"Mean Arterial Pressure Targets in Septic Shock". The New England Journal of Medicine. 2014. 370:1583-1593. PubMed • Full text • PDF

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

Clinical Question

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?

Bottom Line

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.

Major Points

Guidelines

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.

Design

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

Population

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

Interventions

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.

Outcomes

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

Criticisms

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

Funding

Funded by the French Ministry of Health

Further Reading

Not provided