Abstract
BackgroundThe optimal approach to titrate vasopressor therapy is unclear. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines.MethodIn a multicenter prospective cohort study of critically ill adults with severe hypotension, we recorded MAP and vasopressor doses hourly. We investigated variability across patients and centres using multivariable regression models and Analysis of variance (ANOVA), respectively.ResultsWe included data from 56 patients treated in 6 centers. The mean (standard deviation [SD]) age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were 64 (14) and 25 (8). Half (28 of 56) of the patients were at least 65 years old, and half had chronic hypertension. The patient-averaged MAP while receiving vasopressors was 75 mm Hg (6) and the median (1st quartile, 3rd quartile) duration of vasopressor therapy was 43 hours (23, 84). MAP achieved was not associated with history of underlying hypertension (p = 0.46) but did vary by center (p<0.001).ConclusionsIn this multicenter, prospective observational study, the patient-level average MAP while receiving vasopressors for severe hypotension was 75 mmHg, approximately 10 mmHg above current recommendations and stated practices. Moreover, our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but MAP achieved while receiving vasopressors varied by site.
Highlights
In shock, hypotension may lead to hypoperfusion, organ failure and death.[1, 2] Vasopressors are administered under the assumption that vasoconstriction will improve organ perfusion when hypotension is caused by abnormal vasodilation.[3,4,5] vasoconstriction may be excessive and hinder blood flow to vital organs in an unpredictable fashion, especially if concomitant abnormal cardiac function and hypovolemia compound vasodilation
Our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but mean arterial pressure (MAP) achieved while receiving vasopressors varied by site
Practice guidelines suggest that chronic hypertension may warrant higher mean arterial pressure (MAP) targets.[8]
Summary
Hypotension may lead to hypoperfusion, organ failure and death.[1, 2] Vasopressors are administered under the assumption that vasoconstriction will improve organ perfusion when hypotension is caused by abnormal vasodilation.[3,4,5] vasoconstriction may be excessive and hinder blood flow to vital organs in an unpredictable fashion, especially if concomitant abnormal cardiac function and hypovolemia compound vasodilation. Practice guidelines suggest that chronic hypertension may warrant higher mean arterial pressure (MAP) targets.[8] Physicians appear to agree with these recommendations and underlying assumptions. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines
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