Title: Lower MAP goal in Older Patients with Vasodilatory Hypotension<br/>Author: Caleb Chan<br/><a href='http://umem.org/profiles/resident/1583/'>[Click to email author]</a><hr/><p>
<strong>Clinical Question:</strong> Does a lower MAP target (60-65 mmHg) for ICU patients ≥ 65 years-old reduce 90-day mortality?</p>
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<strong>Methodology:</strong></p>
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-<u>Design</u>: multicenter (across 65 UK ICUs), randomized clinical trial (not blinded), ultimately with 2598 patients</p>
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<u>-Inclusion criteria</u>: ICU patients ≥ 65 years-old receiving vasopressors for vasodilatory hypotension with adequate fluid resuscitation</p>
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<u>-Exclusion criteria</u>: vasopressors being solely used for bleeding or acute RV/LV failure or post-cardiopulmonary bypass vasoplegia, ongoing treatment for brain/spinal cord injury, death perceived as imminent</p>
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-<u>Intervention</u>:</p>
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Permissive hypotension group – MAP target of 60-65 mmHg</li>
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Usual care group – received vasopressors at discretion of treating clinician</li>
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Choice of vasopressor (norepi, vaso, terlipressin, phenylephrine, epi, dopamine, and metaraminol) left to discretion of treating clinician</li>
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<strong>Results:</strong></p>
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-Patients in the permissive hypotension group had a lower exposure to vasopressors compared with those in the usual care group</p>
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median duration 33 hours compared with 38 hours (difference, –5.0; 95% CI, –7.8 to –2.2)</li>
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mean duration, 46.0 hours compared with 55.9 hours (mean difference, –9.9 hours; 95% CI, –14.3 to –5.5)</li>
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-Mean MAP was on average 6 mmHg lower in permissive hypotension group</p>
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-At 90 days, there was no statistically significant difference in all-cause mortality</p>
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500 deaths (41.0%) among of 1221 patients in the permissive hypotension group compared with 544 (43.8%) among 1242 patients in the usual care group (absolute risk difference, −2.85%, 95% CI, −6.75 to 1.05; <em>P </em>= .15)</li>
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-No significant difference in mean duration of ICU and hospital stay, duration and days alive and free from advanced respiratory and renal support to day 28</p>
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-No significant different in number of serious adverse events (severe acute renal failure, supraventricular and ventricular cardiac arrhythmia, myocardial injury, mesenteric ischemia, and cardiac arrest)</p>
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<strong>Bottom line:</strong></p>
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A lower MAP goal of 60-65 mm Hg appears to be safe for ICU patients ≥ 65 years-old being treated for vasodilatory hypotension</p>
<fieldset><legend>References</legend>
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Lamontagne F, Richards-belle A, Thomas K, et al. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA. 2020;</p>
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