UMEM Educational Pearls

Title: How low should you go? MAP Goals in Septic Shock

Category: Critical Care

Keywords: map, sepsis, septic shock, hypertension (PubMed Search)

Posted: 4/7/2014 by Feras Khan, MD (Updated: 4/8/2014)
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How low should you go? MAP Goals in Septic Shock

Background:

Since Rivers’ Early-Goal Directed Therapy, a MAP of 65 mm Hg was been the standard goal for blood pressure in septic shock
Some studies have suggested a higher target may be better for patients with hypertension
Potentially less renal failure with a higher target

The Trial:

Outcome:

No significant difference in mortality at 28 days: 36.6% (high target) vs 34% (low target) (95 %CI; 0.84 to 1.38; P=0.57)
No significant difference at 90 days: 43.8% (high target) vs 42.3% (low target) (95% CI; 0.83 to 1.30; P=0.74)
Incidence of newly diagnosed atrial fibrillation was higher in the high-target group
Patients with chronic hypertension: those in the higher target group required less renal-replacement therapy
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

Bottom Line:

A MAP goal of 65 is just fine in most patients
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

Pierre Asfar, M.D., Ph.D. et al. for the SEPSISPAM Investigators

March 18, 2014DOI: 10.1056/NEJMoa1312173