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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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Interactions between mean arterial pressure, central venous pressure, and perfusion pressure.
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Fig2: Interactions between mean arterial pressure, central venous pressure, and perfusion pressure.

Mentions: Central venous pressure (CVP) is often inaccurate for predicting the need for volume expansion [33-35]. However, it represents the downstream pressure, whereas the perfusion pressure determinants are upstream and downstream pressures (Figure 2). The increase in downstream pressure generates congestion [36]. Thus, the optimal MAP most likely also depends on the CVP level. However, CVP does not always reflect the downstream pressure, because of the presence of Starling resistor phenomena in some vascular beds. The Surviving Sepsis Campaign recommends reaching a MAP of at least 65 mm Hg and at the same time a CVP of at least 12 mm Hg (in mechanically ventilated patients) [3]. However, in terms of organ perfusion, the optimal difference between MAP and CVP remains unclear.Figure 2


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)

Interactions between mean arterial pressure, central venous pressure, and perfusion pressure.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Fig2: Interactions between mean arterial pressure, central venous pressure, and perfusion pressure.
Mentions: Central venous pressure (CVP) is often inaccurate for predicting the need for volume expansion [33-35]. However, it represents the downstream pressure, whereas the perfusion pressure determinants are upstream and downstream pressures (Figure 2). The increase in downstream pressure generates congestion [36]. Thus, the optimal MAP most likely also depends on the CVP level. However, CVP does not always reflect the downstream pressure, because of the presence of Starling resistor phenomena in some vascular beds. The Surviving Sepsis Campaign recommends reaching a MAP of at least 65 mm Hg and at the same time a CVP of at least 12 mm Hg (in mechanically ventilated patients) [3]. However, in terms of organ perfusion, the optimal difference between MAP and CVP remains unclear.Figure 2

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