The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

Abstract

PurposeCurrent guidelines recommend maintaining a mean arterial pressure (MAP) ≥ 65 mmHg in septic patients. However, the relationship between hypotension and major complications in septic patients remains unclear. We, therefore, evaluated associations of MAPs below various thresholds and in-hospital mortality, acute kidney injury (AKI), and myocardial injury.MethodsWe conducted a retrospective analysis using electronic health records from 110 US hospitals. We evaluated septic adults with intensive care unit (ICU) stays ≥ 24 h from 2010 to 2016. Patients were excluded with inadequate blood pressure recordings, poorly documented potential confounding factors, or renal or myocardial histories documented within 6 months of ICU admission. Hypotension exposure was defined by time-weighted average mean arterial pressure (TWA-MAP) and cumulative time below 55, 65, 75, and 85 mmHg thresholds. Multivariable logistic regressions determined the associations between hypotension exposure and in-hospital mortality, AKI, and myocardial injury.ResultsIn total, 8,782 patients met study criteria. For every one unit increase in TWA-MAP < 65 mmHg, the odds of in-hospital mortality increased 11.4% (95% CI 7.8%, 15.1%, p < 0.001); the odds of AKI increased 7.0% (4.7, 9.5%, p < 0.001); and the odds of myocardial injury increased 4.5% (0.4, 8.7%, p = 0.03). For mortality and AKI, odds progressively increased as thresholds decreased from 85 to 55 mmHg.ConclusionsRisks for mortality, AKI, and myocardial injury were apparent at 85 mmHg, and for mortality and AKI risk progressively worsened at lower thresholds. Maintaining MAP well above 65 mmHg may be prudent in septic ICU patients.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5218-5) contains supplementary material, which is available to authorized users.

Effects of very early start of norepinephrine in patients with septic shock: a propensity score-based analysis

“…Third, early use of norepinephrine may improve the regional distribution of blood flow and prevent fluid overload [25]. Finally, delays in correcting hypotension are associated with increased risk of death in septic patients [33][34][35], whereby prompt correction of hypotension might influence clinical outcomes. Indeed, a recent phase II randomized controlled trial suggested that early use of norepinephrine might improve the possibility to achieve more sustained mean arterial pressure levels and adequate tissue perfusion parameters [36].…”

MAP of 65: target of the past?

“…However, both trials were underpowered as the mortality rate in the control groups was lower than expected. In addition, patients assigned to the low MAP target groups achieved higher MAPs than planned according to the study protocol.In a recent article in Intensive Care Medicine, Maheshwari et al report the results of a retrospective analysis of 8782 patients admitted to 110 US hospitals exploring the association between MAP and acute kidney and myocardial injury as well as in-hospital mortality in patients with septic shock [8]. Using routinely collected data from an electronic health records database, the authors defined total exposure to hypotension as the time-weighted average mean arterial pressure (TWA-MAP) and calculated the cumulative time spent below 55, 65, 75, and 85 mmHg thresholds.…”

A Machine Learning Approach to Predict Hypotensive Events in ICU Settings

“…This phenomenon is called arterial hypotension and frequently occurs in Intensive Care Units (ICUs) or Operating Rooms (ORs). New researches highlight the importance of predicting hypotensive events in hospital settings by providing evidences that correlate the occurrence of intraoperative or postoperative hypotensive events and various upcoming complications [2] [3] [4] [5] [6].…”