While the Surviving Sepsis Campaign guidelines recommend an initial target value of 65 mmHg as the mean arterial pressure (MAP) in patients with septic shock, the optimal MAP target for improving outcomes remains controversial. We performed a meta-analysis to evaluate the optimal MAP for patients with vasodilatory shock, which included three randomized controlled trials that recruited 3,357 patients. Between the lower (60–70 mmHg) and higher (>70 mmHg) MAP target groups, there was no significant difference in all-cause mortality (risk ratio [RR], 1.06; 95% confidence intervals [CI], 0.98–1.16) which was similar in patients with chronic hypertension (RR, 1.10; 95% CI, 0.98–1.24) and patients aged ≥65 years (RR, 1.10; 95% CI, 0.99–1.21). No significant difference in adverse events was observed between the different MAP groups (RR, 1.04; 95% CI, 0.87–1.24); however, supraventricular arrhythmia was significantly higher in the higher MAP group (RR, 1.73; 95% CI, 1.15–2.60). Renal replacement therapy was reduced in the higher MAP group of patients with chronic hypertension (RR, 0.83; 95% CI, 0.71–0.98). Though the higher MAP control did not improve the mortality rate, it may be beneficial in reducing renal replacement therapy in patients with chronic hypertension.Systematic review registration: UMIN Clinical Trials Registry, identifier UMIN000042624

IntroductionThe optimal target of mean arterial pressure (MAP) for better outcomes in patients with vasodilatory shock remains a matter of debate. Although catecholamines are generally used to maintain target blood pressure in hypotensive patients with vasodilatory shock, the adverse effects of catecholamines must also be considered. We will perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the certainty of evidence determining the optimal target of MAP control for patients with vasodilatory shock in critically ill settings.Methods and analysisThis study protocol was registered in the University Hospital Medical Information Network Clinical Trials Registry. We will include only RCTs that evaluated the two different comparators for target MAP to be maintained for clinical outcomes of all-cause mortality: organ dysfunction and adverse events in critically ill adult patients with vasodilatory shock. We will search the electronic bibliographic databases of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials in November 2020. Two reviewers will independently screen titles and abstracts, perform full article reviews and extract study data. We will report study characteristics and assess methodological quality using the Cochrane Risk-of-Bias 2 tool. If pooling is appropriate, we will calculate relative risks with 95% CIs for all outcome measures. Clinical and methodological subgroup and sensitivity analyses will be performed to explore heterogeneity. Overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.Ethics and disseminationThis study will not involve primary data collection, and formal ethics approval will therefore not be required. We aim to publish this systematic review in a peer-reviewed journal.Trial registration numberUMIN000042624.

While the Surviving Sepsis Campaign guidelines recommend an initial target value of 65 mmHg of mean arterial pressure (MAP) in patients with septic shock, the optimal MAP target for improving outcomes remains controversial. A meta-analysis to evaluate the optimal MAP for patients with vasodilatory shock, which included 3 randomized controlled trials and recruited 3,357 patients. Between the lower (60-70 mmHg) and the higher (over 70 mmHg) MAP target groups, there was no significant difference in all-cause mortality (RR, 1.06; 95% CI, 0.98 to 1.16) also similar in patients with chronic hypertension (RR, 1.10; 95% CI, 0.98 to 1.24) and patients aged ≥ 65 years (RR, 1.10; 95% CI, 0.99 to 1.21). No significant difference in adverse events was observed between the different groups (RR, 1.04; 95% CI, 0.87 1.24), but supraventricular arrhythmia was significantly higher in the higher MAP group (RR, 1.73; 95% CI, 1.15 to 2.60). Renal replacement therapy was reduced in the higher MAP group of patients with chronic hypertension (RR, 0.83; 95% CI, 0.71 0.98). Though the higher MAP control did not improve the mortality rate, it may be beneficial in reducing renal replacement therapy for patients with chronic hypertension.Systematic review registration: UMIN Clinical Trials Registry, UMIN000042624