Title: How low should you go? MAP Goals in Septic Shock<br/>Author: Feras Khan<br/><a href='http://umem.org/profiles/faculty/1145/'>[Click to email author]</a><hr/><p>
<strong>How low should you go? MAP Goals in Septic Shock</strong></p>
<p>
<strong>Background:</strong></p>
<ul>
<li>
Since Rivers’ Early-Goal Directed Therapy, a MAP of 65 mm Hg was been the standard goal for blood pressure in septic shock</li>
<li>
Some studies have suggested a higher target may be better for patients with hypertension</li>
<li>
Potentially less renal failure with a higher target</li>
</ul>
<p>
<strong>The Trial:</strong></p>
<ul>
<li>
776 adult patients in France; Multi-center; randomized; non-blinded</li>
<li>
All patients had septic shock and on vasopressors</li>
<li>
MAP was maintained for 5 days or when the patient was weaned off pressors</li>
<li>
Primary outcome: Mortality at Day 28</li>
<li>
High target <strong>65-70</strong> mm Hg vs Low target <strong>80-85</strong> mm Hg</li>
</ul>
<p>
<strong>Outcome:</strong></p>
<ul>
<li>
<em>No significant difference in mortality at 28 days</em>: 36.6% (high target) vs 34% (low target) (95 %CI; 0.84 to 1.38; P=0.57)</li>
<li>
<em>No significant difference at 90 days: </em>43.8% (high target) vs 42.3% (low target) (95% CI; 0.83 to 1.30; P=0.74)</li>
<li>
Incidence of newly diagnosed atrial fibrillation was higher in the high-target group</li>
<li>
Patients with <u>chronic hypertension:</u> those in the higher target group required less renal-replacement therapy</li>
<li>
Significant percentage of patients in the high target group did not meet goal MAP BUT the trial mirrored actual clinical practice and allowed clinicians the ability to limit blood pressure and differences in actual MAP attained in both groups was significantly different</li>
</ul>
<p>
<strong>Bottom Line:</strong></p>
<ul>
<li>
A MAP goal of 65 is just fine in most patients</li>
<li>
Patients with chronic hypertension and atherosclerosis seem to benefit (less need for renal-replacement therapies) with a higher MAP: so aim higher in these patients or monitor renal function and increase MAP goals accordingly</li>
</ul>
<p>
</p>
<fieldset><legend>References</legend>
<h1 style="margin: 0px; padding: 8px 0px; border: 0px; outline: 0px; font-weight: normal; font-size: 1.45em; vertical-align: baseline; line-height: 1.05em; background-image: none; font-family: 'times new roman';">
High versus Low Blood-Pressure Target in Patients with Septic Shock</h1>
<p class="authors" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; font-size: 0.7em; vertical-align: baseline; line-height: 1.5em; color: rgb(102, 102, 102); font-family: arial, sans-serif;">
Pierre Asfar, M.D., Ph.D. et al. for <span class="NLM_on-behalf-of" style="margin: 0px; padding: 0px; border: 0px; outline: 0px; font-weight: inherit; font-style: inherit; vertical-align: baseline;">the SEPSISPAM Investigators</span></p>
<p class="citationLine" style="margin: 0px 0px 10px; padding: 0px; border: 0px; outline: 0px; font-size: 0.7em; vertical-align: baseline; line-height: 1.5em; color: rgb(102, 102, 102); font-family: arial, sans-serif;">
March 18, 2014<span class="doi" style="margin: 0px 0px 0px 3px; padding: 0px 0px 0px 3px; border-width: 0px 0px 0px 1px; border-left-style: solid; border-left-color: rgb(153, 153, 153); outline: 0px; font-weight: inherit; font-style: inherit; vertical-align: baseline;">DOI: 10.1056/NEJMoa1312173</span></p>
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