The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study

Abstract

IntroductionLiberal and overaggressive use of vasopressors during the initial period of shock resuscitation may compromise organ perfusion and worsen outcome. When transiently applying the concept of permissive hypotension, it would be helpful to know at which arterial blood pressure terminal cardiovascular collapse occurs.MethodsIn this retrospective cohort study, we aimed to identify the arterial blood pressure associated with terminal cardiovascular collapse in 140 patients who died in the intensive care unit while being invasively monitored. Demographic data, co-morbid conditions and clinical data at admission and during the 24 hours before and at the time of terminal cardiovascular collapse were collected. The systolic, mean and diastolic arterial blood pressures immediately before terminal cardiovascular collapse were documented. Terminal cardiovascular collapse was defined as an abrupt (<5 minutes) and exponential decrease in heart rate (>50% compared to preceding values) followed by cardiac arrest.ResultsThe mean ± standard deviation (SD) values of the systolic, mean and diastolic arterial blood pressures associated with terminal cardiovascular collapse were 47 ± 12 mmHg, 35 ± 11 mmHg and 29 ± 9 mmHg, respectively. Patients with congestive heart failure (39 ± 13 mmHg versus 34 ± 10 mmHg; P = 0.04), left main stem stenosis (39 ± 11 mmHg versus 34 ± 11 mmHg; P = 0.03) or acute right heart failure (39 ± 13 mmHg versus 34 ± 10 mmHg; P = 0.03) had higher arterial blood pressures than patients without these risk factors. Patients with severe valvular aortic stenosis had the highest arterial blood pressures associated with terminal cardiovascular collapse (systolic, 60 ± 20 mmHg; mean, 46 ± 12 mmHg; diastolic, 36 ± 10 mmHg), but this difference was not significant. Patients with sepsis and patients exposed to sedatives or opioids during the terminal phase exhibited lower arterial blood pressures than patients without sepsis or administration of such drugs.ConclusionsThe arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients was very low and varied with individual co-morbid conditions (for example, congestive heart failure, left main stem stenosis, severe valvular aortic stenosis, acute right heart failure), drug exposure (for example, sedatives or opioids) and the type of acute illness (for example, sepsis).Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0719-2) contains supplementary material, which is available to authorized users.

The Compensatory Reserve For Early and Accurate Prediction Of Hemodynamic Compromise

“…The continuous LBNP profile allows us to take each subject to a state of intolerance to central blood loss (Fig. 4C) and subsequently the point of decompensation (i.e., depletion of the compensatory reserve) that replicates the terminal cardiovascular collapse observed in critically ill patients (52). This tolerance point is extremely reproducible in experiments repeated in the same individuals over both acute (< 1 h) and chronic (> 1 year) time periods (53,54).…”

Bolus dose of epinephrine for refractory post-arrest hypotension

“…Maintaining sufficient cardiac perfusion is of major importance during and immediately after cardiac arrest. 7 Data have suggested that a mean arterial pressure less than 45 mm Hg is associated with a significantly increased likelihood of hemodynamic collapse among ill patients 8 and is associated with increased mortality and decreased functional recovery in patients after cardiac arrest. [1][2][3] During the post-arrest period, patients are at high risk of re-arrest, and it is important to ensure sufficient coronary perfusion to reduce this risk.…”

The Use of Bolus-Dose Vasopressors in the Emergency Department

“…Both epinephrine and phenylephrine can be considered in the management of significant transient or sustained hypoperfusion. Although the definition of significant hypotension is complex, Brunauer et al 6 have suggested that a mean arterial pressure (MAP) of approximately 35 mm Hg is associated with a significant risk of CV collapse. Of course, a MAP of 40 to 50 mm Hg is also very concerning clinically, with significant risk of deterioration and CV collapse.…”