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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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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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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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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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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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CLINICAL PRACTICE GUIDELINE:
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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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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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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 evidence in the literature to make recommendations regarding orthostatic vital signs in the pediatric or
adolescent population with fluid volume alterations.
1
he 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
T
patient’s arm and back. The legs should be uncrossed.
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CLINICAL PRACTICE GUIDELINE:
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Horam, W. J., & Roscelli, J. D. (1992). Establishing standards of orthostatic measurements in normovolemic adolescents. Am J Dis Child, 146(7):848-51.
Knopp, R., Claypool, R. & Leonardi, D. (1980). Use of the tilt test in measuring acute blood loss. Ann Emerg Med, 9(2):29-32.
Koziol-McLain, J., Lowenstein, S., & Fuller, B. (1991). Orthostatic vital signs in emergency department patients. Ann Emerg Med, 20(6):606-10.
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
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.
McGee, S., Abernethy, W.B., & Simel, D. (1999). The rational clinical examination: Is this patient hypovolemic? JAMA, 281(11):1022-29.
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
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
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
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
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.
Smith, J. J., Porth, C. M., & Erickson, M. (1994). Hemodynamic response to the upright posture. J Clin Pharmacol, 34(5):375-386.
Streeten, D. H. H. P, & Anderson, G. H. (1992). Delayed orthostatic intolerance. Arch Int Med, 152(5):1066-72.
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.
Winters, R. W. (1982) Principles of Pediatric Fluid Therapy (2nd ed.). Boston: Little, Brown, and Company.
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
915 Lee Street, Des Plaines, IL 60016-6569 ¡ 800.900.9659 ¡ www.ena.org ¡ Follow us
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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.
915 Lee Street, Des Plaines, IL 60016-6569 ¡ 800.900.9659 ¡ www.ena.org ¡ Follow us
11
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Purpose of Study: Evaluate
how long patients should
stand prior to vital sign
measurement. Determine
how prevalent orthostatic
hypotension (OH) is in
syncopal patients. Determine
if OH is a risk for recurrence
of symptoms.
Design: prospective
Sample: N= 223 Hospital (ED, inpatient,
outpatient clinics) adults with syncope
Randomization: no
Convenience Sample: Yes
Setting: Hospital
Statistical Analysis: Chisquare, t-test, repeated
measures ANOVA,
life-table, survival analysis,
poisson regression. Supine
vitals taken after 5 minutes.
Standing vitals taken at 0
minutes, 1,2,3,5,10 minutes.
Manual blood pressure
measurements.
Atkins, D., Hanusa, B.,
Sefcik, T., and Kapoor,
W. (1991). Syncope and
orthostatic hypotension.
Am J Med, 91(2):179-85.
Time to reach minimal BP was 2.4 min.
Greatest decrease in blood pressure is
30 seconds and 1 minute after standing.
Recurrence of symptoms was not related to degree of OH.
I
VI
Barraf, L. J., & Schriger,
Purpose of Study: 1) DeterD.L. (1992). Orthostatic
mine the effect of age on orvital signs: variation
thostatic vital signs 2) define
with age, specificity, and sensitivity and specificity of
sensitivity in detecting
alternative definitions of “aba 450-mL blood loss.
normal” orthostatic vital signs
Am J Emerg Med,
in blood donors sustaining an
10(2):99-103.
acute 450ml blood loss.
Design: prospective pretest
posttest design
Sample: N = 200 (100 healthy blood
donors & 100 ambulatory senior citizens)
Randomization: no
Convenience Sample: yes
Setting: blood donation center &
senior citizen center
Statistical Analysis:
Receiver operator characteristics Manual blood
pressure measurements.
Measures were made in
supine position after 1
minute and standing after
30 seconds.
1) pulse rate most sensitive orthostatic
vital sign to changes in detecting acute
450mL blood loss
2) adding diastolic bp measurement
improved sensitivity with little loss
in specificity
3) a pulse rise + DBP fall of more
than 10 performs best
II
III
Design: prospective
Sample: N=814 Randomization: no
Convenience Sample: Yes
Setting: ED
Statistical Analysis: Pearson
and spearman correlation,
chi-square, fishers exact
test, student’s t-test, Duncan
multiple comparison, multivariable stepwise logistic
regression. Blood pressure
measured using (BP-8800).
subjects were supine 5
minutes
Most OH was detected with 3 min of
standing. There was an association
between OH, higher supine systolic and
diastolic BP, and symptoms of syncope.
Patients older than 75 yrs with OH had
higher 1 yr mortality. OH was associated with falls and kidney disease.
I
VI
Design: retrospective
Sample: N=730 Randomization: no
Convenience Sample: yes
Setting: hospital
Statistical Analysis: Receiver operator characteristics
Sit-stand vitals measured
3 minutes after sitting and
Sit-stand sensitivity 15.5%, specificity
30 seconds after stand89.9%, Receiver Operating Characterising. Lying-standing vitals tic (ROC) 0.564, indicating low diagnosmeasured 5 minutes after
tic accuracy for sit-stand test
lying and 3minutes after
standing. Semi-automatic
machine(Omron 705IT).
II
VI
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
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
Purpose of Study: Identify
amount of time patient should
stand prior to vital sign
measurement while standing.
Determine the association
between OH, symptoms, hospitalization, and survival.
Purpose of Study: determine
the ability of the sit-stand to
identify OH measurements
12
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 1: Evidence Table
Reference
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.1440172X.2011.01958.X
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
Research/Purpose
Questions/Hypothesis
This study assessed the accuracy of an automatic device
compared with a manual
aneroid reference standard for
determining orthostatic hypotension and postural drops at
triage. P 525
Purpose of Study: Determine
the accuracy of shock index in
the early detection of hemodynamic changes after acute
blood loss
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Descriptive statics. This study involved
taking sequential postural BP measurements with an automatic and a manual
device. IRB Yes
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
and a standard deviation
of 10mmHG based on
previous studies. Descriptive statics were produced
to show the characteristics
of the participants. Paired
t-test were then conducted
to determine whether the
differences between the two
devices were statistically
significant. Bland-Altman
Plots were used to determine the clinical significance of these differences
and the variation across the
BP range.
Findings suggest that automatic devices
cannot reliability detect or rule out
orthostatic hypotension, indicating
that triage nurses need to use manual
devices to take accurate postural blood
pressures for optimal patient care.
1
3
Design: prospective, observational
Sample: 50 healthy blood donors
Randomization: No
Convenience Sample: Yes
Setting: Blood donation clinic
Blood Pressure measured
manually by auscultation.
Vital signs measured by
one data collector. Blood
pressure measured in
semi-supine position. Data
collection points: before
donation, 1 minute and 5
minutes after donation.
BP and HR variables were
collected prior to blood donation and 1 and 5 minutes
after blood donation.
Statistically significant changes in HR
& DBP in 5 mins post donation; SBP
in 1 & 5 mins post donation. HR = 77
(pre) 81 (post 5 min) p = 0.04; DBP = 76
mmHg (pre) 70mmHg (post 5 min) p =
0.02; SBP = 120 (pre) 106 (post 1 min),
108 (post 5 min) p =0.0001
II
VI
13
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 1: Evidence Table
Reference
Fuchs, S. M., & Jaffe,
D. M. (1987). Evaluation of the “tilt test” in
children. Ann Emerg
Med, 16(4):386-90.
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
Research/Purpose
Questions/Hypothesis
Purpose of Study to evaluate
the “tilt test’ in children by
comparing normally hydrated
children and volume depleted
children
Purpose: To determine
1) the minimum duration of
HUT necessary to detect OH
and 2) to identify different
patterns of orthostatic blood
pressure (BP) response in
patients with OH
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Design: prospective
Sample: n= 21 normal children;
16 dehydrated Randomization: no
Convenience Sample: yes
Variables: BP & HR measured at 1 minute intervals
x 3 sets by noninvasive
blood pressure monitor
(Dinamap® Model 1846P,
Critikon, Inc. Tampa, Fl.)
Position: supine for minimum of 3 minutes before
vital signs taken; standing
position for 1 minute with
arm supported at heart level
before BP & HR at 1 minute
intervals x 2 readings.
Symptoms: dizziness or
lightheadedness recorded.
Statistical Analysis: Chi
square, Fisher’s exact test,
t test.
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) significantly higher (p = 0.001) than normal
group. Mean change in systolic BP
small among both groups. No mean
changes (1 & 2 min.) in HR among
groups, instead of 1 minute standing
values. Cutoff points for positive tilt test
value 20 bpm with history of vomiting
or diarrhea as cause of dehydration.
HR changes 20 bpm or greater, with
sensitivity and specificity of 81% with
a positive test predictive value of 76%
and a negative test predictive value of
85% Specificity increased to 95% with
HR greater than 25 bpm with a positive
test predictive value increase to 92%.
Four dehydrated children’s HR did not
increase more than 25 bpm; pts were febrile 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.
II
VI
Design: Convenience Sample
Evaluated the medical records of 66 con? }10.1
secutive patients (mean age 70.0‪
years; 64% male) seen at Mayo
Clinic-Rochester from 2000ayotiv
who fulfilled the criteria for OH
(systolic blood pressure [SBP] reduction
≥systolic blood pressure [
of HUT) during routine clinical
autonomic studies.
Statistics: Chi square
analysis examined whether
the groups differed in
how often the tilt test was
terminated early (prior to 5
minutes) due to presyncope
and Mann-Whitney U tests
examined differences in
CASS scores between the
two groups. All tests were
2-tailed. P<0.05 was
considered significant. All
statistical analyses were
performed using
SPSS 11.5 for Windows.
II
IV
14
One minute of HUT will detect OH in
the great majority (88%) of patients
and three minutes will detect
the balance. Orthostatic stress
beyond 2 minutes is necessary to
detect the pattern of progressive
OH. Since this group has more
severe adrenergic deficits than the
group with stable OH, we suggest
that the progressive pattern is due
to greater impairment of compensatory
reflexes. Recognition of the
group with progressive fall in BP is
important since this group may be
at greater risk of orthostatic syncope
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Koziol-McLain, J.,
Lowenstein, S., & Fuller, B. (1991). Orthostatic
vital signs in emergency
department patients.
Ann Emerg Med,
20(6):606-10.
Purpose of Study: 1) What is
the range of normal of orthostatc vital signs in a sample
of ED patients who have no
recent fluid or blood losses?
2) What variables (age, medications, fever) are associated
with more marked orthostatic
vital signs in euvolemic ED
patients?
Design: descriptive Sample: N = 132
Randomization: no
Convenience Sample: yes
Setting: urban teaching hospital ED
ANOVA, correlation
Dinamap model 1846 used
to measure vitals. Supine 3
minutes prior to measurement. Standing vitals
measured at 2 minutes.
Wider than expected variation in orthostatic vital signs in presumed euvolemic
ED patients. Correlation between age
and OH. Diastolic BP most reliable
orthostatic vital sign.
I
VI
Design prospective
Sample 100 volunteers 17-55 years
(no medications, no serious illness,
hematocrit over 38%, weight greater
than 110 pounds). There were 56 men
and 44 women.
Vitals measured
supine-stand and supine-sit
prior to blood donation and
then again after 500 ml and
1000 ml blood loss.
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 (syncope, severe dizziness) has a sensitivity
of 98%, specificity 98%. Unable to
distinguish between no blood loss and
500 ml blood loss. The sit-stand test
cannot reliably distinguish no blood loss
from 500 ml blood loss. The percent
blood lost correlates with increase HR
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.
I
VI
Design: Randomized Crossover
Sample: N=35 normotensive young
adults (21.6 avg y/o).
Setting: inpatient research hospital
Variables: blood pressure,
heart rate, dizziness.
Equipment: Stop watch and
dominant arm; Dinamap
model 1846 SX; VAS for
dizziness-10 cm visual analogue scale with left end
=no dizziness and right end
worst dizziness you could
imagine
Lying BP differed between 5 & 10
minutes (F=21.33,p < 0.001 Mean
BP differed between 5 & 10 minutes (F=5.23, <0.03); Standing BP
and dizziness differed between 0 & 2
minutes (F=8.36, p = 0.01) & (F=7.15, p
< 0.10). For normotensive individuals in
this study, vitals were stabilized by 10
min. Standing vitals can be measured
immediately upon standing and again
at 2 min.
I
II
Knopp, R., Claypool, R.
& Leonardi, D. (1980).
Use of the tilt test in
measuring acute blood
loss. Ann Emerg Med,
9(2):29-32.
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):47991. doi:10.1177/10547
730022158708
1) To determine sensitivity
and specificity of the tilt test
in detecting blood loss 2)
compare supine to sitting and
supine to standing 3) identify
the appropriate time interval
after position change to measure vitals.
Compare two lying and
standing procedures for
measuring orthostatic vitals
15
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 1: Evidence Table
Reference
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.
McGee, S., Abernethy,
W.B., & Simel, D.
(1999). The rational
clinical examination:
Is this patient hypovolemic? JAMA,
281(11):1022-29.
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):497501. doi: 10.1053/
ajem.2002.34964
Research/Purpose
Questions/Hypothesis
Purpose of Study: Evaluate
tilt test to identify volume loss
in ED patients.
Purpose of Study: To review,
systematically, the physical
diagnosis of hypovolemia in
adults
Purpose of Study:
Determine how many patients
who present to the ED with a
complaint of syncope have orthostatic changes and describe
the characteristics
of these patients.
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Design: prospective
Sample: N=202 (patients) N=21 healthy
volunteers Randomization: no
Convenience Sample: Yes Setting: ED
Statistical Analysis:
MANOVA, Regression,
2-way ANOVA, 2-tailed
unpaired student’s t-test
The patient was supine 2
minutes prior to vital sign
measurement. Vital signs
were measured 60 seconds
after standing.
Large variance in vital signs and lack
of correlation between vital signs and
amount of dehydration make it difficult
to identify cut offs for orthostatic vital
signs. Change in SBP was statistically but not clinically significant. HR
demonstrated a small association with
level of dehydration.
II
IV
Measures analysis: Studies
were reviewed and graded
by authors based on type
of study and number of
subjects
Clinicians should wait at least 2 minutes
before measuring the supine vital signs
and 1 minute after standing before
measuring the upright vital signs.
Counting the pulse for 30 seconds and
doubling the result is more accurate
than 15 seconds of observation.44 In
normovolemic individuals,a postural
pulse increment of more than 30 beats/
min is uncommon, affecting only about
2% to 4% of individuals.
I
III
Statistical Analysis:
student’s t test, chi-square,
fisher exact test measured
vitals manually. Patients
were supine 5 min prior to
first measurement. Standing vitals were measured at
0, 1, 2, 3, 5, and 10 minutes
(or until symptomatic).
OH was cause of 24% of syncope in this
population of ED patients. Stressed the
importance of symptoms and orthostatic
changes before considering OH as a
cause of syncope. Manually measured
BP and pulse. Rested 5 prior to supine
measurement. Measured standing vitals
at 1, 2, 3, 5, and 10 minutes. N=127 (ED
patients with OH changes) maximal
decline in SBP within 3 minutes of
standing for 75% and with 5 minutes of
standing for 86%.
II
VI
Design: Systematic review of correlated literature with a focus on clinical
presentations of hypovolemia and OH
of health volunteer subjects and patients
presenting to the emergency department
Design: prospective and observational
Sample: N=650 Randomization: No
Convenience Sample: Yes
Setting: Hospital
16
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 1: Evidence Table
Reference
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.
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
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
What was the blood pressure
responses to tilting using two
different techniques, auscultation and oscillometry
Sample:
N=20 healthy adults (7 female, 13 male),
no hx of cardiovascular or other significant diseases; no medications except
contraceptive pills. No oral intake (food
and beverage) or smoking 1 hour prior to
test. Blood pressure cuff size measured/
appropriate to s
Blood pressure measured
in 3 positions: horizontal,
45 degree head-up tilt,
& standing Statistical
analysis included limits of
agreement of measurement
vs. correlation. 1) No significant difference of SBP
in supine position between
conventional, random-zero sphygmomanometer,
and oscillometric device.
Significant difference
between conventional and
random-zero sphygmomanometer Accutorr 1A.
The Accutorr 1A reflects blood
measurements using direct technique.
However, unable to extend the study’s
findings to people with hypertension or
postural hypotension.
I
II
Purpose: Describe the distribution of normal changes in
vital signs related to moving
from a sitting to a standing
position.
Prospective, controlled for non-cardiovascular disease and euvolumic through
inclusion protocol. IRB approved. Data
collection 1999 through 2001. Variables:
blood pressure, heart rate, position - sitting and standing. Convenience sample =
176 adults free of cardiovascular disease
and determined to be euvolumic
Dinemap (Johnson & Johnson, Tampa,
FL): non-invasive BP, HR. Protocol:
Lying for 5 minutes. Position change to
standing for 1 minute before vital signs.
Arm positioned so blood pressure cuff at
heart level.
N=176
Average age 33±10 yrs.
Forty-eight percent females,
79 emergency department
patients, 97 healthcare
providers
Mean sit-stand changes were less
extreme than lying-standing. HR
increased 5.3 + 6.6 bpm, SBP decreased
1.2 + 9.8 mmHg, Shock Index increased
0.05 + 0.07 bpm/mmHg. Different criteria (from lying-standing) are required
for the sit-stand test. HR increase 20
bpm or more had 98 % specificity; SBP
decrease has 97% specificity, Shock
Index increase 0.2 or greater had 99%
specificity and Ratio of Orthostatic
Shock Index (ROSCI) 1.3 or higher had
95% specificity.
I
IV
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
hypotension management. Curr Hypertes Rep, 15(4):304-12.
doi:10.1007/s11906-013-0362-3
Provides an overview of orthostatic hypotension as a clinical condition, discusses various causes, methods of detection and treatment.
Orthostatic hypotension in the elderly has numerous etiologies. Patients
with orthostatic hypotension need to have appropriate symptomatic control in order to prevent syncope and falls.
American Academy of Neurology. (1996). Consensus statement on
the definition of orthostatic hypotension, pure autonomic failure,
and multiple system atrophy. Neurology, 46(5):1740.
Consensus statement American Academy of Neurology.
Defined OH, pure autonomic failure, and multiple system atrophy. OH can
be symptomatic or asymptomatic. Vitals may not change until they have
been standing for 10 minutes. Possible confounders: eating, time of day,
hydration, ambient temperature.
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
Case presentations and discussion of the role of Baroreceptors in the
regulation of blood pressure with change of position
Baro-reflex failure after radiation is an under-reconized cause of orthostatic hypotension and syncope
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.
Research to investigate the effects of redistribution of blood volume
and change in blood pressure and heart rate to standing, forced
breathing and the Valsalva Maneuver.
Posture and period of preceding rest are important quantitative
determinants of cardiovascular reflex responses.
Horam, W. J., & Roscelli, J. D. (1992). Establishing standards
of orthostatic measurements in normovolemic adolescents.
Am J Dis Child, 146(7):848-51.
Research to determine normal orthostatic heart rate, and blood pressure changes in healthy adolescents performed.
Healthy adolescents have wide variations in orthostatic measurements that
exceed previously accepted standards. Further research needs to done to
determine if values to determine individuals with volume depletion can
be identified
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
Guidelines endorsed by European Society of Emergency Medicine,
European Federation of Internal Medicine, European Union Geriatric
Medicine Society, American Geriatrics Society, European Neurological Society, European Federation of Autonomic Societies, American
Autonomic Society
Symptoms of “orthostatic intolerance” syncope, dizziness,
light headiness, pre-syncope, weakness, fatigue, lethargy,
palpitations, sweating are associated with OH.
Different types of OH were presented (initial, classical, delayed, etc.).
Also provided a review of onset of symptoms, pathophysiology, most common symptoms, and associated conditions for each type of OH
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
Reviewed 1996 consensus definition for OH. Reviewed changes in
normal patients. Reviewed literature to determine if one standard OH
test can be used for all patients.
May miss 2/3 of orthostatic patients when only using sit-stand test.
Reports that OH has diurnal, day-to-day, and seasonal variability.
Recommends testing at 5min.
Netea, R.T., Smits, P., Lenders, J.W.M., and Thin. T., (1998). Does
it matter whether blood pressure measurements are taken with
subjects sitting or supine? J Hypertens, 16(3):263-8.
Goal was to determine if sitting or supine affects blood pressure.
Prospective study in outpatient setting with N=245. Evaluated changes in BP when patients change from a sitting to standing position.
Compared sitting and standing SBP, DBP, and HR.
Did not evaluate volume status. Did not evaluate OH.
Sitting DBP was higher than supine. Older patients had lower postural
differences for DBP and HR. Posture influences BP readings and should
be noted along with the BP reading.
AHA scientific statement, blood pressure measurement
Recommendations for measuring blood pressure. Upper arm is standard
location for blood pressure measurement. Wrist is okay for obese. Finger
measurements are not recommended. Legs should be uncrossed. Back
and arm should be supported during measurements. Five minutes of rest
should lapse prior to first measurement.
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
18
CLINICAL PRACTICE GUIDELINE:
Orthostatic Vital Signs
Appendix 2: Other Resources Table
Reference
Research Purpose
Conclusions
Smith, J. J., Porth, C. M., & Erickson, M. (1994). Hemodynamic
response to the upright posture. J Clin Pharmacol, 34(5):375-386.
To review previous studies of immediate and stabilized (30 seconds-20 minutes hemodynamic responses to heads up posture.
In healthy young adults the immediate response is an increase in heart
rate and blood pressure. Beginning at the age of 75 there is an increased
incidence of orthostatic hypotension
Streeten, D. H. H. P, & Anderson, G. H. (1992). Delayed orthostatic intolerance. Arch Int Med, 152(5):1066-72.
Case reports of 7 patients were presented who developed
orthostatic symptoms but failed to show orthostatic vital sign changes
after standing for 3-4 minutes. Evaluated vital signs during position
changes with and without a pressure suit.
These patients were found to have “excessive gravitational pooling of
blood in the dependent veins”. Determined that “impaired sympathetic
innervations of the veins of the lower limb plays a cardinal role in the
pathogenesis of delayed OH in at least some patients”. These patients did
not have volume losses.
Vloet, L.C.M., Smits, R., Frederiks, C.M.A., Hoefnagels, W.,
Janesen, R.W.M.M., (2002). Evaluation of skills and knowledge
on orthostatic blood pressure measurements in elderly patients.
Age Ageing, 31(3):211-6. doi:10.1093/ageing/31.3.211
Observational and descriptive study evaluating nurses’ ability and
knowledge of how to measure blood pressure in the Netherlands.
Observations were made base on the American Heart Association’s
recommendations for blood pressure measurement and the American
Academy of Neurology’s consensus statement definition of OH.
Manual measurement of BP. Did not measure HR
Found that nurses’ practice for measuring BP varies widely.
The first and third minutes after standing are the most practical and useful
times to diagnose orthostatic blood pressure changes.
Wieling, W. and Schatz, I.J. (2008). The consensus statement on
the definition of orthostatic hypotension: A revisit after 13 years. J
Hypertens, 27(5):935-8. doi:10.1097/HJH.0b013e32832b1145.
Reviewed the definition of OH and reviewed results of published
research using this definition.
OH will be underestimated if the arm is allowed to be parallel with the
body while standing.
Active and passive changes in posture produce different cardiovascular
effects within the first 30 seconds. An initial fall in arterial pressure
occurs only with active standing.
About of half of the cases with OH will be detected within 3 minutes
of standing.
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.
Literature review of physiology, research, and practice literature
related to dangling and orthostasis.
Variability in heart rate and blood pressure response to position changes.
Recommended that OH not be defined by “dramatic” changes in vital
signs alone. Dangling for less than 3 minutes will prevent symptom
associated with OH.
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
We undertook this study to describe the procedures for orthostatic
vital sign measurement and their interpretation in an urban academic
emergency department. We also describe the distribution of procedures used by various care providers and estimate the proportion of
nurses who obtain vital signs at triage. P 619
Of the 28 nurses indicating yes/no response, 16 (57%) indicated that they
measure orthostatic vital signs in triage. Among all respondents, the minimum resting period before initial vital sign measurement was distributed
as follows: 1 minute, 10; 2 minutes, 12; 3 minutes, 8; 5 minutes, 8; 15 to
30 minutes, 2; and not specified time, 12. The variation in procedures and
interpretation that we found suggests the potential for great inefficiency in
our emergency department.
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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 involving human subjects
April 2011- October 2015
Studies addressing the PICOT question
Studies not published in English
Non-human studies
Studies not in the timeframe listed
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.
20