Hypotension in the critically ill patient with pulmonary arterial hypertension (PAH) must be rapidly treated to avoid cardiovascular collapse.
Hypotension in the PAH patient is not always due to hypovolemia. In fact, excessive volume loading may further decrease LV stroke volume. Consider starting with a fluid bolus of 250 ml of an isotonic crystalloid solution and monitoring response.
Patients with severe PAH may present to the ED with a continuous flow pump of a pulmonary vasodilator (epoprostenol, treprostinil). These medications can also cause hypotension at excessive doses. Consider decreasing the rate of the infusion by 25% to see if overdosing is the cause.
References
Rubenfire M, Bayram M, Hector-Wood Z. Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management. Crit Care Clin2007;23: 801-834.
