Intraoperative hypotension: Initial approach

FiO₂: fraction of inspired oxygen; PEEP: positive end-expiratory pressure; BP: blood pressure; SPV or PPV: systolic pressure variations or pulse pressure variations with respiration noted on the intra-arterial pressure waveform; CVP: central venous pressure; MAP: mean arterial pressure; PAP: pulmonary artery pressure; PCWP: pulmonary capillary wedge pressure; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography; IV: intravenous; pRBC: packed red blood cells; LV: left ventricular; RV: right ventricle; SBP: systolic blood pressure; SVR: systemic vascular resistance; MI: myocardial infarction; CVC: central venous catheter; CO₂: carbon dioxide; MAP: mean arterial pressure; SBP: systolic blood pressure.
* PEEP is decreased since PEEP impairs venous return. FiO₂ is increased to compensate for the decrease in PEEP.
¶ If hypotension develops without evidence of significant hypovolemia, administration of an alpha-1 agonist (eg, phenylephrine) or direct/indirect sympathomimetic (eg, ephedrine) is appropriate, rather than rapid or significant volume loading. This is particularly important in patients with heart failure or at risk for heart failure. Refer to UpToDate content on management of hypotension related to general or regional anesthesia.
Δ Refer to UpToDate content on use of an individualized transfusion trigger value based upon the patient's clinical characteristics including risk of myocardial ischemia and whether there is significant ongoing bleeding.
◊ Refer to UpToDate content on use of vasopressors and management of shock.
§ Refer to UpToDate content regarding intraoperative fluid management and transfusion.