Target blood pressure in sepsis: between a rock and a hard place

François Beloncle, Nicolas Lerolle, Peter Radermacher, Pierre Asfar, François Beloncle, Nicolas Lerolle, Peter Radermacher, Pierre Asfar

Abstract

The optimal target blood pressure in septic shock is still unknown. Therefore, in a long-term, resuscitated porcine model of fecal peritonitis-induced septic shock, Corrêa and colleagues tested whether different titrations of mean arterial pressure (50 to 60 and 75 to 85 mm Hg) would produce different effects on sepsis-related organ dysfunction. The higher blood pressure window was associated with increased needs for fluid resuscitation and norepinephrine support. However, titrating the lower blood pressure range coincided with an increased incidence of acute kidney injury. In contrast, neither the inflammatory response nor tissue mitochondrial activity showed any difference. This research paper in a clinically relevant model elegantly demonstrates that any standard resuscitation strategy may be a double-edged sword with respect to various therapeutic endpoints. Furthermore, it adds an important piece to the puzzle of the complex pathophysiology of sepsis-related acute kidney injury.

References

    1. Corrêa TD, Vuda M, Takala J, Djafarzadeh S, Silva E, Jakob SM. Increasing mean arterial blood pressure in sepsis: effects on fluid balance, vasopressor load and renal function. Crit Care. 2013;17:R21. doi: 10.1186/cc12495.
    1. Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki L-M, Pettilä V. Hemodynamic variables related to outcome in septic shock. Intensive Care Med. 2005;31:1066–1071. doi: 10.1007/s00134-005-2688-z.
    1. Dünser MW, Takala J, Ulmer H, Mayr VD, Luckner G, Jochberger S, Daudel F, Lepper P, Hasibeder WR, Jakob SM. Arterial blood pressure during early sepsis and outcome. Intensive Care Med. 2009;35:1225–1233. doi: 10.1007/s00134-009-1427-2.
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377. doi: 10.1056/NEJMoa010307.
    1. Dünser MW, Ruokonen E, Pettilä V, Ulmer H, Torgersen C, Schmittinger CA, Jakob S, Takala J. Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial. Crit Care. 2009;13:R181. doi: 10.1186/cc8167.
    1. López A, Lorente JA, Steingrub J, Bakker J, McLuckie A, Willatts S, Brockway M, Anzueto A, Holzapfel L, Breen D, Silverman MS, Takala J, Donaldson J, Arneson C, Grove G, Grossman S, Grover R. Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med. 2004;32:21–30. doi: 10.1097/01.CCM.0000105581.01815.C6.
    1. Russell JA, Walley KR, Singer J, Gordon AC, Hébert PC, Cooper DJ, Holmes CL, Mehta S, Granton JT, Storms MM, Cook DJ, Presneill JJ, Ayers D. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med. 2008;358:877–887. doi: 10.1056/NEJMoa067373.
    1. LeDoux D, Astiz ME, Carpati CM, Rackow EC. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med. 2000;28:2729–2732. doi: 10.1097/00003246-200008000-00007.
    1. Bourgoin A, Leone M, Delmas A, Garnier F, Albanèse J, Martin C. Increasing mean arterial pressure in patients with septic shock: effects on oxygen variables and renal function. Crit Care Med. 2005;33:780–786. doi: 10.1097/01.CCM.0000157788.20591.23.
    1. Badin J, Boulain T, Ehrmann S, Skarzynski M, Bretagnol A, Buret J, Benzekri-Lefevre D, Mercier E, Runge I, Garot D, Mathonnet A, Dequin P-F, Perrotin D. Relation between mean arterial pressure and renal function in the early phase of shock: a prospective, explorative cohort study. Crit Care. 2011;15:R135. doi: 10.1186/cc10253.
    1. Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Oudemans-van Straaten HM, Ronco C, Kellum JA. Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes. Clin J Am Soc Nephrol. 2007;2:431–439. doi: 10.2215/CJN.03681106.
    1. Iversen BM, Sekse I, Ofstad J. Resetting of renal blood flow autoregulation in spontaneously hypertensive rats. Am J Physiol. 1987;252:F480–486.
    1. Johnson PC. Autoregulation of blood flow. Circ Res. 1986;59:483–495. doi: 10.1161/01.RES.59.5.483.
    1. Di Giantomasso D, May CN, Bellomo R. Vital organ blood flow during hyperdynamic sepsis. Chest. 2003;124:1053–1059. doi: 10.1378/chest.124.3.1053.
    1. Benes J, Chvojka J, Sykora R, Radej J, Krouzecky A, Novak I, Matejovic M. Searching for mechanisms that matter in early septic acute kidney injury: an experimental study. Crit Care. 2011;15:R256. doi: 10.1186/cc10517.
    1. Edwards RM. Segmental effects of norepinephrine and angiotensin II on isolated renal microvessels. Am J Physiol. 1983;244:F526–534.

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