the charge for educating doctors and nurses about the importance of early intervention in this deadly disease process.  Everyday I see patients that have been woefully under rescued from their deadly sepsis cycle.  Their hypotension causes them to experience a delay in organ resuscitation.  It's all about time and it's all about volume.   Time saves lives.

Many protocols have been developed to assist physicians in the management of severe hypotension. Some treatments are well established.  Some , such as steroid use in sepsis, are controversial.  One theory  says hypotension causes a relative adrenal insufficiency in patients unable to produce enough mineralocorticoids to maintain their blood pressure.  This is the theory behind giving steroids to patients with sepsis.  The thoughts on steroids seem to change with every passing year.

I define hypotension as a blood pressure that is low enough to cause end organ harm to a patient.  Most of the time, as a matter of default, we are trained to accept a systolic blood pressure (the top number) of less than 90 mmHg or a mean arterial pressure of less than 65 mmHg as hypotensive.  But, this is not always the case.   For some folks hypotension causes problems at higher numbers (acute ischemic stroke patients need higher pressures) and for others hypotension causes problems only at much lower numbers (cirrhosis patients can tolerate much lower blood pressures).  The key for me is whether the hypotension causes organ failure.

Case #1 and  #2:  Hypotension causes me to view steroids with respect.

Both patients complained of  a few days of generalized weakness, malaise and viral like symptoms.   Both patients were terribly sick upon arrival to the hospital. Both presented to the emergency room with critical levels of hypotension causing hemodynamic collapse.  Both patients got a central line.  Both patients began aggressive fluid resuscitation.  Both patients had critically low central venous pressures.   Both patients failed to respond to aggressive fluid resuscitation.  Both patients were initiated on intravenous blood pressure support medication.  Both patients weren't getting better.

What happened?  Why was the aggressive volume resuscitation  not helping in either patient?  In the first case A CT scan of the abdomen confirmed the presence of bilateral adrenal hemorrhage. The presence of bilateral adrenal hemorrhage in meningococcal sepsis patients is known as Waterhouse-Friderichsen syndrome.  My patient did now have meningococcal sepsis.  They had spontaneous bilateral hemorrhage into their adrenal glands from the anticoagulant warfarin.  I don't think I will ever see that again.  But this case will forever be ingrained in my psyche.  Bilateral adrenal hemorrhage causing hypotension causing hemodynamic collapse.  I was amazed at this patients response to steroids.  Within 15 minutes of steroid administration,  this incredible adrenal crisis hypotensive causing  death spiral was completely reversed.  The patient fully recovered almost immediately and all critical parameters had returned to normal.  If your patient does not respond to fluids, give them steroids (hydrocortisone 100mg IV followed by 50mg IV Q6 hours).  You just might save their life.

What about my second patient?  Well, they didn't have bilateral adrenal hemorrhage, but they did have primary adrenal failure with subsequent hypotension causing hemodynamic collapse.  I did a cosyntropin stimulation test on them (drew a baseline serum cortisol then administered 0.25 mg of cosyntropin to stimulate the adrenal glands, drew a 30 minute and then a 60 minute post infusion serum cortisol).  The test is rarely abnormal.  If you're stressed your baseline cortisol should be high and giving a drug to stimulate your adrenal glands should make your cortisol levels go even higher.  In this case both the baseline level and the stimulated levels were low (below 10).  This is pretty diagnostic of an adrenal crises.  In this case, it was probably a viral or perhaps an autoimmune failure of the adrenal glands.   Who knows why.    Both patients responded immediately to intravenous steroids.  That is the clue to adrenal crisis.  When hypotension causes a hemodynamic collapse that reverses almost immediately with IV steroids, you know your adrenal glands have failed you.

Case #3 Hypotension causes me to cover my bases.

The last case was a crazy one.  One day you're normal.  The next day you're in the intensive care unit with a central line, a central venous pressure monitor and an IV pole with five or sex life saving medications hanging by the way.  When you show up in the ER with a systolic blood pressure of 50 with 20 of dopamine hung in the field, you know things are bad.  What could possibly make a grown adult go from normal to a hyptotension causing disease process ready to take your life?  In this case, it turned out to be a reaction to an over the counter medication being used to treat a garden variety headache.

How about that.  A severe allergic reaction, which spared the respiratory and skin centers,  but created a beast of a hypotension causing hemodynamic collapse on the order of severity I had never seen before.  After some steroids, H2 blockers, subQ epi and a ton of fluids, my patient went from near death in the ICU to walking home the next day.  Amazing.

For the vast majority of my patients in the hospital, hypotension causes a brief delay in their recovery process.  They usually respond well to fluids and antibiotics.  They may have gotten  dried out by their diuretics, but they usually recover nicely with fluids or broad specturm antibiotics. Their hypotension causes them no long term consequences.  But sometimes, we must change the game plan when our fluids and antibiotics don't work.  We must think of other causes.

These three cases show the power of the human body's own regulatory network of hormones and the consequences that occur when they fail you.   When your adrenal glands stop working the subsequent hypotension causes a life ending complication  unless steroids are administered.  When your body rejects a medication  the hypotension causing chain reaction can kill you.  Just remember, all hypotension is not caused by infection or volume.  If your patient fails to respond to standard therapies, it's time to go back to the drawing board. 

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