Arterial blood pressure during early sepsis and outcome

Abstract

Objective: To evaluate the association between arterial blood pressure (ABP) during the first 24 h and mortality in sepsis. Design: Retrospective cohort study. Setting: Multidisciplinary intensive care unit (ICU). Patients and participants: A total of 274 septic patients. Interventions: None. Measurements and results: Hemodynamic, and laboratory parameters were extracted from a PDMS database. The hourly time integral of ABP drops below clinically relevant systolic arterial pressure (SAP), mean arterial pressure (MAP), and mean perfusion pressure (MPP = MAP -central venous pressure) levels was calculated for the first 24 h after ICU admission and compared with 28-day-mortality. Binary and linear regression models (adjusted for SAPS II as a measure of disease severity), and a receiver operating characteristic (ROC) analysis were applied. The areas under the ROC curve were largest for the hourly time integrals of ABP drops below MAP 60 mmHg (0.779 vs. 0.764 for ABP drops below MAP 55 mmHg; P B 0.01) and MPP 45 mmHg. No association between the hourly time integrals of ABP drops below certain SAP levels and mortality was detected. One or more episodes of MAP \ 60 mmHg increased the risk of death by 2.96 (CI 95%, 1.06-10.36, P = 0.04). The area under the ROC curve to predict the need for renal replacement therapy was highest for the hourly time integral of ABP drops below MAP 75 mmHg. Conclusions: A MAP level C 60 mmHg may be as safe as higher MAP levels during the first 24 h of ICU therapy in septic patients. A higher MAP may be required to maintain kidney function.

MAP of 65: target of the past?

“…Both studies showed a correlation between MAP thresholds and survival [3,4] and organ dysfunction [4,5]. Best results were seen with a MAP between 60 and 65 mmHg, and the time spent below these values correlated with risk of mortality [3,4].…”

“…MAP is a key component of tissue perfusion and is often viewed as a surrogate of organ perfusion pressure. Both the SSC and ESICM guidelines suggest keeping MAP ≥ 65 mmHg and individualizing this target based on comorbidities.The current MAP target of 65 mmHg is mainly based on the results of two retrospective studies investigating sequential MAP readings and the time spent below different threshold values of MAP during the first 24 or 48 h of management of patients with septic shock [3,4]. Both studies showed a correlation between MAP thresholds and survival [3,4] and organ dysfunction [4,5].…”

Early evaluation of severity in patients with severe sepsis: a comparison with “septic shock” — subgroup analysis of the Japanese Association for Acute Medicine Sepsis Registry (JAAM‐SR)

“…The relationship between hypotension and the outcome of severe sepsis has been extensively examined in several reports because the definition of septic shock includes hypotension after fluid resuscitation 8, 9, 15. Nevertheless, as far as we know, there have been no reports similar to the current one that focus on initial hypotension as the predictive outcome measure for patients with severe sepsis.…”

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage

“…The most prevalent risk factor for ICH is chronic hypertension,24, 25 which also causes a rightward shift in the renal autoregulation curve26 and increases the threshold value of mean arterial pressure needed to maintain renal perfusion 27, 28. Drastic and rapid lowering of blood pressure may also shift the renal autoregulation curve rightward9 and create a new less robust limit, where even nonhypotensive or normotensive blood pressures decrease renal blood flow and exacerbate renal injury.…”