Mean Arterial Pressure Goal in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Current guidelines recommend targeting a mean arterial pressure (MAP) goal of 65 mm Hg or more in critically ill medical patients. Prospective studies have shown that a higher MAP goal can improve survival and decrease end-organ damage. However, randomized controlled trials (RCTs) have failed to show similar results. Thus, we performed this meta-analysis to evaluate whether a high MAP goal compared to a standard or low MAP goal will improve clinical outcomes in critically ill medical patients. Methods:We searched electronic databases for RCTs comparing standard MAP goals versus high MAP goals in critically ill medical patients. A standard MAP goal was defined as a MAP of 60 -70 mm Hg, and a MAP of 70 mm Hg or more was considered a high MAP goal. Outcomes of interest were mortality, duration of mechanical ventilation, and intensive care unit (ICU) length of stay. Subgroup analysis was performed based on the type of critically ill patients: cardiac arrest and septic shock. We used random-effects meta-analysis to estimate risk ratio (RR) with a 95% confidence interval (CI) for a dichotomous outcome. For continuous outcomes, the inverse variance method was used to calculate the standardized mean difference (SMD) with 95% CI. A P value of 0.05 or less was considered significant.Results: Six RCTs with a total of 3,753 patients (standard MAP goal: n = 1,872 and high MAP goal: n = 1,881) were included in the final analysis. Both standard/low MAP goal and high MAP goal were associated with similar risk for mortality (RR 0.94, 95% CI (0.87, 1.01), P = 0.11), duration of mechanical ventilation (SMD 0.51, 95% CI (-0.29, 1.31), P = 0.21) and ICU length of stay (SMD 0.22, 95% CI (-0.07, 0.5), P = 0.14). Subgroup analysis in cardiac arrest patient showed decreased ICU stay (SMD 0.55, 95% CI (0.31, 0.80), P < 0.000001) in patients with higher MAP goal compared to the stand-ard MAP goal group without any difference in mortality or duration of mechanical ventilation. Subgroup analysis of patients with septic shock had similar outcomes in both MAP targets. Conclusions:In critically ill patients, a higher MAP goal of > 70 mm Hg was associated with a similar risk of mortality, duration of mechanical ventilation, and ICU length of stay when compared with a standard MAP goal of 60 -70 mm Hg.

Higher versus lower blood pressure targets after cardiac arrest: A meta-analysis of randomized controlled trials

“…Similar to the results of our study, a recent meta-analysis done in critical patients by Sarkar et al. demonstrated no significant difference in mortality, and duration of mechanical ventilation between the two groups 11 ; however, the included population contained mostly patients with septic shock rather than OHCA. Contrary to their results which showed no reduction in the duration of ICU stay, we found a shorter ICU length of stay in the higher BP target group.…”

Association between mean arterial pressure and clinical outcomes among patients with heart failure

“…29 Furthermore, two meta-analyses including randomized controlled trials failed to demonstrate any benefits of a high MAP goal in terms of survival. 30,31 These findings suggested that a specific MAP goal or a one-size-fits-all approach may not be clinically beneficial for all population. Thus, it was urgent to set patient-specific optimal MAP goals.…”

“…However, a study showed that targeting a MAP of 80–85 mmHg in patients with septic shock, compared with 65–70 mmHg, did not result in significant differences in 28 and 90 days of mortality 29 . Furthermore, two meta‐analyses including randomized controlled trials failed to demonstrate any benefits of a high MAP goal in terms of survival 30,31 . These findings suggested that a specific MAP goal or a one‐size‐fits‐all approach may not be clinically beneficial for all population.…”

Perioperative Management on Septic Condition et Causa General Peritonitis: Case Report

“…The administration of epinephrine as a vasopressor is aimed at meeting the initial MAP target of >65 mmHg, resulting in increased perfusion to organs (Dewitte et al, 2021; G. T. Lee et al, 2019;S. H. Lee et al, 2021;Leone et al, 2015;Sarkar et al, 2022;Yoshimoto et al, 2022).…”