Blood-Pressure Target in Patients with Septic Shock

Posted by • April 25th, 2014

In a multicenter, open-label trial, patients with septic shock were treated to maintain a mean arterial pressure target of either 80 to 85 mm Hg or 65 to 70 mm Hg. There were no significant between-group differences in 28-day mortality or in 90-day mortality.

Septic shock is characterized by arterial hypotension despiteadequate fluid resuscitation.

Clinical Pearls

What are the guidelines of the Surviving Sepsis Campaign with respect to mean arterial pressure in patients with septic shock?

The guidelines of the Surviving Sepsis Campaign recommended initial resuscitation with vasopressors to reverse hypotension, with a mean arterial pressure target of at least 65 mm Hg (grade 1C, indicating a strong recommendation with a low level of evidence). This recommendation is based on the findings of small studies, which showed no significant differences in lactate levels or regional blood flow when the mean arterial pressure was elevated to more than 65 mm Hg in patients with septic shock.

What were the primary outcomes of this study, which randomly assigned patients with septic shock to undergo resuscitation with a mean arterial pressure target of either 80 to 85 mm Hg (high-target group) or 65 to 70 mm Hg (low-target group)?

At 28 days, there was no significant between-group difference in the rate of death, with deaths reported in 142 of 388 patients (36.6%) in the high-target group and 132 of 388 patients (34.0%) in the low-target group (hazard ratio in the high-target group, 1.07; 95% confidence interval [CI], 0.84 to 1.38; P=0.57). There was also no significant between-group difference in mortality at 90 days, with 170 deaths (43.7%) and 164 deaths (42.3%), in the two groups, respectively (hazard ratio, 1.04; 95% CI, 0.83 to 1.30; P=0.74).

Table 2. Clinical Results, Primary and Secondary Outcomes, and Serious Adverse Events.

Figure 3. Kaplan-Meier Curves for Cumulative Survival.

Morning Report Questions

Q: What were the secondary outcomes in this study?

A: There were no significant differences in the secondary outcomes: need for mechanical ventilation, length of stay in the ICU and hospital, and the SOFA score by day 7. However, in patients with chronic arterial hypertension, there was a significant interaction between study group and hypertension stratum with respect to the doubling of the blood creatinine level (P=0.009) and with respect to the need for renal-replacement therapy (P=0.04). Multivariate logistic-regression analysis indicated that none of the potentially nephrotoxic therapies influenced this result.

Q: What differential adverse events occurred between the two study groups?

A: There was no significant difference between the two study groups in the overall incidence of serious adverse events (P=0.64). Although the total number of cardiac adverse events did not differ between the groups, the incidence of newly diagnosed atrial fibrillation was significantly higher in the high-target group, with events reported in 26 patients (6.7%) in the high-target group and 11 patients (2.8%) in the low-target group (P=0.02). The frequencies of ischemic events and bleeding complications were similar in the two study groups.

Table 2. Clinical Results, Primary and Secondary Outcomes, and Serious Adverse Events.

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