High versus Low Blood-Pressure Target in Patients with Septic Shock

Pierre Asfar, M.D., Ph.D., Ferhat Meziani, M.D., Ph.D., Jean-François Hamel, M.D., Fabien Grelon, M.D., Bruno Megarbane, M.D., Ph.D., Nadia Anguel, M.D., Jean-Paul Mira, M.D., Ph.D., Pierre-François Dequin, M.D., Ph.D., Soizic Gergaud, M.D., Nicolas Weiss, M.D., Ph.D., François Legay, M.D.,

N Engl J Med 2014; 370:1583-1593April 24, 2014DOI: 10.1056/NEJMoa1312173

In septic shock which is the best MAP target to reduce mortality 65-70mm Hg or 80-85mm Hg?

Multicenter, randomised, open label, controlled trial.

Inclusion Criteria

  • Age ≥18 years with septic shock refractory to administration of 30 mL/kg NS or colloids or was deemed to have inadequate response on right-heart catheterization, pulse-pressure measurement, SV measurement, or echocardiography
    • Sepsis defined by ≥2 SIRS criteria, likely or proven infection, and ≥1 organ with new dysfunction
  • If requiring norepinephrine or epinephrine:
    • Minimum infusion rate of 0.1 ug/kg/min
    • Evaluation for enrollment within six hours of initiation of vasopressor therapy

Exclusion Criteria

  • Lack of competence and no legal guardian, incarceration, pregnancy, or other legal protection
  • No French health system affiliation
  • Recent participation in another study
  • Recent participation in an interventional study with a primary outcome of mortality
  • Investigator’s decision to withhold resuscitation

Methods

Randomisation to one of two groups:

  • Aim for mean 65-70mm Hg
  • Aim for mean 80-85mm Hg

Maps were maintained for up to 5 days

Noradrenaline was the first agent in all but one centre which used adrenaline

Fluids given according to FICS guidelines, defined as non-fluid responsive after 30ml/kg

Diuretics, NSAIDS, IV contrast, and nephrotoxic agents were disallowed.

Main Results

No significant difference in the 28 and 90 day mortality rate found between targeting higher and lower blood pressure, so it would seem in the septic patient there is no benefit to targeting the higher blood pressure.

However, those patients with hypertension or kidney disease did seem to benefit from targeting the higher blood pressure so it maybe valuable to target the higher BP under these circumstances.

Review of article by Intensive Care Society

 PulmCCM

Portsmouth ICU

 WikiJournalClub

See Jones Trial- Is Lactate Clearance a Useful Indicator on this website

See also Rivers Trial on this web site

EMBasic- Introducing EM Basic Essential Evidence- The Rivers Sepsis Study

WikiJournalClub- Rivers Trial

Paul Mariks assertion that Lactate clearance is flawed

LITFL- EGDT

EMCRIT- Podcast 54- Dr Rivers on Severe Sepsis

Listen to Stitcher

Get in touch with Jonathan

I would love to hear from you so that we can start to work together.
  • Send an email to contact@criticalcarepractitioner.co.uk
  • Use my voicemail service link to the right of this page
  • Fill in contact form at the bottom of the page
[123-contact-form i882618]

Originally posted 2014-07-04 13:47:47. Republished by Blog Post Promoter

Share →

Leave a Reply

Your email address will not be published. Required fields are marked *