Optimal blood pressure for the organs (Vignon)
There is no ‘one size fits all’ approach
Minimal MAP target ≥ 65 mmHg but MAP is not the sole target. Low DAP is also bad (DAP < 40 mmHg is a warning sign (vasopressors))
In cases of pre-existing hypertension: a higher target (80-90 mmHg) might be appropriate
Personalised blood pressure (Asfar)
Surviving sepsis campaign guidelines: target MAP ≥ 65, however the optimal MAP should be individualized.
The problem: Low perfusion pressure vs. excessive vasoconstriction.
A low threshold? à higher number of MAP periods < 60 during early sepsis = higher mortality (Dünser et al.)
Studies showed no beneficial effect of increasing MAP step by step on renal function
SEPSISPAM Multicenter trial: MAP target 65-70 vs. 80-85 mmHg. No difference in survival at day 28.
Patients with chronic hypertension: MAP target 80-85 mmHg improved renal failure and neurologic status
SEPSISPAM posthoc analysis: no benefit with MAP increase when acute kidney injury is already installed and in cardiac patients
What is my daily practice? (Hollenberg)
Higher or lower MAP? Better perfusion perhaps vs. possible side effects
Target MAP 65 à Trouble? à Target MAP 60 à Trouble? à Consider lower MAP
However, always ask: Perfusion adequate? If not, consider higher MAP and use other measures/advanced monitoring.
Don’t forget other considerations:
- Genetic variation
- Pharmacologic variation
- Disease course
Look at the relationship of perfusion to pressure in an individual patient!
By Dr Julia Wagner