Optimizing mean arterial pressure in septic shock: a critical reappraisal of the literature

Marc Leone, Pierre Asfar, Peter Radermacher, Jean-Louis Vincent, Claude Martin, Marc Leone, Pierre Asfar, Peter Radermacher, Jean-Louis Vincent, Claude Martin

Abstract

Guidelines recommend that a mean arterial pressure (MAP) value greater than 65 mm Hg should be the initial blood pressure target in septic shock, but what evidence is there to support this statement? We searched Pubmed and Google Scholar by using the key words 'arterial pressure', 'septic shock', and 'norepinephrine' and retrieved human studies published between 1 January 2000 and 31 July 2014. We identified seven comparative studies: two randomized clinical trials and five observational studies. The results of the literature review suggest that a MAP target of 65 mm Hg is usually sufficient in patients with septic shock. However, a MAP of around 75 to 85 mm Hg may reduce the development of acute kidney injury in patients with chronic arterial hypertension. Because of the high prevalence of chronic arterial hypertension in patients who develop septic shock, this finding is of considerable importance. Future studies should assess interactions between time, fluid volumes administered, and doses of vasopressors.

Figures

Figure 1
Figure 1
Organ blood flow and blood pressure relationships in healthy individuals, individuals with chronic hypertension, and patients with septic shock. The third linear relationship is theoretical.
Figure 2
Figure 2
Interactions between mean arterial pressure, central venous pressure, and perfusion pressure.

References

    1. Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki LM, Pettilä V. Hemodynamic variables related to outcome in septic shock. Intensive Care Med. 2005;31:1066–71. 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;35:1225–33. doi: 10.1007/s00134-009-1427-2.
    1. Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637. doi: 10.1097/CCM.0b013e31827e83af.
    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. Hatib F, Jansen JR, Pinsky MR. Peripheral vascular decoupling in porcine endotoxic shock. J Appl Physiol. 1985;111:853–60. doi: 10.1152/japplphysiol.00066.2011.
    1. Terborg C, Schummer W, Albrecht M, Reinhart K, Weiller C, Röther J. Dysfunction of vasomotor reactivity in severe sepsis and septic shock. Intensive Care Med. 2001;27:1231–4. doi: 10.1007/s001340101005.
    1. Albanèse J, Leone M, Garnier F, Bourgoin A, Antonini F, Martin C. Renal effects of norepinephrine in septic and nonseptic patients. Chest. 2004;126:534–9. doi: 10.1378/chest.126.2.534.
    1. Strandgaard S, Olesen J, Skinhoj E, Lassen NA. Autoregulation of brain circulation in severe arterial hypertension. Br Med J. 1973;1:507–10. doi: 10.1136/bmj.1.5852.507.
    1. Wolff CB. Normal cardiac output, oxygen delivery and oxygen extraction. Adv Exp Med Biol. 2007;599:169–82. doi: 10.1007/978-0-387-71764-7_23.
    1. Elbers PW, Ince C. Mechanisms of critical illness - classifying microcirculatory flow abnormalities in distributive shock. Crit Care. 2006;10:221. doi: 10.1186/cc4969.
    1. De Backer D, Orbegozo Cortes D, Donadello K, Vincent JL. Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence. 2014;5:73–9. doi: 10.4161/viru.26482.
    1. Andrades MÉ, Morina A, Spasić S, Spasojević I. Bench-to-bedside review: sepsis - from the redox point of view. Crit Care. 2011;15:230. doi: 10.1186/cc10334.
    1. Leone M, Blidi S, Antonini F, Meyssignac B, Bordon S, Garcin F, Charvet A, Blasco V, Albanèse J, Martin C. Oxygen tissue saturation is lower in nonsurvivors than in survivors after early resuscitation of septic shock. Anesthesiology. 2009;111:366–71. doi: 10.1097/ALN.0b013e3181aae72d.
    1. Payen D, Luengo C, Heyer L, Resche-Rigon M, Kerever S, Damoisel C, Losser MR. Is thenar tissue hemoglobin oxygen saturation in septic shock related to macrohemodynamic variables and outcome? Crit Care. 2009;13:S6. doi: 10.1186/cc8004.
    1. Dünser MW, Hasibeder WR. Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress. J Intensive Care Med. 2009;24:293–316. doi: 10.1177/0885066609340519.
    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. Georger JF, Hamzaoui O, Chaari A, Maizel J, Richard C, Teboul JL. Restoring arterial pressure with norepinephrine improves muscle tissue oxygenation assessed by near-infrared spectroscopy in severely hypotensive septic patients. Intensive Care Med. 2010;36:1882–9. doi: 10.1007/s00134-010-2013-3.
    1. LeDoux D, Astiz ME, Carpati CM, Rackow EC. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med. 2000;28:2729–32. 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;33:780–6. doi: 10.1097/01.CCM.0000157788.20591.23.
    1. Deruddre S, Cheisson G, Mazoit JX, Vicaut E, Benhamou D, Duranteau J. Renal arterial resistance in septic shock: effects of increasing mean arterial pressure with norepinephrine on the renal resistive index assessed with Doppler ultrasonography. Intensive Care Med. 2007;33:1557–62. doi: 10.1007/s00134-007-0665-4.
    1. Jhanji S, Stirling S, Patel N, Hinds CJ, Pearse RM. The effect of increasing doses of norepinephrine on tissue oxygenation and microvascular flow in patients with septic shock. Crit Care Med. 2009;37:1961–6. doi: 10.1097/CCM.0b013e3181a00a1c.
    1. Thooft A, Favory R, Salgado DR, Taccone FS, Donadello K, De Backer D, Creteur J, Vincent JL. Effects of changes in arterial pressure on organ perfusion during septic shock. Crit Care. 2011;15:R222. doi: 10.1186/cc10462.
    1. Dubin A, Pozo MO, Casabella CA, Pálizas F, Jr, Murias G, Moseinco MC, Kanoore Edul VS, Pálizas F, Estenssoro E, Ince C. Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care. 2009;13:R92. doi: 10.1186/cc7922.
    1. Asfar P, Meziani F, Hamel JF, Grelon F, Megarbane B, Anguel N, Mira JP, Dequin PF, Gergaud S, Weiss N, Legay F, Le Tulzo Y, Conrad M, Robert R, Gonzalez F, Guitton C, Tamion F, Tonnelier JM, Guezennec P, Van Der Linden T, Vieillard-Baron A, Mariotte E, Pradel G, Lesieur O, Ricard JD, Hervé F, du Cheyron D, Guerin C, Mercat A, Teboul JL, Radermacher P, SEPSISPAM Investigators High versus low blood-pressure target in patients with septic shock. N Engl J Med. 2014;370:1583–93. doi: 10.1056/NEJMoa1312173.
    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. Badin J, Boulain T, Ehrmann S, Skarzynski M, Bretagnol A, Buret J, Benzekri-Lefevre D, Mercier E, Runge I, Garot D, Mathonnet A, Dequin PF, 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. Poukkanen M, Wilkman E, Vaara ST, Pettilä V, Kaukonen KM, Korhonen AM, Uusaro A, Hovilehto S, Inkinen O, Laru-Sompa R, Hautamäki R, Kuitunen A, Karlsson S, the FINNAKI Study Group Hemodynamic variables and progression of acute kidney injury in critically ill patients with severe sepsis: data from the prospective observational FINNAKI study. Crit Care. 2013;17:R295. doi: 10.1186/cc13161.
    1. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77. doi: 10.1056/NEJMoa010307.
    1. ARISE Investigators; ANZICS Clinical Trials Group. Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ, Higgins AM, Holdgate A, Howe BD, Webb SA, Williams P. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371:1496–506. doi: 10.1056/NEJMoa1404380.
    1. Investigators PCESS, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370:1683–93. doi: 10.1056/NEJMoa1401602.
    1. Leone M, Ragonnet B, Alonso S, Allaouchiche B, Constantin JM, Jaber S, Martin C, Fabbro-Peray P, Lefrant JY, AzuRéa Group Variable compliance with clinical practice guidelines identified in a 1-day audit at 66 French adult intensive care units. Crit Care Med. 2012;40:3189–95. doi: 10.1097/CCM.0b013e31826571f2.
    1. Waechter J, Kumar A, Lapinsky SE, Marshall J, Dodek P, Arabi Y, Parillo JE, Dellinger RP, Garland A, for the Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group Interaction between fluids and vasoactive agents on mortality in septic shock: a multicentre, observational study. Crit Care Med. 2014;42:2158–68. doi: 10.1097/CCM.0000000000000520.
    1. Pinsky MR, Payen D. Functional hemodynamic monitoring. Crit Care. 2005;9:566–72. doi: 10.1186/cc3927.
    1. Pinsky MR, Teboul JL. Assessment of indices of preload and volume responsiveness. Curr Opin Crit Care. 2005;11:235–9. doi: 10.1097/01.ccx.0000158848.56107.b1.
    1. Michard F, Teboul JL. Using heart-lung interactions to assess fluid responsiveness during mechanical ventilation. Crit Care. 2000;4:282–9. doi: 10.1186/cc710.
    1. Taylor AE, Moore TM. Capillary fluid exchange. Am J Physiol. 1999;277:S203–10.
    1. Donati A, Tibboel D, Ince C. Towards integrative physiological monitoring of the critically ill: from cardiovascular to microcirculatory and cellular function monitoring at the bedside. Crit Care. 2013;17:S5. doi: 10.1186/cc12906.
    1. Ekbal NJ, Dyson A, Black C, Singer M. Monitoring tissue perfusion, oxygenation, and metabolism in critically ill patients. Chest. 2013;143:1799–808. doi: 10.1378/chest.12-1849.
    1. De Backer D, Ospina-Tascon G, Salgado D, Favory R, Creteur J, Vincent JL. Monitoring the microcirculation in the critically ill patient: current methods and future approaches. Intensive Care Med. 2010;36:1813–25. doi: 10.1007/s00134-010-2005-3.
    1. Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med. 2004;32:1825–31. doi: 10.1097/01.CCM.0000138558.16257.3F.
    1. Trzeciak S, McCoy JV, Phillip Dellinger R, Arnold RC, Rizzuto M, Abate NL, Shapiro NI, Parrillo JE, Hollenberg SM, Microcirculatory Alterations in Resuscitation and Shock (MARS) investigators Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis. Intensive Care Med. 2008;34:2210–7. doi: 10.1007/s00134-008-1193-6.
    1. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40:1795–815. doi: 10.1007/s00134-014-3525-z.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa