High Versus Low Blood-Pressure Target in Patients With Septic Shock
What is the optimal mean arterial pressure target during initial resuscitation of patients with septic shock?
In a multicenter, open-label trial, the investigators randomly assigned 776 patients with septic shock to undergo resuscitation with a mean arterial pressure target of either 80-85 mm Hg (high-target group) or 65-70 mm Hg (low-target group). The primary endpoint was mortality at day 28. The authors used Cox regression models to calculate between-group differences in mortality at 28 days and 90 days, and analyzed Schoenfeld residuals to test the assumption of proportional hazards and used the Kaplan–Meier method to calculate survival curves.
At 28 days, there was no significant between-group difference in mortality, with deaths reported in 142 of 388 patients in the high-target group (36.6%) and 132 of 388 patients in the low-target group (34.0%) (hazard ratio [HR] in the high-target group, 1.07; 95% confidence interval [CI], 0.84-1.38; p = 0.57). There was also no significant difference in mortality at 90 days, with 170 deaths (43.8%) and 164 deaths (42.3%), respectively (HR, 1.04; 95% CI, 0.83-1.30; p = 0.74). The occurrence of serious adverse events did not differ significantly between the two groups (74 events [19.1%] and 69 events [17.8%], respectively; p = 0.64). However, the incidence of newly diagnosed atrial fibrillation was higher in the high-target group than in the low-target group. Among patients with chronic hypertension, those in the high-target group required less renal-replacement therapy than did those in the low-target group, but such therapy was not associated with a difference in mortality.
The authors concluded that targeting a mean arterial pressure of 80-85 mm Hg, as compared with 65-70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days.
This analysis suggests that among patients with septic shock, 28-day and 90-day mortality did not differ significantly between those who were treated to reach a target mean arterial pressure of 80-85 mm Hg and those who were treated to reach a target of 65-70 mm Hg. The results support the guidelines of the Surviving Sepsis Campaign, which recommend targeting a mean arterial pressure of at least 65 mm Hg. The results in the subgroup with chronic hypertension may indicate that targeting a higher mean arterial pressure is acceptable because it was not associated with greater harms, but needs additional prospective studies.
Keywords: Shock, Septic, Resuscitation, Arterial Pressure, Atrial Fibrillation, Hypertension
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