Adjusting mean arterial pressure alarms improves the time spent within blood pressure targets in patients with septic shock: A quasi-experimental study

Florens, Nans; Chabert, B.; Stevic, Neven; Vareon, Julie; Malatray, Arnaud; Argaud, Laurent; Cour, Martin

doi:10.1016/j.aucc.2020.10.002

Australian Critical Care

2021

DOI: 10.1016/j.aucc.2020.10.002

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Adjusting mean arterial pressure alarms improves the time spent within blood pressure targets in patients with septic shock: A quasi-experimental study

Nans Florens

B. Chabert

Neven Stevic

et al.

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Cited by 1 publication

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“…If we can set a lower MAP goal at 60–65 mm Hg instead of greater than 65 mm Hg, we are more likely to achieve an overall lower average MAP. Standardization of vasopressor algorithms and leveraging automated systems can also assist in implementation (13). We would argue that strict targeting of lower MAPs must be balanced by preventing recurring and prolonged episodes of MAPs below 60 mm Hg to the potential complications of lower MAP.…”

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confidence: 99%

Under Pressure: Do We “Dare Change Our Way of Caring” for Patients With Shock?*

Roberts

Chen

Sevransky

et al. 2023

Critical Care Medicine

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Circulatory shock is a common condition leading to ICU admission which occurs when there is a mismatch between oxygen supply and demand resulting in altered tissue perfusion, deficient oxygen, and nutrient delivery to tissues and ultimately to cellular and organ dysfunction (1). In addition to treating the underlying cause of the shock state (e.g., infection in septic shock), the initial hemodynamic goal of therapy is to provide adequate perfusion to the tissues and organs and normalize cellular metabolism (2).In patients with shock requiring vasopressor therapy, the mean arterial pressure (MAP) has been a long-standing hemodynamic variable targeted as a surrogate measure of tissue perfusion. A MAP goal is typically included in most clinical vasopressor order sets. Physiologic studies suggest that vascular bed autoregulation is compromised below a MAP of 60 mm Hg leading to a linear dependence of regional blood flow on MAP (2). These critical autoregulation MAP set points may vary by organ and depend on patient factors such as age and comorbidity (2). The most recent Surviving Sepsis Campaign (SSC) treatment guidelines recommend targeting an initial MAP of 65 mm Hg versus higher MAP targets in patients with septic shock requiring vasopressor support (3). These recommendations are based upon three recent multicenter prospective clinical trials in distributive shock looking at associations between MAP target goals and outcomes (4-6). The Sepsis and Mean Arterial Pressure (SEPSISPAM) (4) and Optimal Vasopressor Titration (OVATION) (5) studies randomized patients to target MAP goals of 65-70 mm Hg versus 80-85 mm Hg and 60-65 mm Hg versus 75-80 mm Hg, respectively, and found no significant difference in mortality between groups. Even though the SEPISPAM study found that targeting a higher MAP was associated with a higher occurrence rate of arrhythmia and more vasopressor exposure, it also reported that targeting a higher MAP was associated with a lower occurrence rate of renal impairment in the subgroup of patients with chronic hypertension. More recently, the 65 Trial (6) did not show a difference in mortality when comparing treatment aiming for a specified MAP target of 60-65 mm Hg versus "usual care" that was based on the SSC treatment guidelines. Similar to the SEPSISPAM study, the 65 Trial found that targeting a higher MAP was associated with more vasopressor exposure.A number of unanswered questions remain regarding the optimal MAP target and the balance between maintaining tissue perfusion and avoiding vasopressor-induced adverse effects. To that end, two independent systematic reviews and meta-analyses (SRMAs) in this issue of Critical Care Medicine provide further insight regarding optimal MAP targets for the treatment of shock *See also p. 241 and 254.

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confidence: 99%

Under Pressure: Do We “Dare Change Our Way of Caring” for Patients With Shock?*

Roberts

Chen

Sevransky

et al. 2023

Critical Care Medicine

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Adjusting mean arterial pressure alarms improves the time spent within blood pressure targets in patients with septic shock: A quasi-experimental study

Cited by 1 publication

References 19 publications

Under Pressure: Do We “Dare Change Our Way of Caring” for Patients With Shock?*

Under Pressure: Do We “Dare Change Our Way of Caring” for Patients With Shock?*

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