"Mean Arterial Pressure Targets in Septic Shock". The New England Journal of Medicine. 2014. 370:1583-1593. PubMed
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Contents 1 Clinical Question 2 Bottom Line 3 Major Points 4 Guidelines 5 Design 6 Population 6.1 Inclusion Criteria 6.2 Exclusion Criteria 6.3 Baseline Characteristics 7 Interventions 8 Outcomes 8.1 Primary Outcome 8.2 Secondary Outcomes 9 Criticisms 10 Funding 11 Further Reading
In patients with septic shock, does targeting a higher mean arterial pressure (80 to 85 mm Hg) compared to a lower target (65 to 70 mm Hg) affect mortality?
In patients with septic shock, targeting a higher mean arterial pressure did not lead to significant differences in mortality at 28 or 90 days when compared to a lower target. In patients with chronic arterial hypertension, a higher mean arterial pressure reduced the need for renal-replacement therapy but not mortality.
The optimal blood pressure target during initial resuscitation of septic shock is unclear. The Surviving Sepsis Campaign recommends a mean arterial pressure of at least 65 mm Hg, but whether higher targets might improve outcomes was unknown. The SEPSISPAM trial directly compared two blood pressure targets (high vs. low) and found no significant difference in mortality rates at 28 or 90 days, nor in early fluid balance or secondary outcomes. A significant increase in episodes of atrial fibrillation was observed in the high-target group.
As of August 2017, Surviving Sepsis Campaign guidelines recommend an initial resuscitation target mean arterial pressure of at least 65 mm Hg in patients with septic shock.
Multicenter, open-label, randomized controlled trial N=776 patients with septic shock High-target group (mean arterial pressure 80 to 85 mm Hg, n=388) Low-target group (mean arterial pressure 65 to 70 mm Hg, n=388) Setting: 29 centers in France Enrollment: 2010-2011 Mean follow-up: 90 days Analysis: Intention-to-treat Primary outcome: Mortality at day 28
Inclusion Criteria Age ≥18 years Septic shock refractory to fluid resuscitation requiring vasopressors Enrollment within 6 hours after vasopressor initiation Exclusion Criteria Incompetence to provide consent without a guardian No affiliation with French health care system Pregnancy Recent enrollment in another mortality-focused interventional study Clinician decision against resuscitation Baseline Characteristics Similar in both groups; majority critically ill based on scoring systems, confirmed infection, and organ dysfunction
Patients were assigned to vasopressor treatment to maintain either a high or low mean arterial pressure target, for a maximum of 5 days or until vasopressor weaning.
Primary Outcome 28-day mortality: No significant difference (High: 36.6% vs. Low: 34.0%; HR 1.07, 95% CI 0.84 to 1.38; P=0.57) Secondary Outcomes 90-day mortality: No significant difference (High: 43.8% vs. Low: 42.3%; HR 1.04, 95% CI 0.83 to 1.30; P=0.74) Increased incidence of newly diagnosed atrial fibrillation in high-target group Significant interaction between the study group and hypertension stratum for kidney function No significant differences in early fluid balance or length of ICU and hospital stay
Higher-than-targeted mean arterial pressures observed in both groups Lower-than-expected rate of death led to an underpowered study Increase in atrial fibrillation episodes in the high-target group
Funded by the French Ministry of Health
Not provided