Some patients with severe OH need acute hospital management. In addition to a search for the cause of OH and specific treatment, management is aimed at improving orthostatic tolerance to the degree that subsequent management can be continued on an outpatient basis. A regimen of treatment extending for approximately 3 days is suggested. These patients are volume-depleted, either absolutely or relatively (because of increased capacity as a result of denervation). Intravenous infusion of 1-2 L of isotonic saline is needed to expand plasma volume. Early volume expansion is critically important because hypovolemia greatly reduces the effectiveness of vasoconstrictors in increasing BP, markedly affecting the sensitivity of cardiopulmonary, but not carotid-cardiac baroreflex responses to a-agonists (48). In elderly patients, care needs to be exercised to avoid heart failure. Postural training is needed. The head of the bed is elevated 4 inches or at an angle of 10-30°. The patient spends an increasing period of time seated and standing. Treatment with fludrocortisone, 0.2 mg per day, is commenced, as is sodium chloride, 1 g three times daily, and high fluid intake. During this time, the patient is educated about dietary salt content, maintenance of postural normotension, physical countermaneuvers, management of periods of increased orthostatic stress, and supine hypertension. Blood pressure is measured with the patient supine and standing 1 minute before and 1 hour after 10 mg of midodrine, and the supine and standing values are recorded hourly to establish the optimal dose and duration of action.
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