Targeting blood pressure in sepsis

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

References:

Timing of norepinephrine in septic shock and mortality

Hemodynamic parameters and acute kidney injury in sepsis

 

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

 

References

Surviving sepsis campaign guidelines

NEJM: High vs. low blood pressure target in septic shock

Hemodynamic variables and progression of kidney injury in sepsis (FINNAKI study)

 

 

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
  • Comorbidities
  • Disease course

Look at the relationship of perfusion to pressure in an individual patient!

 

References:

Animal study: Autoregulation of renal blood flow

 

By Dr Julia Wagner