Management of Hypotensive Episode Assessment Answer

Part 1

The patient was admitted to post operation for hypotension management. The main diagnosis in the patient was L2-L5 ATP. The patient has history of severe spinal canal stenosis with radiculopathy and cloudification, AF on flecainide and apixaban, CCF, and COPD. The patient is obese, has chronic pain, and faces difficulty in intubation. Initially fluids and 4% albumen 500mls was given HB was 90 and BP was stabilized MAP> 70mmHg. However, the patient developed high fever 38.0 and postural drop BP when trying to sit out of bed next day.

Strategies that can be used in the management of the patients’ hypotensive episode are:

1. Trendelenburg positioning: as stated in the case study, the patient faces postural drop BP; this can be corrected by the Trendelenburg position. It involves lying flat on the back with the legs elevated higher than the head (London & Mark, 2020). Passive leg raising or shifting to a head down position mobilizes blood volume from the lower extremities into the central circulation, and may temporarily improve hemodynamic stability, presumably by increasing venous return to improve CO and BP (London & Mark, 2020).
2. Compression stockings: Compression stockings can be beneficial in managing orthostatic hypotension (OH), a type of blood pressure that happens when a person stands up from sitting or lying down. The use of compression stockings can help the patient by squeezing the veins in the legs, aiding in the circulation of blood back to the heart. This can prevent a rapid drop in blood pressure when transitioning after sitting or lying down to a standup position. However, nurses should make sure that stockings should fit properly without being too tight or causing discomfort London & Mark, 2020). It is essential to consider compression stockings as part of a comprehensive management plan for hypotension, along with other strategies like adequate hydration, postural change and if necessary, medication adjustment under the guidance of a healthcare provider (Woo et al., 2018).
3. Fluid management: Given the patients complex medical history, fluid management should be tailored to balance the need for maintaining adequate perfusion without exacerbating underlying conditions like heart failure. As mentioned in the case study, the patient was having fever, which increases metabolic demand and fluid loss through sweating. Treating the underlying cause of the fever is crucial to prevent further complications and address hypotension related to increased fluid loss. Administering fluids, such as saline solutions or colloids like albumin, increases the total volume of blood in circulation. This expanded blood volume helps raise blood pressure by enhancing the filling of the heart’s chambers and subsequently increases cardiac output, which can elevate blood pressure. As mentioned in the case study 4% albumin was administered to the patient, which can help in maintaining colloid osmotic pressure and intravascular volume. However, nurses should regularly monitor daily weights, input/output, and clinical signs of fluid overload or dehydration. As, caution is needed with fluid administration to prevent fluid overload and exacerbation of symptoms (Valverde, 2021).

Part 2

Here, we are conducting a literature search related to the use of compression stocking to the management of the acute hypotensive episode. Orthostatic hypotension (OH) is a common problem in older people with a prevalence of 23-50%. OH, is majorly related to an increase in fall, stroke, cardiovascular disease, and impaired mobility. Quinn et al (2015) in their study highlighted the use of compression stockings for OH and aimed to review the opinion of patients and physicians regarding the use of electric compression stockings (ECS). They conducted a questionnaire-based survey of 90 patients and 69 consultant physicians for the data collection. The result of their study revealed that the use of CS is helpful in maintaining low blood pressure by applying external counter-pressure to the lower limbs or abdomen with the effect of reducing venous pooling and capillary filtration. However, the results of the survey conducted by Quinn et al (2015) showed that only one third of the participants wore ECS daily while over half used them rarely or never. This showed that the older adults are more inclined to comply with pharmacological treatments. Meanwhile, the participants who used ECS on daily basis reported improvements in symptoms and seems motivated to use ECS more frequently for the management of hypotension (Quinn et al., 2015).

Now, if we talk about the views of physician to the use of ECS, it has been identified that majority of the physicians prescribed ECS for OH. They recognize the benefits of compression stockings in preventing blood pooling in the legs upon standing, thereby reducing the severity of hypotensive episode. Newton & Frith (2018) in their study stated that many physicians view CS as a part of a broader strategy to manage OH rather than a standalone solution. They may recommend lifestyle modifications, hydration, medication adjustments, and gradual postural change alongside the use of CS. 

Newton & Frith (2018) worked to identify the efficiency and security of non-pharmacologic methods for OH management. They compare four non-pharmacological interventions including bolus water drinking, standing cross legged, CS, and abdominal compression. Their study showed that bolus water drinking is the most effective nondrug therapy for OH in older adults. The of CS also showed reasonable response, however, the participants reported poor compliance due to the difficulty of applying and removing these single-handedly (Newton & Frith, 2018).

Another study conducted by Logan et al (2020) aims to identify the efficiency of non-pharmacological ways to manage OH. Logan et al (2020) conducted a systemic review in which they compare interventions like aerobic or resistance exercise, neuromuscular stimulation, sleeping with head tilted up, promoting fluid and salt consumption, compression stockings, physical counter-maneuvers, and timing and size of meals. If we particularly talk about the use of CS, the study reported that they may be suitable for people with moderate to severe disability are compression and electrical stimulation. The study highlighted the use of CS and electrical stimulation as CS may allow repeated safe standing or sitting (Logan et al., 2020). Meanwhile if we compare the result of Julie et al (2018) and Logan et al (2020), it can be stated that the results of Logan et al (2020) slightly vary with the findings of Julie et al (2018). It is clear that the water ingestion had a positive effect on OH and would be suitable for many people. However, water ingestion cannot be appropriate for people suffering with neurological conditions like swallow impairment. Meanwhile, the use of CS does not have such limitations people with degenerative neurological condition can also use CS without any restrictions (Logan et al., 2020).

By using the similar approach like Logan et al (2020) another systemic review was conducted by Subbarayan et al (2019). They also evaluate the effectiveness of non-pharmacological intervention in older adults with OH. The study both randomized and nonrandomized studies that evaluated any type of nonpharmacological intervention and described consequences. The result of the study supported the use of CS, the meta-analysis of lower limb compression showed a reduction in the postural drop in systolic blood pressure (SBP). Overall, they concluded that CT can benefit the reduction in OH symptoms and recommended the use of CS. However, before using CS, it is crucial to consult with a healthcare professional, preferably a physician or specialist familiar with your medical history. The study also described the understanding benefits and risks like the healthcare workers must educate patients about the compliance and consistency. Compliance with wearing them regularly, especially during times when you are prone to experiencing OH, can improve their effectiveness (Subbarayan et al., 2019).

Woo et al (2018) performed a RCT to measure the efficiency of CS in dropping the incidence of hypotension. This study highlighted the role of CSs to decrease venous pooling in the lower extremities and maintain venous tone. The result of the study by Woo et al (2018) resembles wit the result of Quinn et al (2015), they reported that the use of CSs decrease the incidence of hypotension as these are readily appropriate medical product, requiring no special device (Woo et al., 2018). Palma et al (2023) conducted a study in which they discussed about both non-pharmacological and pharmacological measures to treat OH. The non-pharmacological measures highlighted in the study are lifestyle modification, dietary interventions, an increase in salt and water intake and the use of compression stockings and abdominal binders. The use of custom-fitted elastic CS permits the application of graded pressure to the lower extremities and lower abdomen, thereby minimizing peripheral blood pooling. The study reported that 10 patients found that CS for patients with OH and a history of falls reduced the average degree of orthostasis in the group as a whole and abolished orthostatic dizziness in seven (Palma et al., 2023). 

Palma et al. (2023) highlighted specific benefits over non-pharmacological interventions for managing hypotension, particularly in cases of OH. One of the advantages is unlike dietary interventions or lifestyle modifications, CS are non-invasive and do not require significant changes in behaviour or diet. They are relatively easy to use and don’t necessitate major alterations in daily routine, making them more accessible for some individuals (Palma et al., 2023). Similarly, Smeenk et al (2021) conducted a systemic review to evaluate the use of compression therapy (CT) in patients with OH. It has been reported that most of the time physicians recommend the use of CT, however its beneficial effects are unclear. Smeenk et al (2021) aimed to summaries all the available evidence on the effect of CT in the treatment of OH. The study stated that the use of CS has a specific targeted effect as CS directly target blood pooling in the leg, which is a primary contributor to OH. This targeted effect may make them more efficient in managing the immediate physiological response that leads to a drop in blood pressure upon standing. Another advantage is when used correctly, CS typically have minimal side effects compared to other interventions. However, improper use or sizing may lead to discomfort or skin irritation in some cases. CS can be widely used for versatility and convenience as it comes in various sizes, styles, and compression levels, offering options that suit individual needs and preferences. Additionally, they are generally easy to wear and can be used as needed, providing convenience for those prone to OH (Smeenk et al., 2021)

While CS offers benefits in managing OH, it also comes with certain limitations and disadvantages. Smeenk et al (2021) highlighted the limitations of CS, like some individual may find CS uncomfortable to wear, especially if they are too tight or don't fit properly. The process of putting them on can also be challenging for those with limited mobility or certain medical conditions that affect dexterity. Also, the prolonged use or improper fitting of CS can lead to skin irritation, chafing, or even allergic reactions in some individuals. Skin conditions like dermatitis or fragile skin can be exacerbated by the constant pressure and friction from the stockings. Stockings can also be problematic to put on, particularly for older adults who may require home care nurses to help them with it. CS can lead to the extra cost of such care, this reductions the patients’ independence, as they will have to wait each day somebody to help them put the CS on take them off over in the evening (Smeenk et al., 2021).

Part 3

In evaluating the use of CS for managing hypotension in this patient scenario, it is significant to deliberate the patient’s complex medical history and the development of new symptoms. For evaluation, nurses should evaluate the patient's medical history, including any underlying conditions such as COPD and severe spinal canal stenosis with radiculopathy and claudication. Another step needed in evaluation is conducting baseline measurement. Before conducting these measurements ensure the person has been resting comfortably in supine position for at least five minutes. Measure the patient’s baseline blood pressure and heart rate in supine position, take the blood pressure reading and note both systolic and diastolic pressures along with the heart rate (Pickering & Stevens, 2013). The healthcare professional should record these measurements as the baseline supine blood pressure and heart rate. After recording supine measurements, have the patient sit up slowly on the edge of the examination table or bed. After sitting a few minutes, instruct the patient to stand up gradually. It is essential to emphasize a slow transition to avoid sudden changes that might affect blood pressure. Record the standing blood pressure and heart rate (Pickering & Stevens, 2013).

If we follow the information provided by the literature for the use of CS, then it can be expected that the patient may show a better ability to maintain blood pressure levels upon postural changes when wearing CS. This can be seen in less fluctuation or a smaller drop in blood pressure when transitioning from lying or standing to sitting (Lim & Davies, 2014). Also, the patient may demonstrate improved tolerance to standing for longer duration without experiencing significant drops in blood pressure. This increased tolerance signifies better adaptations to changes in posture. The healthcare professional should observe the change in the symptoms associated with OH, such as dizziness, lightheadedness, blurred vision, or fainting upon standing. Improvements in these symptoms suggests better blood pressure regulation (London & Mark, 2020) The literature review highlighted the challenges that patients face while using the CS like inability to wear or take off the stockings by their own. In the current case study, the nurses appointed for his care should obtain feedback from the patient regarding the comfort, tolerability, and any adverse effects associated with wearing CS (Lim & Davies, 2014). The healthcare professional should consult the patient and evaluate the comfort and fit of the stockings while standing, sitting, and walking by assessing for any areas of pressure or discomfort. For this, the healthcare worker can use the questionnaire to evaluate the symptom changes experienced by the patient. The patient can be asked to assess the severity of each of the aforementioned symptoms on a visual scale from 0 to 10. Lastly, for the evaluation, schedule follow-up appointments to reassess the fit and effectiveness of the stockings, regularly review the stockings to ensure they remain appropriate for the condition and make adjustments as necessary (Podoleau et al., 2016).

References:

Frith, J., & Newton, J. L. (2020). Combination non-pharmacologic intervention for orthostatic hypotension in older people: a phase 2 study. Age and Ageing, 49(2), 253-257. https://doi.org/10.1093/ageing/afz173

Lim, C. S., & Davies, A. H. (2014). Graduated compression stockings. Cmaj, 186(10), E391-E398.https://doi.org/10.1503%2Fcmaj.131281

Logan, A., Freeman, J., Pooler, J., Kent, B., Gunn, H., Billings, S., ... & Marsden, J. (2020). Effectiveness of non-pharmacological interventions to treat orthostatic hypotension in elderly people and people with a neurological condition: a systematic review. JBI Evidence Synthesis, 18(12), 2556-2617. https://doi.org/10.4097%2Fkjae.2018.71.2.127

London, M. J., & Mark, J. B. (2020). Hemodynamic management during anesthesia in adults. UpToDate [Internet]. https://www.uptodate.com/contents/hemodynamic-management-during-anesthesia-in-adults#topicContent

Newton, J. L., & Frith, J. (2018). The efficacy of nonpharmacologic intervention for orthostatic hypotension associated with aging. Neurology, 91(7), e652-e656. https://doi.org/10.1212/WNL.0000000000005994

Palma, J. A., Kaufmann, H., & Kowey, P. (2022). Treatment of orthostatic and postprandial hypotension. UpToDate, Waltham. https://www.uptodate.com/contents/treatment-of-orthostatic-and-postprandial-hypotension#topicContent

Pickering, D., & Stevens, S. (2013). How to measure and record blood pressure. Community Eye Health, 26(84), 76. https://pubmed.ncbi.nlm.nih.gov/24782587

Podoleanu, C., Maggi, R., Brignole, M., Croci, F., Incze, A., Solano, A., ... & Carasca, E. (206). Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study. Journal of the American College of Cardiology, 48(7), 1425-1432. https://doi.org/10.1016/j.jacc.2006.06.052

Quinn, C., Deegan, B., Cooke, J., Carew, S., Hannigan, A., Dunne, C., & Lyons, D. (2014). Therapeutic use of compression stockings for orthostatic hypotension: an assessment of patient and physician perspectives and practices. Age and Ageing, 44(2), 339-342.https://doi.org/10.1093/ageing/afu162

Smeenk, H. E., Koster, M. J., Faaij, R. A., de Geer, D. B., & Hamaker, M. E. (2014). Compression therapy in patients with orthostatic hypotension: a systematic review. Neth J Med, 72(2), 80-85. https://njmonline.nl/getpdf.php?id=1411

Subbarayan, S., Myint, P. K., Martin, K. R., Abraha, I., Devkota, S., O'Mahony, D., ... & Soiza, R. L. (2019). Nonpharmacologic management of orthostatic hypotension in older people: a systematic review. The SENATOR ONTOP series. Journal of the American Medical Directors Association, 20(9), 1065-1073. https://doi.org/10.1016/j.jamda.2019.03.032 

Valverde, A. (2021). Fluid resuscitation for refractory hypotension. Frontiers in Medical Science, 8, 621696.https://doi.org/10.3389%2Ffvets.2021.621696

Woo, J. H., Kim, Y. J., Jeong, J. S., Chae, J. S., Lee, Y. R., & Chon, J. Y. (2018). Compression stockings reduce the incidence of hypotension but not that of cerebral desaturation events in the beach-chair position: a randomized controlled trial. Korean Journal of Anesthesiology, 71(2), 127-134. https://doi.org/10.4097%2Fkjae.2018.71.2.127

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