High vs Low blood pressure target in patients with septic shock

8/16/2019 High vs Low blood pressure target in patients with septic shock

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High versus Low Blood-Pressure Target in Patientswith Septic ShockThe New England Journal of Medicine

established in !"#pril "$% "&$ vol' ()& no' )

Palgunadi

&*+&,&&&)Pebibing. dr' Susana M'Sc Sp'#n


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/ntroduction

Septic shock 0 arterial h1potension% despite ade2uate 3uid resuscitation

The guidelines initial resuscitation 4vasopressors reverse h1potension% M#P target0 +, Hg% no signi5cant di6erences in lactate levels or regional blood 3ow when M#Pwas elevated 7 +, Hg in patients with septic shock'

Moreover% a large% retrospective stud1 M#P 7 ), Hg 0 aintain kidne1 8unction'

Stud1 o8 ph1siological echaniss o8 chronic arterial h1pertension 0 h1pertension arightward shi8t in cerebral pressure-3ow autoregulation higher ean arterial pressure'

E6ective blood-pressure targets 0 controversial patients with septic shock deterine whether targeting a ean arterial pressure o8 !& to !, Hg decrease

"!-da1 ortalit1copared with targeting a ean arterial pressure o8 +, to )& Hg

Bene5cial e6ects o8 a higher target ore pronounced% patients with chronich1pertension


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Background

The Surviving Sepsis 9apaign 0targeting a M#P o8 at least +, Hg initial resuscitation patients with

septic shock

Blood-pressure target is ore or lesse6ective than a higher target isunknown


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Methods

Multicenter% open-label trial% rando))+ patients with septic shock toundergo resuscitation with a ean

arterial pressure target o8 either !& to!, Hg 4high-target group: or +, to)& Hg 4low-target group:'

The priar1 end point was ortalit1 atda1 "!'


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Stud1 ;esign

March "&& - ;eceber "&% at "*centers in


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Stud1 Patients

Patients older than ! 1ears o8 age 4had septicshock% re8ractor1 to 3uid resuscitation% re2uiredvasopressor 4norepinephrine or epinephrine: at ainiu in8usion rate o8 &' >g per kilogra perinute% evaluated within + hours a8ter theinitiation o8 vasopressors

Septic shock 0 presence o8 two or ore diagnosticcriteria o8 the s1steic in3aator1 responses1ndroe% proven or suspected in8ection% andsudden d1s8unction o8 at least one organ'


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Stud1 Treatents

ol per liter:

Patients vasopressor treatent aintain a M#P o8 !& to !, Hg 4high-targetgroup: or +, to )& Hg 4low-target group:

Maintained 8or a a?iu o8 , da1s


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Stud1 utcoes

The priar1 outcoe 0 death 8ro an1 cause b1"! da1s a8ter inclusion

Secondar1 outcoes 0 *&-da1 ortalit1% da1s aliveand 8ree 8ro organ d1s8unction b1 da1 "!% and thelength o8 sta1 in the intensive care unit 4/9=: andhospital'

Survival b1 da1 "! without organ support 0 nubero8 da1s without catecholaine in8usion% echanicalventilation% or renalreplaceent therap1


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Statistical #nal1sis

!&& patients 0 power o8 !&C absolutebetween-group di6erence o8 & percentagepoints in the priar1 outcoe% assuing a

rate o8 death o8 $,C

Statistical signi5cance P value o8 &'&&

in the three interi anal1ses and a two-sided P value o8 &'&$*" in the 5nal anal1sis


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Aesults

Study Population

• ))+ patients% *& da1s Baseline characteristics were siilar in the two groups

• +) o8 (!! patients 4$('&C: in the high target group and )( o8 (!! 4$$'+C: inthe low target group had a histor1 o8 chronic h1pertension

• , protocol-speci5ed da1s the M#P in low-target group 0 signi5cantl1 lower

Vasopressor Use and Fluid Balance

• The in8usion rates o8 vasopressors were signi5cantl1 higher% and the duration o8vasopressor treatent signi5cantl1 longer% in the high-target group

• # total o8 +$ patients 4+',C: in the high-target group and $& patients 4&'(C:in the low-targetgroup 4P 0 &'&: did not reach M#P targets ph1sicianDsdecision to liit the vasopressor in8usion rates

• $ patients 4('+C: in the high-target group vasopressor in8usion rates wereadusted downward aintain a ean arterial pressure o8 +, to )& Hg adverse e6ects

• Falues 8or total 3uid adinistration and total urine output 0 siilar


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Aesults

Primary Outcome

• #t "! da1s no signi5cant between group di6erence in the rate o8 death

• ;eaths reported in $" o8 (!! patients 4(+'+C: in the high-target group%(" o8 (!! patients 4($'&C: in the low-target group 4haGard ratio in the

high-target group% '&)@ *,C con5dence interval 9/I% &'!$ to '(!@ P 0&',):

• No signi5cant between-group di6erence in ortalit1 at *& da1s% with )&deaths 4$(')C: and +$ deaths 4$"'(C:% in the two groups% respectivel14haGard ratio% '&$@ *,C 9/% &'!( to '(&@ P 0 &')$:

• No signi5cant di6erences in the secondar1 outcoes. need 8or echanicalventilation% length o8 sta1 in the /9= and hospital% and the S


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Aesults

Adverse Events

• No signi5cant di6erence between the two stud1groups in the overall incidence o8 serious adverseevents 4P 0 &'+$:

• The total nuber o8 cardiac adverse events did notdi6er between the groups incidence o8 newl1diagnosed atrial 5brillation 77 the high-target group

– events reported "+ patients 4+')C: in the high target

group and patients 4"'!C: in the low target group 4P 0&'&":

•


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Aesults

#t "! da1s 0 no signi5cant between-group di6erence in ortalit1% with

deaths reported in $" o8 (!! patients in the high-target group 4(+'+C:and (" o8 (!! patients in the low-target group 4($'&C:

4haGard ratio in the high-target group% '&)@ *,C con5dence interval 9/I%&'!$ to '(!@ P 0 &',):

No signi5cant di6erence in ortalit1 at *& da1s% with )& deaths 4$('!C:and +$ deaths 4$"'(C:% respectivel1 4haGard ratio% '&$@ *,C 9/% &'!( to'(&@ P 0 &')$:

The incidence o8 newl1 diagnosed atrial 5brillation 77 high-target group

#ong patients with chronic h1pertension

• the high-target group 0 re2uired less renal-replaceent therap1

• Therap1 was not associated with a di6erence in ortalit1


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9onclusions

Targeting a ean arterial pressure o8!& to !, Hg% as copared with +,to )& Hg% in patients with septic

shock undergoing resuscitation did notresult in signi5cant di6erences inortalit1 at either "! or *& da1s'


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;iscussion

• 9oparing the strateg1 o8 targeting a high ean arterialpressure 4!& to !, Hg: with the strateg1 o8 targeting alow pressure 4+, to )& Hg: in patients with septic shock

• The high-target group higher doses o8 vasopressorcatecholaines no signi5cant di6erence in "!-da1 ortalit1

• The association between atrial 5brillation and septic shock 0h1pothesis- generating concept 8or 8uture trials'

• ! #ong patients with chronic h1pertension% a rightwardshi8t o8 the curve 8or organ pressure-3ow autoregulation 0e?pected an increased M#P iproved organ per8usionand% eventuall1% in iproved survival rates

• H1pertension 0 targeting a higher ean arterial acceptable not associated with greater hars


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Documents

High vs Low blood pressure target in patients with septic shock