Treatment For Periods Of Orthostatic Decompensation

Patients who have restricted autonomic neuropathy and associated postural tachycardia have periods of orthostatic decompensation. Patients with generalized autonomic failure also have episodes of apparent decompensation when they have greater OH or less response to pressor agents. These patients need to be evaluated for a cause of decompensation. The causes include fluid deficit, hypokalemia, anemia, deconditioning related to a recent period of recumbency, and another illness (including pump [cardiac]

Fig. 1. Systolic (A) and diastolic (B) blood pressure in the supine position (light bars) and during head-up tilt (dark bars) before and after medication. * = significant difference (p < 0.05) comparing parameters for the same body position before and after medication, # = significant difference (p < 0.05) comparing position-induced changes before and after medication.

Fig. 1. Systolic (A) and diastolic (B) blood pressure in the supine position (light bars) and during head-up tilt (dark bars) before and after medication. * = significant difference (p < 0.05) comparing parameters for the same body position before and after medication, # = significant difference (p < 0.05) comparing position-induced changes before and after medication.

failure). Often, however, no cause is found. The patient appears to respond to management with volume expansion. The first approach is the "bouillon treatment." The patient makes one of these extremely salty soups and drinks about five 8-ounce servings in half a day. An alternative is supplemental sodium chloride, 2 g three times daily, and a minimum of eight 8-ounce servings of fluids daily for 2 days. If the patient does not have improvement with this regimen or reports that fluid is not being retained, desmopressin, one puff each nostril at bedtime, is taken for 1 week. The dose of vasoconstrictor can be adjusted upward. This is when a tight-fitting body stocking (e.g., Jobst) can be beneficial. Fludrocortisone, 0.2 mg three times daily, can be taken for 1 week. The drug is traditionally considered to be slowly cumulative in its action; however, recent studies have suggested that it also has a rapid mode of action. If all these measures are unsuccessful, the treatment is isotonic saline, 1-2 L, given intravenously.

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