Acute Blood Pressure Management in Neurocritically Ill Patients

The safety and efficacy of clevidipine for blood pressure management in neurocritical patients: a systematic review and meta-analysis

We aim to determine the safety and efficacy of clevidipine for neurocritical patients. To comprehensively identify relevant studies, a systematic search strategy was employed using the following keywords: "clevidipine", "high blood pressure", "hypertension", "Neuroscience Intensive Care", "neuro critical", and "neurosurgical patients". Searches were conducted in the Clinicaltrials.gov, PubMed, and EuroPMC databases, with the search extending until September 1, 2023. The primary outcomes of interest were the time needed to achieve the target systolic blood pressure (SBP) and the percentage of time a patient remained within the targeted SBP range. Secondary outcomes included SBP values, duration of intensive care unit (ICU) stay in days, rates of hypotension, and rates of tachycardia. We included five retrospective cohort studies (n = 443), utilizing nicardipine as the primary comparator. Comparison of the time to reach target systolic blood pressure (SBP) revealed no significant difference between medications (SMD = - 1.09, p = 0.33). Likewise, the achieved SBP target showed no notable distinction (RR = 1.15, p = 0.81). However, clevidipine exhibited a slightly higher percentage of time within the target SBP range (SMD = 0.33, p = 0.04), albeit with moderate heterogeneity. Importantly, all included studies were retrospective cohort studies, underscoring the methodological context of the investigation. Clevidipine and the control group were found to be comparable in terms of achieving target SBP. Clevidipine may have a slight advantage in maintaining blood pressure within the desired range, but further research is needed to confirm this finding.

The association between blood pressure at admission and in-hospital mortality in patients with subarachnoid hemorrhage

PURPOSE

The objective of this study was to examine the association between mean arterial pressure (MAP) at admission and in-hospital mortality among patients diagnosed with subarachnoid hemorrhage (SAH).

METHODS

In this cohort study, 1420 SAH patients were categorized into four groups based on quartiles of MAP: <82 mmHg group, 82-93 mmHg group, 93-103 mmHg group, and >103 mmHg group. Furthermore, the X-tile program was used to divide all patients into four groups: < 81.7 mmHg group, 81.7-92.3 mmHg group, 92.3-103.7 mmHg group, and > 103.7 mmHg group. The association between MAP and in-hospital mortality of SAH patients was evaluated using univariate and multivariable Cox proportional hazards models. A restricted cubic spline (RCS) was plotted to explore the association between MAP at admission and in-hospital mortality in patients with SAH.

RESULTS

The median follow-up duration was 7.87 days, during which, 1219 (85.85%) patients survived. After adjusting for confounding factors, MAP <82 mmHg (hazard ratio (HR)=1.67, 95% confidence interval (CI): 1.08-2.57) or MAP >103 mmHg (HR=2.13, 95% CI: 1.38-3.29) was associated with increased risk of in-hospital mortality of SAH patients. Subgroup analysis depicted that MAP <82 mmHg or MAP >103 mmHg was associated with increased risk of in-hospital mortality in male patients or those aged ≥ 65 years. MAP >103 mmHg was linked with elevated risk of in-hospital mortality in patients aged <65 years; individuals with normal and underweight, overweight, and obesity; or people with hypertension.

CONCLUSION

The findings may offer a preliminary estimate of the optimum range for SAH patients for future randomized trials.

Blood Pressure Control in Acute Stroke: Labetalol or Nicardipine?

PURPOSE

To assess the safety and efficacy of continuous infusion (CIV)-labetalol compared to -nicardipine in controlling blood pressure (BP) in the acute stroke setting.

MATERIALS

Patients were eligible if they had a diagnosis of an acute stroke and were administered either CIV-labetalol or CIV-nicardipine. Study outcomes were assessed within the first 24 h of the antihypertensive infusion.

RESULTS

A total of 3,093 patients were included with 3,008 patients in the CIV-nicardipine group and 85 in the CIV-labetalol group. No significant difference was observed in percent time at goal BP between the nicardipine (82%) and labetalol (85%) groups (p = 0.351). There was also no difference in BP variability between nicardipine (37%) and labetalol (39%) groups (p = 0.433). Labetalol was found to have a shorter time to goal BP as compared to nicardipine (24 min vs. 40 min; p = 0.021). While CIV-nicardipine did have a higher incidence of tachycardia compared to labetalol (17% vs. 4%; p <0.001), the incidence of hypotension (13% vs. 15%; p = 0.620) and bradycardia (24% vs. 22%; p = 0.797) were similar.

CONCLUSIONS

These results indicate that CIV-labetalol and CIV-nicardipine are comparable in safety and efficacy in controlling BP for patients with acute stroke.