Clinical Practice Guideline

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CLINICAL PRACTICE GUIDELINE:

Orthostatic Vital Signs What orthostatic vital sign procedure is needed to detect significant fluid volume alteration in adult and pediatric patients?

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CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Table of Contents Background and Significance______3 Methodology______3 Summary of Literature Review______5 Description of Decision Options/Interventions and the Level of Recommendation______9 References______10 Authors______11 Acknowledgments______11 Appendix 1: Evidence Table______12 Appendix 2: Other Resources Table______18 Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria______20

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2 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Background and Significance Orthostatic, or postural, vital signs are used to evaluate the body’s response to position changes when volume loss is suspected. Under normal conditions blood pooling in the lower extremities during position change is directed back to the upper body through the vasoconstriction of blood vessels (Winslow, Lane, & Woods, 1995). This vasoconstriction is accomplished through unloading of the arterial baroreceptors to enhance sympathetic outflow, which increases systemic vascular resistance, venous return and cardiac output (Arnold, Shibao, 2013). Baroreceptors are mechanoreceptor sensory neurons that are excited by stretching of the corresponding blood vessel. The most important arterial baroreceptors are the carotid sinus baroreceptors, and the aortic arch baroreceptors (Aung, 2013). However, conditions leading to hypovolemia and autonomic failure may result in a sudden drop in blood pressure known as orthostatic hypotension (OH) and result in impaired perfusion to the upper body. The American Autonomic Society and the American Academy of Neurology define OH as a 20 mmHg or greater decrease in systolic blood pressure (SBP) and a 10 mmHg or greater decrease in diastolic blood pressure (DBP) within three minutes of standing (American Academy of Neurology, 1996). This drop in blood pressure may be associated with symptoms such as lightheadedness, dizziness, blurred vision, weakness, fatigue, cognitive impairment, nausea, palpitations, tremulousness, headache, neck ache and syncope (American Academy Neurology, 1996; Cooke et al., 2009; Koziol-McLain, Lowenstein, & Fuller, 1991; Naschitz, & Rosner, 2007; Sarasin et al., 2002).

An increase in heart rate is often noted when there is a change in posture. This compensatory change occurs in response to the sudden drop in blood pressure (Naschitz & Rosner, 2007; Winslow, Lane, & Woods, 1995; Smith, Porth, & Erickson, 1994). While heart rate is not included in the official definition for OH per the American Academy of Neurology, changes in heart rate aid the differential diagnosis for OH. For instance, a drop in blood pressure accompanied by a rise in heart rate indicates volume depletion, while no change in heart rate may point to a neurogenic cause (Naschitz, & Rosner, 2007). Knopp, Claypool, and Leonardi (1980) found that in adults a heart rate increase of 30 beats per minute or more is considered indicative of volume loss.

The most common reason for performing orthostatic vital signs in the emergency department (ED) is to evaluate fluid volume status. However, research has shown orthostatic vitals are not reliably sensitive to volume losses less than 1000-mL in adult patients (Barraf, & Schriger, 1992; Knopp, Claypool, & Leonardi, 1980). Studies have also revealed wide variations in response to the orthostatic challenge among normal adult individuals (Koziol-McLain, Lowenstein, & Fuller, 1991; Levitt, Lopez, Lieberman, & Sutton, 1992).

To add to the confusion, the procedure for measurement of orthostatic vital signs is not standardized as evidenced by a review of the literature reflecting significant variations in practice. The duration of position change differs between research studies as do the position changes (lying to standing, lying to sitting to standing). There is even some debate as to which findings are the most important indicators of OH and what the cut-points are for vital signs changes.

Methodology This CPG was created based on a thorough review and critical analysis of the literature following ENA’s Requirements for the Development of Clinical Practice Guidelines. Via a comprehensive literature search, all articles relevant to the topic were identified. The following databases were searched: Medline (PubMed), CINAHL, Cochrane Library, BioMed Central-Open Access, Google Scholar, and the National Guideline Clearinghouse. The articles reviewed to formulate the recommendations in this CPG are described Appendix 1. Various terms appear in the literature relating to vital sign changes with position changes. These terms are: tilt test (which may involve passive versus active position change), postural vital signs, and orthostatic vital signs. Searches were conducted using the key words and subject headings: blood pressure, hypotension, orthostatics, orthostatic hypotension, orthostatic vital signs, orthostatic, and vital signs. The search term of “hypovolemic” was added to identify orthostatic vital sign research related to volume status rather than pharmacological treatment. Initial searches were limited to English language from January 1990 to March 2011. This timeframe was later expanded to include orthostatic research dating back to the 1940s to retrieve the seminal orthostatic vital sign studies. In addition, the reference lists in the selected articles were scanned for pertinent research findings. For this revision, an additional literature search was preformed from April 2011 to June 2015 with a paucity of new research found (Appendix 3). Research articles from ED settings, non- ED settings, position statements and guidelines from other sources were also reviewed. Clinical findings and levels of recommendations regarding patient management were made by the Clinical Practice Guideline Committee according to ENA’s classification of levels of recommendation for practice (Table 1).

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3 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Table 1. Levels of Recommendation for Practice Level A recommendations: High • Reflects a high degree of clinical certainty • Based on availability of high quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-Overholt, 2005) • Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice • Is beneficial Level B recommendations: Moderate • Reflects moderate clinical certainty • Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-Overholt, 2005) • There are some minor or inconsistencies in quality evidence; has relevance and applicability to emergency nursing practice • Is likely to be beneficial Level C recommendations: Weak • Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-Overholt, 2005) - Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence and/or opinion • There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice • Has limited or unknown effectiveness Not recommended for practice

• No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or uncontrolled studies • Other indications for not recommending evidence for practice may include: ◦◦ Conflicting evidence ◦◦ Harmfulness has been demonstrated ◦◦ Cost or burden necessary for intervention exceeds anticipated benefit ◦◦ Does not have relevance or applicability to emergency nursing practice • There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. For example: ◦◦ Heterogeneity of results ◦◦ Uncertainty about effect magnitude and consequences, ◦◦ Strength of prior beliefs ◦◦ Publication bias

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4 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Summary of Literature Review

SUMMARY OF DEFINITIONS The definition of orthostatic vital signs warrants further research despite its common use in clinical practice, textbooks, guidelines and research studies. A review of definitions from the literature indicates that the assessment parameter labeled as orthostatic vital signs can be summarized by its: physiological variables, measurement method, and purpose. The physiological variables include blood pressure, heart rate, and stroke index (Durukan et al., 2009; Fuchs & Jaffe, 1987; Horam & Roscelli, 1992; Koziol-McLain et al., 1991; Levitt et al., 1992; Witting & Gallagher, 2003), as well as symptoms of dizziness or lightheadedness (Lance et al., 2009; Sarasin et al., 2002). Stated purposes of orthostatic vital signs assessment include identification of hypovolemia (both dehydration and blood loss) and treatment efficacy of pharmacological agents for neurological conditions. Assessment for hypovolemia is the purpose of orthostatic vital signs for this review. The most common variables measured to assess orthostatic vital signs in potentially hypovolemic patients include blood pressure and heart rate, measured with the patient in different positions (supine, sitting, standing). Equipment used to obtain orthostatic vital signs, as well as the feasibility of obtaining orthostatic vital signs in the clinical setting will be described. For the purposes of this document, orthostatic vital signs are defined as a change in blood pressure, heart rate, or onset of symptoms after a change in position in individuals (adult, child, and adolescent) with a decrease in intravascular volume (Durukan et al., 2009; Fuchs & Jaffe, 1987; Horam & Roscelli, 1992; Koziol-McLain et al., 1991; Levitt et al., 1992; Witting & Gallagher, 2003).

BODY POSITIONING AND TIMING

Supine The period of rest prior to the supine measurement is variously identified as one minute (Barraf, & Schriger, 1992), two minutes (Knopp, Claypool, & Leonardi, 1980; Levitt et al., 1992), three minutes (Cooke et al., 2009; Koziol-McLain et al., 1991), or five minutes (Atkins, Hanusa, Sefcik, & Kapoor, 1991; Cohen et al., 2006; Kennedy & Crawford, 1984; Sarasin et al., 2002).

Harkel and colleagues (1990) discovered that the period of rest did impact the changes in blood pressure and heart rate with more pronounced changes identified following a longer period of rest. They measured vital signs following one minute, five minutes and 20 minutes of rest and found that “the augmentation of the BP and HR response is small when the period of rest is increased from five to 20 minutes, it seems adequate to perform this test after at least five minutes of supine rest” (Harkel, Lieshout, Lieshout, & Wieling, 1990, p. 152). However, Lance et al. (2009) found that 10 minutes of rest was required for accurate measurement of orthostatic vital signs. It should be noted that both studies by Harkel et al. and Lance et al. were conducted on small samples of 10 and 34 (respectively) of young, healthy, normotensive subjects. In addition, different methods of recording vital signs were used by the researchers: Harkel et al. used the Ohmeda 2300 Finapres continuous, non-invasive finger blood pressure device, and heart rate was measured via electrocardiogram; Lance et al. used the Johnson and Johnson Critikon DINAMAP model 1846 SX to measure blood pressure and heart rate in the upper arm.

The American Heart Association recommends blood pressure measurements to be made in the upper arm with 5 minutes of rest time prior to the first blood pressure measurement (Pickering et al., 2005). Furthermore, the subject should refrain from talking and the legs should be “uncrossed, and the back and arm supported” (Pickering et al., 2005, p.104). Crossing the legs elevates the SBP while an unsupported back raises the diastolic blood pressure (Pickering et al., 2005). Failure to support the arm will also impact blood pressure readings: readings taken above the level of the heart are artificially low while those taken below heart level are artificially high (Pickering et al., 2005).

Sitting The definition of OH provided by the American Autonomic Society and the American Academy of Neurology only considers blood pressure changes from the supine to the standing, not the sitting, position. Measuring vitals in the sitting position can actually lessen the orthostatic effect of standing (Kennedy & Crawford, 1984; McGee, Abernethy, & Simel, 1999). Cooke and colleagues (2009) found that, in adults on a syncope unit (n=730), the sit-stand test had low diagnostic accuracy. In a review of the literature,

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5 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Winslow, Lane, and Woods (1995) reported less dramatic changes in SBP when the sitting position is included but this finding was not statistically significant. However, it may be unsafe to move from the lying position directly to standing, especially in patients with large volume losses (Koziol-McLain et al., 1991). Kennedy and Crawford (1984) recommended measuring vitals in the sitting position first and, if no change occurs, measuring in the standing position to avoid falls in orthostatic individuals.

Standing Empirical evidence reveals inconsistencies in the process of measuring vital signs after standing. OH can be detected within two minutes of standing in most cases (Atkins et al., 1991; Lance et al., 2000). Cohen and colleagues (2006) found that 83.5% of OH could be detected within three minutes of standing. Knopp and colleagues (1980) determined that measurements taken one minute after standing demonstrated the greatest change in pulse rate between no blood loss and 1000 ml blood loss. However, the detection of OH is enhanced by the measurement of vital signs at multiple points per position (Atkins et al., 1991). This is especially true in cases where OH is delayed.

Delayed OH occurs within 10 to 30 minutes of standing (Streeten, & Anderson, 1992) classical OH occurs with three minutes (Moya, Sutton, Ammirati, Blanc, Brignole, Dahm, & Wieling, 2009; Streeten & Anderson, 1992). Delayed OH may occur more frequently in the elderly, with vasoactive and diuretic drug use, and co-morbidities (Moya et al., 2009). In mildly symptomatic individuals who have normal orthostatic vital signs within two minutes of standing, it is recommended that additional vital signs be taken to rule out delayed OH.

SENSITIVITY TO FLUID VOLUME LOSS Researchers have shown that orthostatic vitals are not reliably sensitive to volume losses less than 1000 ml in adult patients (Barraf & Schriger, 1992; Knopp, Claypool, & Leonardi, 1980). Barraf and Schriger (1991) determined that pulse rate was the most sensitive vital sign in detecting a 450 ml blood loss (9% sensitivity for a pulse rate increase of 20 or higher). Knopp et al. (1980) had similar findings comparing two groups: Group 1 with a 450 ml blood loss and Group 2 with a 1000 ml blood loss in 500 ml increments. Pulse change (supine to standing) at one minute had the greatest change between no blood loss and 1000 ml blood loss. Blood pressure change did not distinguish patients with no blood loss; patients with 500 ml blood loss; or patients with 1000 ml blood loss (Knopp et al., 1980).

Levitt et al. (1992) evaluated the degree of volume loss and orthostatic vital sign changes in ED patients. They found wide variation in orthostatic vital sign changes for healthy and ill individuals and poor correlation of vital signs and level of dehydration (Levitt et al., 1992). Heart rate (p=0.0165) and age (p=0.0047) had a small correlation (r2=0.098) with level of dehydration. While SBP did not demonstrate a statistically significant association with the degree of dehydration (r2= 0.032, p=0.56), SBP was the only vital sign to distinguish between patients with blood loss and healthy volunteers. Patients with blood loss had a mean SBP change of -10.7 mmHg (± 13.7 mmHg, p=0.001).

ORTHOSTATIC VITAL SIGNS

Blood Pressure Blood pressure and heart rate were the most frequent physiological variables measured during orthostatic vital sign assessment. Generally, orthostatic hypotension in an adult can be described as a drop in blood pressure and an increase in heart rate associated with position change. Several studies reported blood pressure changes following position changes. In a convenience sample of 814 adult ED patients suspected to be hypovolemic, Cohen and colleagues (2006) found that, of those with diagnosed OH, 83.5% could be detected at one and three minutes after standing. Similarly, a decline in SBP of 20 mmHg or more in 31% of the patients (n = 69) and decline in diastolic blood pressure of 10 mmHg or more in 14% of the patients (n = 31) within 10 minutes of standing were reported by Atkins et al., 1991.

As discussed in section on Body Position and Timing: Supine (page 5), it is important that the patient rest prior to the first blood pressure measurement. Physical activity immediately preceding orthostatic vital signs can influence the results. Generally, 5-10

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6 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

minutes is thought to be a sufficient period of time. The important thing to remember is that patients should not have their orthostatic vital signs measured immediately after physical exertion.

In a contrasting population, different blood pressure changes were found in a convenience sample of 100 normovolemic adolescent patients, ages 12 to 19 years, in a study by Horam and Roscelli (1992). The mean SBP change ranged from a 17 mmHg decrease to a 19 mmHg increase, and diastolic blood pressure change ranged from a 7 mmHg decrease to a 24 mmHg increase. In other words, systolic and diastolic blood pressure tended to increase rather than decrease upon position changes in many adolescents. These findings suggest the physiological response to position changes yields a different blood pressure response in adolescents compared to hypovolemic adults. Compensatory mechanisms that may influence the blood pressure response in adolescents include: baroreceptor activity, arteriolar vasoconstriction, capillary hydrostatic forces, renin aldosterone stimulation and antidiuretic hormone release (Horam & Roscelli, 1992). Given the wide variability of orthostatic vital signs in the adolescent population, further research is warranted.

Orthostatic vital signs were compared between normally-hydrated and volume-depleted children aged 4-15 in a 1987 study by Fuchs & Jaffe. Volume status was determined using an adaptation of the method discussed by Winters and Finberg (1982) which evaluates mucous membranes, eyes, skin color, urine output and urine specific gravity. Mean changes in systolic blood pressure were small and non-significant (-0.38 ±8 mmHg) for both groups of children (Fuchs & Jaffe, 1987).

Heart Rate Heart rate was the second most frequent variable used during orthostatic vital sign assessment. Five of the 12 research studies used heart rate as a measurement variable. Heart rate showed significant changes in two studies of healthy blood donors (Barraf & Schriger, 1992; Durukan, 2009). Barraf and colleagues conducted a study to determine the effect of age on orthostatic vital signs, whereas early detection of acute blood loss was the purpose of the study by Durukan et al. (2009). The heart rate variable by itself showed a sensitivity of 9% and a specificity of 98% with an increase in heart rate greater than 20 beats per minute in the Barraf et al. (1992) study. Also, an increase in heart rate greater than 20 beats per minute, plus a drop in diastolic blood pressure more than 10 mmHg, increased the sensitivity to 17% while maintaining a specificity of 98%. Levitt, Lopez, Liberman, and Sutton (1992) reported a weak, non-significant change in heart rate, in 202 dehydrated or acutely bleeding adults compared to 21 healthy individuals. Heart rate changes for the healthy individuals were 11.26 ± 11.3 bpm, whereas the ill adults had heart rate changes of 13.63 ± 10.3 bpm (Levitt, Lopez, Liberman, & Sutton, 1992).

The study by Fuchs and Jaffe (1987) investigated orthostatic vital sign changes in children. Like adults, children typically respond to a decrease in intravascular volume with an increase in heart rate. This study involved two groups of children between the ages of four and 15 years old who were seen in an ED. Group 1 consisted of 16 children meeting the dehydration criteria, compared to 21 children evaluated as normal. The mean orthostatic rise in heart rate was significantly different (p=0.001) between groups: 29.1 bpm (± 10.7) in the dehydrated group versus 13.1 bpm (± 8.5) in the normovolemic group. Further research of hypovolemic children is warranted to learn how the heart rate increase compares with the adult population.

Syncope Symptoms and Shock Index In addition to blood pressure and heart rate, syncope symptoms and shock index (SI) are two other variables reported in the literature related to orthostatic hypotension. Adults, 16 years and older, presenting with complaints of syncope to an ED were studied to learn the relationship between syncope symptoms and orthostatic vital signs (Atkins, Hanusa, Seflik, & Kapoor, 1991). Syncope was defined as a “sudden, transient loss of consciousness associated with an inability to maintain postural tone that was not compatible with a seizure disorder, vertigo, dizziness, coma, shock, or other states of altered consciousness” (Atkins, Hanusa, Seflik, & Kapoor, 1991, p. 180). A significant number, 31% (n=69/223) of patients with syncope as the chief complaint demonstrated a reduction in SBP of 20 mmHg or more upon standing (n=34, p=0.001; Atkins, Hanusa, Seflik, & Kapoor, 1991). Syncopal patients with and without OH were reported to be similar in age, medications, baseline blood pressure, and timing of blood pressure changes (one, two, three, five and 10 minutes after standing).

Similar findings regarding syncopal symptoms were reported in a study by Gehrking, Hines, Benurd-Larson, Orson-Gehrking, and Low (2005). Episodes referred to as presyncope, were reported in 67% of the patients (n = 24) after a 70 degree head up tilt

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7 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

(Gehrking, 2005). Presyncope was defined by the patient’s indication of feeling faint or the observer’s visual judgment of the patient. The study measured vital signs at one, two, three, and five minute intervals. The presyncopal symptoms occurred after the three minute but before the five minute interval.

Durukan and colleagues (2009) added SI (heart rate divided by SBP) along with blood pressure and heart rate to detect hemodynamic changes after acute blood loss. The researchers reported significant changes in SBP and SI. Five minutes after blood donation, while remaining in a semi-supine position, SBP (108 ± 12mmHg), and SI (0.76 ± 0.15) were significantly different (p = 0.0001) from pre-donation (SBP 120 ± 20 mmHg; SI 0.66 ± 0.15). While they only tested vital signs while participants remained in a semi-supine position, change in shock-index with position change might be investigated as an indicator of volume status in future research. The time to calculate SI could be a limitation in an emergency setting unless a calculator is readily available.

EQUIPMENT Blood pressure equipment varied by type and manufacturer throughout the selected research studies. The studies were conducted from 1980 to 2011 using manual and automatic equipment. The automatic equipment used the oscillometric method to measure blood pressure. Manual equipment consisted of auscultation and human manipulation of pressure values (Atkins, 1991; Barrak, 1992; Durukan, 2009). The study reports did not indicate the manufacturer of the manual equipment. When auscultation was used, whether diastolic was noted at phase four or five Korotkoff sound was not consistently reported.

Automatic (Fuchs & Jaffe, 1987) or semi-automatic (Cooke, 2009) equipment measured blood pressure in four studies. Dinamap® Model 1846P, Critikon, Inc. Tampa, Florida was used in three studies (Fuchs & Jaffe, 1987; Koziol-McLain, 1991; Witting, 2003), whereas one study used Accucor 1A (Sidery, 2009). One study by Lance (1993) used a combination of manual and automatic blood pressure equipment. Two studies did not report the type of blood pressure equipment, rather referred to “standardized method” for obtaining blood pressure and heart rate (Sarasin, et al., 2002). One small study compared the accuracy of an automatic device versus a manual aneroid blood pressure cuff. The study findings suggest automatic devices cannot reliably detect or rule out orthostatic hypotension because of the low sensitivity of the device. (Dind, Short, Ekholm, & Holdgate, 2011).

PATIENT SAFETY Patient safety is a responsibility of the healthcare provider during the measurement of orthostatic vital signs. During position change, from supine to standing, complex homeostatic mechanisms such as increased heart rate and vascular resistance typically compensate for the effects of gravity on the circulation to maintain cerebral blood flow (Atkins, Hanusa, Sefcik, & Kapoor, 1991; Beddoe, 2010). In general, the literature suggests the compensatory mechanisms may be impaired in the hypovolemic person predisposing them to weakness, dizziness, syncope, and the increased risk of falls. Contraindications for measuring orthostatic vital signs include: supine hypotension, shock, severe altered mental status and injuries to the spine, pelvis, or lower extremities (Beddoe, 2010).

CONCLUSION This review highlights the variations in empirical evidence on several aspects of obtaining and interpreting orthostatic vital signs. While further research is warranted, recommendations about measuring and interpreting orthostatic vital signs follow.

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8 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Description of Decision Options/Interventions and the Level of Recommendation 1. Adults (age 17 years and older1 ◦◦ The individual should rest in a flat, supine position 5-10 minutes prior to the first blood pressure measurement.Level B – Moderate. (Atkins, Hanusa, Sefcik, & Kapoor, 1991; Sarasin et al, 2002; Cohen et al, 2006; Lance et a .2009) ◦◦ Blood pressure measurements should be taken at one and three minutes after standing. Level B – Moderate (McGee, Abernethy, & Simel, 1999; Gehrking, 2005; Cooke, 2009) ◦◦ Position change from supine to standing has better diagnostic accuracy in volume depleted adults compared to position changes from supine to sitting and then to standing. Level B -Moderate (Knopp, 1980; Barraf, 1992) ◦◦ Orthostatic vital signs alone lack the sensitivity to reliably detect volume losses less than 1,000 ml. Level B - Moderate. (McGee, 1999) ◦◦ Symptoms such as dizziness and syncope, in combination with orthostatic vital signs, are more sensitive indicators of volume loss that vital sign changes alone. Therefore, symptoms and vital signs should be documented as the orthostatic variables. Level B - Moderate (McGee, 1999) ◦◦ When measuring orthostatic vital signs, one or more of the following findings may indicate intravascular volume loss in adult patients (Level B - moderate): a. Decrease in systolic blood pressure of 20 mmHg or more( b. Decrease in diastolic blood pressure of 10 mmHg or more c. Increase in heart rate of 20 or greater beats per minute (Gehrking, 2005; Durukan et al, 2009) 2. Pediatric and Adolescent (less than 17 years) i. There is insufficient evidencein the literature to make recommendations regarding orthostatic vital signs in the pediatric or adolescent population with fluid volume alterations.

1 The correct procedure for measuring blood pressure while the patient is seated or standing is to measure the blood pressure in the upper arm while supporting the patient’s arm and back. The legs should be uncrossed.

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9 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

References 1. American Academy of Neurology. (1996). Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Neurology, 46(5):1740. 2. Arnold, A., Shibao, C., (2013). Current concepts in orthostatic hypotension management. Curr Hypertes Rep, 15(4):304-12. doi:10.1007/s11906-013-0362-3 3. Atkins, D., Hanusa, B., Sefcik, T., and Kapoor, W. (1991). Syncope and orthostatic hypotension. Am J Med, 91(2):179-85. 4. Aung, T., Fan, W., Krishnamurthy, M. (2013). Recurrent syncope, orthostatic hypotension and volatile hypertion: think outside the box. J Community Hosp Intern Med Perspect, 3(2):104. doi:10.3402/jchimp.v3I2.20741 5. Beddoe, A. E. (2010). Nursing Practice & Skill Vital Signs, Postural: Measuring (pp. 1-3). Glendale, CA: CINAHL Information System. 6. Barraf, L. J., & Schriger, D.L. (1992). Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss. Am J Emerg Med, 10(2):99-103. 7. Cohen, E., Grossman, E., Sapoznikov, R., Sulkes, J., Kagan, I., & Garty, M. (2006). Assessment of orthostatic hypotension in the emergency room. Blood Press, 15(5):263-7. doi:10.1080/08037050600912070 8. Cooke, J., Carew, S., O’Connor, M., Costelloe, A., Sheehy, T., & Lyons, D. (2009). Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension. QJM, 102(5):335-9. doi: 10.1093/qjmed/hcp020 9. Dind, A., Short, A., Ekholm, J., Holdgate, A. (2011). The inaccuracy of automatic devices taking postural measurements in the emergency department. Int J Nurs Prac, 17(5):525-33. doi:10.111/j.1440-172X.2011.01958.X 10. Durukan, P., Ikizceli, I., Akdur, O., Ozkan, S., Sozuer, E. M., Avsarogullari, L., & Akpinar, G. (2009). Use of the shock index to diagnose acute hypovolemia. Turk J Med Sci, 39(6):833-35. doi: 10.3906/sag-0710-10 11. Fuchs, S. M., & Jaffe, D. M. (1987). Evaluation of the “tilt test” in children. Ann Emerg Med, 16(4):386-90. 12. Gehrking, J. A., Hines, S. M., Benrud-Larson, L. M., Opher-Gehrking, T. L., & Low, P. A. (2005). What is the minimum duration of head-up tilt necessary to detect orthostatic hypotension? Clin Auton Res, 15(2):71-5. doi: 10.1007/s10286-005-0246-y 13. Harkel, T., Lieshout, J. J., Lieshout, E. J., & Wieling, W. (1990). Assessment of cardiovascular reflexes: influence of posture and period of preceding rest. J Appl Physiol, 68(1):147-53. 14. Horam, W. J., & Roscelli, J. D. (1992). Establishing standards of orthostatic measurements in normovolemic adolescents. Am J Dis Child, 146(7):848-51. 15. Knopp, R., Claypool, R. & Leonardi, D. (1980). Use of the tilt test in measuring acute blood loss. Ann Emerg Med, 9(2):29-32. 16. Koziol-McLain, J., Lowenstein, S., & Fuller, B. (1991). Orthostatic vital signs in emergency department patients. Ann Emerg Med, 20(6):606-10. 17. Lance, R., Link, M. E., Padua, M., Clavell, L. E., Johnson, G., & Knebel, A. (2009). Comparison of different methods of obtaining orthostatic vital signs. Clin Nurs Res, 9(4):479-91. doi:10.1177/10547730022158708 18. Levitt, M. A., Lopez, B., Lieberman, M. E., & Sutton, M. (1992). Evaluation of the tilt test in an adult emergency medicine population. Ann Emerg Med, 21(6):713-18. 19. McGee, S., Abernethy, W.B., & Simel, D. (1999). The rational clinical examination: Is this patient hypovolemic? JAMA, 281(11):1022-29. 20. Moya, A., Sutton, R., Ammirati, F., Blanc, J. J, Brignole, M., Dahm, J.B., …Wieling, W. (2009). Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J, 30(21):2631-71. doi: 10.1093/eurheartj/ehp298 21. Naschitz, J. E., & Rosner, I. (2007). Orthostatic hypotension: Framework for the syndrome. Postgrad Med J, 83(983):568-74. doi:10.1136/pgmj.2007.058198 22. Pickering, T. G, Hall, J. E., Appel, L. J., Falconer, B. E., Graves, J. W., Hill, M. N., … Roccella, E. J. (2005). Recommendations for blood pressure measurement in humans: An AHA scientific statement from the council on high blood pressure research professional and public education subcommittee. J Clin Hypertens, 7(2):102-9. doi :10.1111/j.1524-6175.2005.04377.x 23. Sarasin, F. P., Louis-Simonet, M., Carballo, D., Slama, S., Junod, A., & Unger, P. F. (2002). Prevalence of orthostatic hypotension among patients presenting with syncope in the ED. Am J Emerg Med, 20(6):497-501. doi: 10.1053/ajem.2002.34964 24. Sidery, M. B., & Macdonald, I. A. (1991). Blood pressure changes associated with tilting in normotensive subjects: differences in response pattern as measured by oscillometry and auscultation. Clinical Autonomic Research, 1, 161-166. 25. Smith, J. J., Porth, C. M., & Erickson, M. (1994). Hemodynamic response to the upright posture. J Clin Pharmacol, 34(5):375-386. 26. Streeten, D. H. H. P, & Anderson, G. H. (1992). Delayed orthostatic intolerance. Arch Int Med, 152(5):1066-72. 27. Winslow, E. H., Lane, L. D., & Woods, R. J. (1995). Dangling: A review of relevant physiology, research, and practice. Heart Lung, 24(4):263-72. 28. Winters, R. W. (1982) Principles of Pediatric Fluid Therapy (2nd ed.). Boston: Little, Brown, and Company. 29. Witting, M. D., & Gallagher, M. S. (2003). Unique cutpoints for sitting-to-standing orthostatic vital signs. Am J Emerg Med, 21(1):45-7. doi:10.1053/ ajem.2003.50009

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10 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs

Authors 2015 ENA Clinical Practice Guideline Committee Marsha Cooper, MSN, RN, CEN Janis Farnholtz-Provinse, MS, RN, CNS, CEN Marylou Killian, DNP, MS, RN, CEN, FNP-BC, Chairperson Karen Gates, DNP, RN, NE-BC Mary Kamienski, PhD, APRN, CEN, FAEN, FAAN David McDonald, MSN, RN, APRN, CEN, CCNS Nancy Erin Reeve, MSN, RN, CEN Anne Renaker, DNP, RN, CNS, CPEN Alysa Reynolds, RN Stephen Stapleton, PhD, MSN, MS, RN, CEN, FAEN Patricia Sturt, MSN, MBA, RN, CEN, CPEN Anna Maria Valdez, PhD, MSN, RN, CEN, CRFRN, CNE Mary Alice Vanhoy, MSN, RN, CEN, CPEN, NREMT-P, FAEN Mary Ellen Zaleski, MSN, RN, CEN

ENA 2015 Board of Directors Liaison: Jean A. Proehl, MN, RN, CEN, CPEN, FAEN

ENA Staff Liaisons Lisa Wolf, PhD, RN, CEN, FAEN, Director, IENR Altair Delao, MPH, Senior Research Associate, IENR

Acknowledgments ENA would like to acknowledge the following member of the 2015 Institute for Emergency Nursing Research (IENR) Advisory Council for his review of this document:

Paul Clark, PhD, MS, RN

Developed: October 2015 © Emergency Nurses Association, 2015.

ENA’s Clinical Practice Guidelines (CPGs), including the information and recommendations set forth herein (i) reflects ENA’s current position with respect to the subject matter discussed herein based on current knowledge at the time of publication; (ii) is only current as of the publication date; (iii) is subject to change without notice as new information and advances emerge; and (iv) does not necessarily represent each individual member’s personal opinion. The positions, information and recommendations discussed herein are not codified into law or regulations. Variations in practice and a practitioner’s best nursing judgment may warrant an approach that differs from the recommendations herein. ENA does not approve or endorse any specific sources of information referenced. ENA assumes no liability for any injury and/or damage to persons or property arising from the use of the information in this Clinical Practice Guidelines.

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11 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 1: Evidence Table

Research/Purpose Design/Sample Variables/Measures Quality of Level of Reference Findings/Implications Questions/Hypothesis Setting Analysis Evidence Evidence

Statistical Analysis: Chi- Purpose of Study: Evaluate square, t-test, repeated how long patients should Design: prospective measures ANOVA, Atkins, D., Hanusa, B., stand prior to vital sign Time to reach minimal BP was 2.4 min. Sample: N= 223 Hospital (ED, inpatient, life-table, survival analysis, Sefcik, T., and Kapoor, measurement. Determine Greatest decrease in blood pressure is outpatient clinics) adults with syncope poisson regression. Supine W. (1991). Syncope and how prevalent orthostatic 30 seconds and 1 minute after standing. I VI Randomization: no vitals taken after 5 minutes. orthostatic hypotension. hypotension (OH) is in Recurrence of symptoms was not relat- Convenience Sample: Yes Standing vitals taken at 0 Am J Med, 91(2):179-85. syncopal patients. Determine ed to degree of OH. Setting: Hospital minutes, 1,2,3,5,10 minutes. if OH is a risk for recurrence Manual blood pressure of symptoms. measurements.

Barraf, L. J., & Schriger, Purpose of Study: 1) Deter- Design: prospective pretest Statistical Analysis: 1) pulse rate most sensitive orthostatic D.L. (1992). Orthostatic mine the effect of age on or- posttest design Receiver operator char- vital sign to changes in detecting acute vital signs: variation thostatic vital signs 2) define Sample: N = 200 (100 healthy blood acteristics Manual blood 450mL blood loss with age, specificity, and sensitivity and specificity of donors & 100 ambulatory senior citizens) pressure measurements. 2) adding diastolic bp measurement II III sensitivity in detecting alternative definitions of “ab- Randomization: no Measures were made in improved sensitivity with little loss a 450-mL blood loss. normal” orthostatic vital signs Convenience Sample: yes supine position after 1 in specificity Am J Emerg Med, in blood donors sustaining an Setting: blood donation center & minute and standing after 3) a pulse rise + DBP fall of more 10(2):99-103. acute 450ml blood loss. senior citizen center 30 seconds. than 10 performs best

Cohen, E., Grossman, Statistical Analysis: Pearson E., Sapoznikov, R., and spearman correlation, Purpose of Study: Identify Most OH was detected with 3 min of Sulkes, J., Kagan, I., chi-square, fishers exact amount of time patient should standing. There was an association & Garty, M. (2006). Design: prospective test, student’s t-test, Duncan stand prior to vital sign between OH, higher supine systolic and Assessment of ortho- Sample: N=814 Randomization: no multiple comparison, mul- measurement while standing. diastolic BP, and symptoms of syncope. I VI static hypotension in the Convenience Sample: Yes tivariable stepwise logistic Determine the association Patients older than 75 yrs with OH had emergency room. Blood Setting: ED regression. Blood pressure between OH, symptoms, hos- higher 1 yr mortality. OH was associat- Press, 15(5):263-7. measured using (BP-8800). pitalization, and survival. ed with falls and kidney disease. doi:10.1080/ subjects were supine 5 08037050600912070 minutes

Cooke, J., Carew, S., Statistical Analysis: Receiv- O’Connor, M., Costel- er operator characteristics loe, A., Sheehy, T., & Sit-stand vitals measured Lyons, D. (2009). Sitting Design: retrospective 3 minutes after sitting and Sit-stand sensitivity 15.5%, specificity and standing blood Purpose of Study: determine Sample: N=730 Randomization: no 30 seconds after stand- 89.9%, Receiver Operating Characteris- pressure measurements the ability of the sit-stand to II VI Convenience Sample: yes ing. Lying-standing vitals tic (ROC) 0.564, indicating low diagnos- are not accurate for the identify OH measurements Setting: hospital measured 5 minutes after tic accuracy for sit-stand test diagnosis of orthostatic lying and 3minutes after hypotension. QJM, standing. Semi-automatic 102(5):335-9. doi: machine(Omron 705IT). 10.1093/qjmed/hcp020

12 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 1: Evidence Table

Research/Purpose Design/Sample Variables/Measures Quality of Level of Reference Findings/Implications Questions/Hypothesis Setting Analysis Evidence Evidence

The data were analyzed using SPSS Version 16 with the alpha level set at 0.05. The power of this study was >90% to detect a clinically significant difference of 10 mm HG Dind, A., Short, A., and a standard deviation Ekholm, J., Holdgate, A. This study assessed the accu- of 10mmHG based on (2011). The inaccuracy Findings suggest that automatic devices racy of an automatic device previous studies. Descrip- of automatic devices Descriptive statics. This study involved cannot reliability detect or rule out compared with a manual tive statics were produced taking postural mea- taking sequential postural BP measure- orthostatic hypotension, indicating aneroid reference standard for to show the characteristics 1 3 surements in the emer- ments with an automatic and a manual that triage nurses need to use manual determining orthostatic hypo- of the participants. Paired gency department. Int J device. IRB Yes devices to take accurate postural blood tension and postural drops at t-test were then conducted Nurs Prac, 17(5):525-33. pressures for optimal patient care. triage. P 525 to determine whether the doi:10.111/j.1440- differences between the two 172X.2011.01958.X devices were statistically significant. Bland-Altman Plots were used to determine the clinical significance of these differences and the variation across the BP range.

Blood Pressure measured manually by auscultation. Durukan, P., Ikizceli, Vital signs measured by I., Akdur, O., Ozkan, one data collector. Blood Statistically significant changes in HR S., Sozuer, E. M., Purpose of Study: Determine Design: prospective, observational pressure measured in & DBP in 5 mins post donation; SBP Avsarogullari, L., & the accuracy of shock index in Sample: 50 healthy blood donors semi-supine position. Data in 1 & 5 mins post donation. HR = 77 Akpinar, G. (2009). the early detection of hemo- Randomization: No collection points: before (pre) 81 (post 5 min) p = 0.04; DBP = 76 II VI Use of the shock index dynamic changes after acute Convenience Sample: Yes donation, 1 minute and 5 mmHg (pre) 70mmHg (post 5 min) p = to diagnose acute hy- blood loss Setting: Blood donation clinic minutes after donation. 0.02; SBP = 120 (pre) 106 (post 1 min), povolemia. Turk J Med BP and HR variables were 108 (post 5 min) p =0.0001 Sci, 39(6):833-35. doi: collected prior to blood do- 10.3906/sag-0710-10 nation and 1 and 5 minutes after blood donation.

13 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 1: Evidence Table

Research/Purpose Design/Sample Variables/Measures Quality of Level of Reference Findings/Implications Questions/Hypothesis Setting Analysis Evidence Evidence

5 children excluded (3 dehydrated; 2 hydrated) due to machine malfunction (2), inability to obtain urine (3), did not meet dehydration score (1) Results: rise in HR 29.1 beats (+10.7) signifi- Variables: BP & HR mea- cantly higher (p = 0.001) than normal sured at 1 minute intervals group. Mean change in systolic BP x 3 sets by noninvasive small among both groups. No mean blood pressure monitor changes (1 & 2 min.) in HR among (Dinamap® Model 1846P, groups, instead of 1 minute standing Critikon, Inc. Tampa, Fl.) values. Cutoff points for positive tilt test Position: supine for mini- Fuchs, S. M., & Jaffe, Purpose of Study to evaluate value 20 bpm with history of vomiting Design: prospective mum of 3 minutes before D. M. (1987). Evalua- the “tilt test’ in children by or diarrhea as cause of dehydration. Sample: n= 21 normal children; vital signs taken; standing tion of the “tilt test” in comparing normally hydrated HR changes 20 bpm or greater, with II VI 16 dehydrated Randomization: no position for 1 minute with children. Ann Emerg children and volume depleted sensitivity and specificity of 81% with Convenience Sample: yes arm supported at heart level Med, 16(4):386-90. children a positive test predictive value of 76% before BP & HR at 1 minute and a negative test predictive value of intervals x 2 readings. 85% Specificity increased to 95% with Symptoms: dizziness or HR greater than 25 bpm with a positive lightheadedness recorded. test predictive value increase to 92%. Statistical Analysis: Chi Four dehydrated children’s HR did not square, Fisher’s exact test, increase more than 25 bpm; pts were fe- t test. brile and tachycardic in supine position. A HR Increase 25 bpm or greater is indicative of a positive tilt test. Including symptoms with vital signs improves the predictive ability. One minute of HUT will detect OH in Statistics: Chi square the great majority (88%) of patients analysis examined whether and three minutes will detect Gehrking, J. A., Hines, the groups differed in Design: Convenience Sample the balance. Orthostatic stress S. M., Benrud-Larson, how often the tilt test was Evaluated the medical records of 66 con- beyond 2 minutes is necessary to L. M., Opher-Gehrk- Purpose: To determine terminated early (prior to 5 secutive patients (mean age 70.0‪?}10.1 detect the pattern of progressive ing, T. L., & Low, P. 1) the minimum duration of minutes) due to presyncope years; 64% male) seen at Mayo OH. Since this group has more A. (2005). What is the HUT necessary to detect OH and Mann-Whitney U tests Clinic-Rochester from 2000ayotiv severe adrenergic deficits than the minimum duration of and 2) to identify different examined differences in II IV who fulfilled the criteria for OH group with stable OH, we suggest head-up tilt necessary to patterns of orthostatic blood CASS scores between the (systolic blood pressure [SBP] reduction that the progressive pattern is due detect orthostatic hypo- pressure (BP) response in two groups. All tests were ≥systolic blood pressure [ to greater impairment of compensatory tension? Clin Auton Res, patients with OH 2-tailed. P<0.05 was of HUT) during routine clinical reflexes. Recognition of the 15(2):71-5. doi: 10.1007/ considered significant. All autonomic studies. group with progressive fall in BP is s10286-005-0246-y statistical analyses were important since this group may be performed using at greater risk of orthostatic syncope SPSS 11.5 for Windows.

14 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 1: Evidence Table

Research/Purpose Design/Sample Variables/Measures Quality of Level of Reference Findings/Implications Questions/Hypothesis Setting Analysis Evidence Evidence

Purpose of Study: 1) What is the range of normal of ortho- Koziol-McLain, J., statc vital signs in a sample ANOVA, correlation Lowenstein, S., & Full- Wider than expected variation in ortho- of ED patients who have no Design: descriptive Sample: N = 132 Dinamap model 1846 used er, B. (1991). Orthostatic static vital signs in presumed euvolemic recent fluid or blood losses? Randomization: no to measure vitals. Supine 3 vital signs in emergency ED patients. Correlation between age I VI 2) What variables (age, medi- Convenience Sample: yes minutes prior to measure- department patients. and OH. Diastolic BP most reliable cations, fever) are associated Setting: urban teaching hospital ED ment. Standing vitals Ann Emerg Med, orthostatic vital sign. with more marked orthostatic measured at 2 minutes. 20(6):606-10. vital signs in euvolemic ED patients? Able to distinguish between no blood loss and blood loss of 1000 ml blood loss with the sit-stand test. HR 30 bpm or greater and severe symptoms (syn- 1) To determine sensitivity cope, severe dizziness) has a sensitivity Knopp, R., Claypool, R. and specificity of the tilt test Design prospective of 98%, specificity 98%. Unable to Vitals measured & Leonardi, D. (1980). in detecting blood loss 2) Sample 100 volunteers 17-55 years distinguish between no blood loss and supine-stand and supine-sit Use of the tilt test in compare supine to sitting and (no medications, no serious illness, 500 ml blood loss. The sit-stand test prior to blood donation and I VI measuring acute blood supine to standing 3) identify hematocrit over 38%, weight greater cannot reliably distinguish no blood loss then again after 500 ml and loss. Ann Emerg Med, the appropriate time interval than 110 pounds). There were 56 men from 500 ml blood loss. The percent 1000 ml blood loss. 9(2):29-32. after position change to mea- and 44 women. blood lost correlates with increase HR sure vitals. and severe symptoms but there was a wide variation in response. Therefore, a negative tilt test does not rule out blood loss. A positive test indicated acute blood loss 99% of the time.

Lying BP differed between 5 & 10 Lance, R., Link, M. Variables: blood pressure, minutes (F=21.33,p < 0.001 Mean E., Padua, M., Clavell, h e a r t r a t e , d i z z i n e s s . BP differed between 5 & 10 min- L. E., Johnson, G., & Equipment: Stop watch and utes (F=5.23, <0.03); Standing BP Knebel, A. (2009). Design: Randomized Crossover dominant arm; Dinamap Compare two lying and and dizziness differed between 0 & 2 Comparison of different Sample: N=35 normotensive young model 1846 SX; VAS for standing procedures for minutes (F=8.36, p = 0.01) & (F=7.15, p I II methods of obtaining adults (21.6 avg y/o). dizziness-10 cm visual an- measuring orthostatic vitals < 0.10). For normotensive individuals in orthostatic vital signs. Setting: inpatient research hospital alogue scale with left end this study, vitals were stabilized by 10 Clin Nurs Res, 9(4):479- =no dizziness and right end min. Standing vitals can be measured 91. doi:10.1177/10547 worst dizziness you could immediately upon standing and again 730022158708 imagine at 2 min.

15 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 1: Evidence Table

Research/Purpose Design/Sample Variables/Measures Quality of Level of Reference Findings/Implications Questions/Hypothesis Setting Analysis Evidence Evidence

Statistical Analysis: Levitt, M. A., Lopez, Large variance in vital signs and lack MANOVA, Regression, B., Lieberman, M. E., of correlation between vital signs and 2-way ANOVA, 2-tailed & Sutton, M. (1992). Design: prospective amount of dehydration make it difficult Purpose of Study: Evaluate unpaired student’s t-test Evaluation of the tilt test Sample: N=202 (patients) N=21 healthy to identify cut offs for orthostatic vital tilt test to identify volume loss The patient was supine 2 II IV in an adult emergency volunteers Randomization: no signs. Change in SBP was statistical- in ED patients. minutes prior to vital sign medicine population. Convenience Sample: Yes Setting: ED ly but not clinically significant. HR measurement. Vital signs Ann Emerg Med, demonstrated a small association with were measured 60 seconds 21(6):713-18. level of dehydration. after standing.

Clinicians should wait at least 2 minutes before measuring the supine vital signs McGee, S., Abernethy, and 1 minute after standing before W.B., & Simel, D. Design: Systematic review of correlat- Measures analysis: Studies measuring the upright vital signs. Purpose of Study: To review, (1999). The rational ed literature with a focus on clinical were reviewed and graded Counting the pulse for 30 seconds and systematically, the physical clinical examination: presentations of hypovolemia and OH by authors based on type doubling the result is more accurate I III diagnosis of hypovolemia in Is this patient hy- of health volunteer subjects and patients of study and number of than 15 seconds of observation.44 In adults povolemic? JAMA, presenting to the emergency department subjects normovolemic individuals,a postural 281(11):1022-29. pulse increment of more than 30 beats/ min is uncommon, affecting only about 2% to 4% of individuals. Sarasin, F. P., OH was cause of 24% of syncope in this Louis-Simonet, M., population of ED patients. Stressed the Statistical Analysis: Carballo, D., Slama, importance of symptoms and orthostatic Purpose of Study: student’s t test, chi-square, S., Junod, A., & Unger, changes before considering OH as a Determine how many patients fisher exact test measured P. F. (2002). Preva- Design: prospective and observational cause of syncope. Manually measured who present to the ED with a vitals manually. Patients lence of orthostatic Sample: N=650 Randomization: No BP and pulse. Rested 5 prior to supine complaint of syncope have or- were supine 5 min prior to II VI hypotension among Convenience Sample: Yes measurement. Measured standing vitals thostatic changes and describe first measurement. Stand- patients presenting with Setting: Hospital at 1, 2, 3, 5, and 10 minutes. N=127 (ED the characteristics ing vitals were measured at syncope in the ED. Am J patients with OH changes) maximal of these patients. 0, 1, 2, 3, 5, and 10 minutes Emerg Med, 20(6):497- decline in SBP within 3 minutes of (or until symptomatic). 501. doi: 10.1053/ standing for 75% and with 5 minutes of ajem.2002.34964 standing for 86%.

16 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 1: Evidence Table

Research/Purpose Design/Sample Variables/Measures Quality of Level of Reference Findings/Implications Questions/Hypothesis Setting Analysis Evidence Evidence

Blood pressure measured in 3 positions: horizontal, 45 degree head-up tilt, Sidery, M. B., & & standing Statistical Macdonald, I. A. Sample: analysis included limits of (1991). Blood pressure N=20 healthy adults (7 female, 13 male), agreement of measurement changes associated with The Accutorr 1A reflects blood What was the blood pressure no hx of cardiovascular or other signif- vs. correlation. 1) No sig- tilting in normotensive measurements using direct technique. responses to tilting using two icant diseases; no medications except nificant difference of SBP subjects: differences However, unable to extend the study’s I II different techniques, ausculta- contraceptive pills. No oral intake (food in supine position between in response pattern as findings to people with hypertension or tion and oscillometry and beverage) or smoking 1 hour prior to conventional, random-ze- measured by oscillom- postural hypotension. test. Blood pressure cuff size measured/ ro sphygmomanometer, etry and auscultation. appropriate to s and oscillometric device. Clinical Autonomic Significant difference Research, 1, 161-166. between conventional and random-zero sphygmomanometer Accutorr 1A.

Prospective, controlled for non-cardio- Mean sit-stand changes were less vascular disease and euvolumic through extreme than lying-standing. HR inclusion protocol. IRB approved. Data increased 5.3 + 6.6 bpm, SBP decreased Witting, M. D., & collection 1999 through 2001. Variables: 1.2 + 9.8 mmHg, Shock Index increased Gallagher, M. S. (2003). blood pressure, heart rate, position - sit- N=176 Purpose: Describe the distri- 0.05 + 0.07 bpm/mmHg. Different cri- Unique cutpoints for ting and standing. Convenience sample = Average age 33±10 yrs. bution of normal changes in teria (from lying-standing) are required sitting-to-standing 176 adults free of cardiovascular disease Forty-eight percent females, vital signs related to moving for the sit-stand test. HR increase 20 I IV orthostatic vital signs. and determined to be euvolumic 79 emergency department from a sitting to a standing bpm or more had 98 % specificity; SBP Am J Emerg Med, Dinemap (Johnson & Johnson, Tampa, patients, 97 healthcare position. decrease has 97% specificity, Shock 21(1):45-7. doi:10.1053/ FL): non-invasive BP, HR. Protocol: providers Index increase 0.2 or greater had 99% ajem.2003.50009 Lying for 5 minutes. Position change to specificity and Ratio of Orthostatic standing for 1 minute before vital signs. Shock Index (ROSCI) 1.3 or higher had Arm positioned so blood pressure cuff at 95% specificity. heart level.

17 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 2: Other Resources Table

Reference Research Purpose Conclusions

Arnold, A., Shibao, C., (2013). Current concepts in orthostatic Orthostatic hypotension in the elderly has numerous etiologies. Patients Provides an overview of orthostatic hypotension as a clinical condi- hypotension management. Curr Hypertes Rep, 15(4):304-12. with orthostatic hypotension need to have appropriate symptomatic con- tion, discusses various causes, methods of detection and treatment. doi:10.1007/s11906-013-0362-3 trol in order to prevent syncope and falls. Defined OH, pure autonomic failure, and multiple system atrophy. OH can American Academy of Neurology. (1996). Consensus statement on be symptomatic or asymptomatic. Vitals may not change until they have the definition of orthostatic hypotension, pure autonomic failure, Consensus statement American Academy of Neurology. been standing for 10 minutes. Possible confounders: eating, time of day, and multiple system atrophy. Neurology, 46(5):1740. hydration, ambient temperature. Aung, T., Fan, W., Krishnamurthy, M. (2013). Recurrent syncope, orthostatic hypotension and volatile hypertion: think outside Case presentations and discussion of the role of Baroreceptors in the Baro-reflex failure after radiation is an under-reconized cause of ortho- the box. J Community Hosp Intern Med Perspect, 3(2):104. regulation of blood pressure with change of position static hypotension and syncope doi:10.3402/jchimp.v3I2.20741

Harkel, T., Lieshout, J. J., Lieshout, E. J., & Wieling, W. (1990). Research to investigate the effects of redistribution of blood volume Posture and period of preceding rest are important quantitative Assessment of cardiovascular reflexes: influence of posture and and change in blood pressure and heart rate to standing, forced determinants of cardiovascular reflex responses. period of preceding rest. J Appl Physiol, 68(1):147-53. breathing and the Valsalva Maneuver.

Healthy adolescents have wide variations in orthostatic measurements that Horam, W. J., & Roscelli, J. D. (1992). Establishing standards Research to determine normal orthostatic heart rate, and blood pres- exceed previously accepted standards. Further research needs to done to of orthostatic measurements in normovolemic adolescents. sure changes in healthy adolescents performed. determine if values to determine individuals with volume depletion can Am J Dis Child, 146(7):848-51. be identified Symptoms of “orthostatic intolerance” syncope, dizziness, Guidelines endorsed by European Society of Emergency Medicine, Moya, A., Sutton, R., Ammirati, F., Blanc, J. J, Brignole, M., light headiness, pre-syncope, weakness, fatigue, lethargy, European Federation of Internal Medicine, European Union Geriatric Dahm, J.B., …Wieling, W. (2009). Guidelines for the diagno- palpitations, sweating are associated with OH. Medicine Society, American Geriatrics Society, European Neurolog- sis and management of syncope (version 2009). Eur Heart J, Different types of OH were presented (initial, classical, delayed, etc.). ical Society, European Federation of Autonomic Societies, American 30(21):2631-71. doi:10.1093/eurheartj/ehp298 Also provided a review of onset of symptoms, pathophysiology, most com- Autonomic Society mon symptoms, and associated conditions for each type of OH Naschitz, J. E., & Rosner, I. (2007). Orthostatic hypotension: Reviewed 1996 consensus definition for OH. Reviewed changes in May miss 2/3 of orthostatic patients when only using sit-stand test. Framework for the syndrome. Postgrad Med J, 83(983):568-74. normal patients. Reviewed literature to determine if one standard OH Reports that OH has diurnal, day-to-day, and seasonal variability. doi:10.1136/pgmj.2007.058198 test can be used for all patients. Recommends testing at 5min.

Goal was to determine if sitting or supine affects blood pressure. Did not evaluate volume status. Did not evaluate OH. Netea, R.T., Smits, P., Lenders, J.W.M., and Thin. T., (1998). Does Prospective study in outpatient setting with N=245. Evaluated chang- Sitting DBP was higher than supine. Older patients had lower postural it matter whether blood pressure measurements are taken with es in BP when patients change from a sitting to standing position. differences for DBP and HR. Posture influences BP readings and should subjects sitting or supine? J Hypertens, 16(3):263-8. Compared sitting and standing SBP, DBP, and HR. be noted along with the BP reading.

Pickering, T. G, Hall, J. E., Appel, L. J., Falconer, B. E., Graves, Recommendations for measuring blood pressure. Upper arm is standard J. W., Hill, M. N., … Roccella, E. J. (2005). Recommendations location for blood pressure measurement. Wrist is okay for obese. Finger for blood pressure measurement in humans: An AHA scientific AHA scientific statement, blood pressure measurement measurements are not recommended. Legs should be uncrossed. Back statement from the council on high blood pressure research pro- and arm should be supported during measurements. Five minutes of rest fessional and public education subcommittee. J Clin Hypertens, should lapse prior to first measurement. 7(2):102-9. doi :10.1111/j.1524-6175.2005.04377.x

18 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 2: Other Resources Table

Reference Research Purpose Conclusions In healthy young adults the immediate response is an increase in heart Smith, J. J., Porth, C. M., & Erickson, M. (1994). Hemodynamic To review previous studies of immediate and stabilized (30 sec- rate and blood pressure. Beginning at the age of 75 there is an increased response to the upright posture. J Clin Pharmacol, 34(5):375-386. onds-20 minutes hemodynamic responses to heads up posture. incidence of orthostatic hypotension These patients were found to have “excessive gravitational pooling of Case reports of 7 patients were presented who developed blood in the dependent veins”. Determined that “impaired sympathetic Streeten, D. H. H. P, & Anderson, G. H. (1992). Delayed orthostat- orthostatic symptoms but failed to show orthostatic vital sign changes innervations of the veins of the lower limb plays a cardinal role in the ic intolerance. Arch Int Med, 152(5):1066-72. after standing for 3-4 minutes. Evaluated vital signs during position pathogenesis of delayed OH in at least some patients”. These patients did changes with and without a pressure suit. not have volume losses. Observational and descriptive study evaluating nurses’ ability and Vloet, L.C.M., Smits, R., Frederiks, C.M.A., Hoefnagels, W., knowledge of how to measure blood pressure in the Netherlands. Found that nurses’ practice for measuring BP varies widely. Janesen, R.W.M.M., (2002). Evaluation of skills and knowledge Observations were made base on the American Heart Association’s on orthostatic blood pressure measurements in elderly patients. recommendations for blood pressure measurement and the American The first and third minutes after standing are the most practical and useful Age Ageing, 31(3):211-6. doi:10.1093/ageing/31.3.211 Academy of Neurology’s consensus statement definition of OH. times to diagnose orthostatic blood pressure changes. Manual measurement of BP. Did not measure HR OH will be underestimated if the arm is allowed to be parallel with the body while standing. Wieling, W. and Schatz, I.J. (2008). The consensus statement on Active and passive changes in posture produce different cardiovascular Reviewed the definition of OH and reviewed results of published the definition of orthostatic hypotension: A revisit after 13 years.J effects within the first 30 seconds. An initial fall in arterial pressure research using this definition. Hypertens, 27(5):935-8. doi:10.1097/HJH.0b013e32832b1145. occurs only with active standing. About of half of the cases with OH will be detected within 3 minutes of standing.

Variability in heart rate and blood pressure response to position changes. Winslow, E. H., Lane, L. D., & Woods, R. J. (1995). Literature review of physiology, research, and practice literature Recommended that OH not be defined by “dramatic” changes in vital Dangling: A review of relevant physiology, research, and practice. related to dangling and orthostasis. signs alone. Dangling for less than 3 minutes will prevent symptom Heart Lung, 24(4):263-72. associated with OH.

Of the 28 nurses indicating yes/no response, 16 (57%) indicated that they We undertook this study to describe the procedures for orthostatic measure orthostatic vital signs in triage. Among all respondents, the min- Witting, M. D., & Gallagher, M. S. (2003). Unique cutpoints vital sign measurement and their interpretation in an urban academic imum resting period before initial vital sign measurement was distributed for sitting-to-standing orthostatic vital signs. Am J Emerg Med, emergency department. We also describe the distribution of proce- as follows: 1 minute, 10; 2 minutes, 12; 3 minutes, 8; 5 minutes, 8; 15 to 21(1):45-7. doi:10.1053/ajem.2003.50009 dures used by various care providers and estimate the proportion of 30 minutes, 2; and not specified time, 12. The variation in procedures and nurses who obtain vital signs at triage. P 619 interpretation that we found suggests the potential for great inefficiency in our emergency department.

19 CLINICAL PRACTICE GUIDELINE: Orthostatic Vital Signs Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria

Potentially relevant publications identified by electronic search (n=52) Publications excluded as they did not meet the PICOT question (n=38)

Publications reviewed in full text (n=14)

Publications excluded as they did not meet the PICOT question upon full review (n=7)

Publications reviewed in full (n=7)

Publications excluded (did not meet evidence analysis criteria) (n=3) Publications that met criteria to be included in evidence analysis (sound and relevant studies) (n=3) Publications not excluded from evidence analysis, but included as background information (n=1) Inclusion Criteria Exclusion Criteria

Studies published in English Studies not published in English Studies involving human subjects Non-human studies April 2011- October 2015 Studies not in the timeframe listed Studies addressing the PICOT question Studies not addressing the PICOT questions

The following databases were searched: PubMed, Google Scholar, CINAHL, Cochrane Library, BioMed Central-Open Access, Agency for Healthcare Research and Quality, and the National Guideline Clearinghouse.

Search terms included: “tilt test,” “postural vital signs,” “orthostatic vital signs,” “blood pressure,” “hypotension,” “orthostatics,” and “hypovolemic,” using a variety of different search combinations.