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

Leone M, Asfar P, Radermacher P, Vincent JL, Martin C - Crit Care (2015)

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, 13015, Marseille, France. marc.leone@ap-hm.fr.

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.

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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.
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Fig1: 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.

Mentions: Septic shock is characterized by both vasodilation and cardiac dysfunction, leading to a decrease in blood pressure. Hypotension generates organ failure due to hypoperfusion, with the MAP reflecting the driving pressure at the organ level. The goal of resuscitation is to restore adequate organ perfusion (that is, to optimize the relationship between oxygen needs and oxygen supply). In healthy individuals, blood flow remains constant over a large range of blood pressures, at least in the brain and the kidney. For many years, researchers have hypothesized that this autoregulatory mechanism is impaired in septic shock [5-7], so that increasing blood pressure will increase organ blood flow (Figure 1). In addition, the autoregulation threshold is dependent on the basal level of blood pressure, tending to be higher in patients with than in those without a prior history of arterial hypertension (Figure 1) [8]. The ‘optimal’ MAP target, therefore, may differ according to the patient’s medical history. Moreover, there are many autoregulatory thresholds depending on the specific tissue. In general, our goal is to provide an adequate perfusion to vital organs, which tend to have higher thresholds than less critical organs, such as skeletal muscle [9].Figure 1


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

Leone M, Asfar P, Radermacher P, Vincent JL, Martin C - Crit Care (2015)

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.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4355573&req=5

Fig1: 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.
Mentions: Septic shock is characterized by both vasodilation and cardiac dysfunction, leading to a decrease in blood pressure. Hypotension generates organ failure due to hypoperfusion, with the MAP reflecting the driving pressure at the organ level. The goal of resuscitation is to restore adequate organ perfusion (that is, to optimize the relationship between oxygen needs and oxygen supply). In healthy individuals, blood flow remains constant over a large range of blood pressures, at least in the brain and the kidney. For many years, researchers have hypothesized that this autoregulatory mechanism is impaired in septic shock [5-7], so that increasing blood pressure will increase organ blood flow (Figure 1). In addition, the autoregulation threshold is dependent on the basal level of blood pressure, tending to be higher in patients with than in those without a prior history of arterial hypertension (Figure 1) [8]. The ‘optimal’ MAP target, therefore, may differ according to the patient’s medical history. Moreover, there are many autoregulatory thresholds depending on the specific tissue. In general, our goal is to provide an adequate perfusion to vital organs, which tend to have higher thresholds than less critical organs, such as skeletal muscle [9].Figure 1

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, 13015, Marseille, France. marc.leone@ap-hm.fr.

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.

Show MeSH
Related in: MedlinePlus