Orthostatic hypotension management

Orthostatic hypotension can occur at any spinal cord injury (SCI) level and transitions between lying, sitting or standing should be taken slowly and with caution. Drops in blood pressure can severely impact the ability to participate in rehabilitation programs and daily activities. It is important to provide education to the person with SCI on common triggers and strategies for managing postural hypotension.

Non-pharmacological strategies: 

• Planning and management applicable to the level of SCI. 
• Ensure adequate oral fluid intake. 
• Consider an oral fluid bolus around 300ml prior to mobilisation.  
• Avoidance of diuretics.  
• Salt intake to maintain plasma volume, especially with high-level SCI (unless contraindicated). 
• Orthostatic management of pre-syncopal symptoms. 
• Mobilisation and transitions to be completed slowly and gradually.  
• Use of an abdominal binder. 
• Lower-limb compression garments or stockings are advisable. 
• a tilt in space chair as well as a tilt in space high back shower chair can be used, particularly for injuries above T6. Sitting should commence in the wheelchair first, eventually progressing to a commode.  
• A tilt table could be used in conjunction with the rehabilitation process. 

Pharmacological strategies: 

• Consider discontinuing medications with hypotensive effects.  
• If conservative measures are ineffective, pharmacological measures may be appropriate. Pseudoephedrine and midodrine are usually trialled, in consultation with a specialty medical team experienced in their use. An example of medication is Pseudoephedrine 30 to 60mg administered 30 minutes before mobilisation. A few second-line agents for profound orthostatic hypotension could also be trialled, including fludrocortisone. Clinicians will need to be mindful that these agents can cause hypertension. This may be problematic if the person is prone to autonomic dysreflexia.  

As sitting tolerance improves and orthostatic hypotension diminishes, pharmacological interventions should be tapered before introducing non-pharmacological interventions.  

Additional factors to investigate in persistent orthostatic hypotension: 

• Being unwell can increase the symptoms of orthostatic hypotension. 
• Cardiac causes, especially if the person has a pre-existing health condition or has experienced a syncopal event at the time of injury. 

A person with SCI who has persisting orthostatic hypotension, despite both pharmacological and non-pharmacological interventions, should be referred to a specialist in a Spinal Injuries Unit.