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Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial.

Dünser MW, Ruokonen E, Pettilä V, Ulmer H, Torgersen C, Schmittinger CA, Jakob S, Takala J - Crit Care (2009)

Bottom Line: These associations were not influenced by age or pre-existent arterial hypertension (all P > 0.05).The mean vasopressor load was associated with mortality (relative risk (RR), 1.83; confidence interval (CI) 95%, 1.4-2.38; P < 0.001), the number of disease-related events (P < 0.001) and the occurrence of acute circulatory failure (RR, 1.64; CI 95%, 1.28-2.11; P < 0.001), metabolic acidosis (RR, 1.79; CI 95%, 1.38-2.32; P < 0.001), renal failure (RR, 1.49; CI 95%, 1.17-1.89; P = 0.001) and thrombocytopenia (RR, 1.33; CI 95%, 1.06-1.68; P = 0.01).Elevating MAP >70 mmHg by augmenting vasopressor dosages may increase mortality.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Intensive Care Medicine, Inselspital, Freiburgstrasse, 3010 Bern, Switzerland. Martin.Duenser@insel.ch

ABSTRACT

Introduction: It is unclear to which level mean arterial blood pressure (MAP) should be increased during septic shock in order to improve outcome. In this study we investigated the association between MAP values of 70 mmHg or higher, vasopressor load, 28-day mortality and disease-related events in septic shock.

Methods: This is a post hoc analysis of data of the control group of a multicenter trial and includes 290 septic shock patients in whom a mean MAP > or = 70 mmHg could be maintained during shock. Demographic and clinical data, MAP, vasopressor requirements during the shock period, disease-related events and 28-day mortality were documented. Logistic regression models adjusted for the geographic region of the study center, age, presence of chronic arterial hypertension, simplified acute physiology score (SAPS) II and the mean vasopressor load during the shock period was calculated to investigate the association between MAP or MAP quartiles > or = 70 mmHg and mortality or the frequency and occurrence of disease-related events.

Results: There was no association between MAP or MAP quartiles and mortality or the occurrence of disease-related events. These associations were not influenced by age or pre-existent arterial hypertension (all P > 0.05). The mean vasopressor load was associated with mortality (relative risk (RR), 1.83; confidence interval (CI) 95%, 1.4-2.38; P < 0.001), the number of disease-related events (P < 0.001) and the occurrence of acute circulatory failure (RR, 1.64; CI 95%, 1.28-2.11; P < 0.001), metabolic acidosis (RR, 1.79; CI 95%, 1.38-2.32; P < 0.001), renal failure (RR, 1.49; CI 95%, 1.17-1.89; P = 0.001) and thrombocytopenia (RR, 1.33; CI 95%, 1.06-1.68; P = 0.01).

Conclusions: MAP levels of 70 mmHg or higher do not appear to be associated with improved survival in septic shock. Elevating MAP >70 mmHg by augmenting vasopressor dosages may increase mortality. Future trials are needed to identify the lowest acceptable MAP level to ensure tissue perfusion and avoid unnecessary high catecholamine infusions.

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Number of DRE by MAP and mean vasopressor load quartiles as predicted by the adjusted logistic regression model. Mean arterial blood pressure (MAP) quartile I = 70 to 74.3 mmHg; MAP quartile II = 74.3 to 77.8 mmHg; MAP quartile III = 77.8 to 82.1 mmHg; MAP quartile IV = 82.1 to 99.7 mmHg. DRE = disease-related events.
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Figure 2: Number of DRE by MAP and mean vasopressor load quartiles as predicted by the adjusted logistic regression model. Mean arterial blood pressure (MAP) quartile I = 70 to 74.3 mmHg; MAP quartile II = 74.3 to 77.8 mmHg; MAP quartile III = 77.8 to 82.1 mmHg; MAP quartile IV = 82.1 to 99.7 mmHg. DRE = disease-related events.

Mentions: MAP or MAP quartiles were not associated with the total number of disease-related events (linear regression model; MAP: standardized Beta-Coefficient, -0.052; P = 0.36; MAP quartiles: standardized Beta-Coefficient, -0.035; P = 0.55) or the occurrence of any single disease-related event. These associations were not influenced by age or pre-existent arterial hypertension. However, the mean vasopressor load was significantly associated with the total number of disease-related events (standardized Beta-Coefficient, 0.225; P < 0.001). Figure 2 presents the predicted number of total disease-related events by MAP and mean vasopressor load quartiles as predicted by the adjusted logistic regression model. The mean vasopressor load (per ln unit) was associated with the occurrence of acute circulatory failure (RR, 1.64; 95% CI, 1.28 to 2.11; P < 0.001), metabolic acidosis (RR, 1.79; 95% CI, 1.38 to 2.32; P < 0.001), renal failure (RR, 1.49; 95% CI, 1.17 to 1.89; P = 0.001) and thrombocytopenia (RR, 1.33; 95% CI, 1.06 to 1.68; P = 0.01) in single adjusted logistic regression models. Study patients still had a significantly lower mean and maximum vasopressor load during the shock period when compared with the 68 patients excluded from the analysis (mean vasopressor load, 0.64 ± 1.92 vs. 2.31 ± 6.56 μg/kg/min, P = 0.003; maximum vasopressor load, 1.19 ± 3.54 vs. 3.06 ± 7.4 μg/kg/min, P = 0.01) [Figure S1 in Additional data file 1].


Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial.

Dünser MW, Ruokonen E, Pettilä V, Ulmer H, Torgersen C, Schmittinger CA, Jakob S, Takala J - Crit Care (2009)

Number of DRE by MAP and mean vasopressor load quartiles as predicted by the adjusted logistic regression model. Mean arterial blood pressure (MAP) quartile I = 70 to 74.3 mmHg; MAP quartile II = 74.3 to 77.8 mmHg; MAP quartile III = 77.8 to 82.1 mmHg; MAP quartile IV = 82.1 to 99.7 mmHg. DRE = disease-related events.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2811945&req=5

Figure 2: Number of DRE by MAP and mean vasopressor load quartiles as predicted by the adjusted logistic regression model. Mean arterial blood pressure (MAP) quartile I = 70 to 74.3 mmHg; MAP quartile II = 74.3 to 77.8 mmHg; MAP quartile III = 77.8 to 82.1 mmHg; MAP quartile IV = 82.1 to 99.7 mmHg. DRE = disease-related events.
Mentions: MAP or MAP quartiles were not associated with the total number of disease-related events (linear regression model; MAP: standardized Beta-Coefficient, -0.052; P = 0.36; MAP quartiles: standardized Beta-Coefficient, -0.035; P = 0.55) or the occurrence of any single disease-related event. These associations were not influenced by age or pre-existent arterial hypertension. However, the mean vasopressor load was significantly associated with the total number of disease-related events (standardized Beta-Coefficient, 0.225; P < 0.001). Figure 2 presents the predicted number of total disease-related events by MAP and mean vasopressor load quartiles as predicted by the adjusted logistic regression model. The mean vasopressor load (per ln unit) was associated with the occurrence of acute circulatory failure (RR, 1.64; 95% CI, 1.28 to 2.11; P < 0.001), metabolic acidosis (RR, 1.79; 95% CI, 1.38 to 2.32; P < 0.001), renal failure (RR, 1.49; 95% CI, 1.17 to 1.89; P = 0.001) and thrombocytopenia (RR, 1.33; 95% CI, 1.06 to 1.68; P = 0.01) in single adjusted logistic regression models. Study patients still had a significantly lower mean and maximum vasopressor load during the shock period when compared with the 68 patients excluded from the analysis (mean vasopressor load, 0.64 ± 1.92 vs. 2.31 ± 6.56 μg/kg/min, P = 0.003; maximum vasopressor load, 1.19 ± 3.54 vs. 3.06 ± 7.4 μg/kg/min, P = 0.01) [Figure S1 in Additional data file 1].

Bottom Line: These associations were not influenced by age or pre-existent arterial hypertension (all P > 0.05).The mean vasopressor load was associated with mortality (relative risk (RR), 1.83; confidence interval (CI) 95%, 1.4-2.38; P < 0.001), the number of disease-related events (P < 0.001) and the occurrence of acute circulatory failure (RR, 1.64; CI 95%, 1.28-2.11; P < 0.001), metabolic acidosis (RR, 1.79; CI 95%, 1.38-2.32; P < 0.001), renal failure (RR, 1.49; CI 95%, 1.17-1.89; P = 0.001) and thrombocytopenia (RR, 1.33; CI 95%, 1.06-1.68; P = 0.01).Elevating MAP >70 mmHg by augmenting vasopressor dosages may increase mortality.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Intensive Care Medicine, Inselspital, Freiburgstrasse, 3010 Bern, Switzerland. Martin.Duenser@insel.ch

ABSTRACT

Introduction: It is unclear to which level mean arterial blood pressure (MAP) should be increased during septic shock in order to improve outcome. In this study we investigated the association between MAP values of 70 mmHg or higher, vasopressor load, 28-day mortality and disease-related events in septic shock.

Methods: This is a post hoc analysis of data of the control group of a multicenter trial and includes 290 septic shock patients in whom a mean MAP > or = 70 mmHg could be maintained during shock. Demographic and clinical data, MAP, vasopressor requirements during the shock period, disease-related events and 28-day mortality were documented. Logistic regression models adjusted for the geographic region of the study center, age, presence of chronic arterial hypertension, simplified acute physiology score (SAPS) II and the mean vasopressor load during the shock period was calculated to investigate the association between MAP or MAP quartiles > or = 70 mmHg and mortality or the frequency and occurrence of disease-related events.

Results: There was no association between MAP or MAP quartiles and mortality or the occurrence of disease-related events. These associations were not influenced by age or pre-existent arterial hypertension (all P > 0.05). The mean vasopressor load was associated with mortality (relative risk (RR), 1.83; confidence interval (CI) 95%, 1.4-2.38; P < 0.001), the number of disease-related events (P < 0.001) and the occurrence of acute circulatory failure (RR, 1.64; CI 95%, 1.28-2.11; P < 0.001), metabolic acidosis (RR, 1.79; CI 95%, 1.38-2.32; P < 0.001), renal failure (RR, 1.49; CI 95%, 1.17-1.89; P = 0.001) and thrombocytopenia (RR, 1.33; CI 95%, 1.06-1.68; P = 0.01).

Conclusions: MAP levels of 70 mmHg or higher do not appear to be associated with improved survival in septic shock. Elevating MAP >70 mmHg by augmenting vasopressor dosages may increase mortality. Future trials are needed to identify the lowest acceptable MAP level to ensure tissue perfusion and avoid unnecessary high catecholamine infusions.

Show MeSH
Related in: MedlinePlus