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Rajkumar KP, Hicks MH, Marchant B, Khanna AK. Blood Pressure Goals in Critically Ill Patients. Methodist Debakey Cardiovasc J 2023; 19:24-37. [PMID: 37547901 PMCID: PMC10402811 DOI: 10.14797/mdcvj.1260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/08/2023] [Indexed: 08/08/2023] Open
Abstract
Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.
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Affiliation(s)
- Karuna Puttur Rajkumar
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Megan Henley Hicks
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Bryan Marchant
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Ashish K. Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
- Outcomes Research Consortium, Cleveland, Ohio, US
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Sáez de la Fuente I, Sáez de la Fuente J, Martín Badia I, Chacón Alves S, Molina Collado Z, Sánchez-Bayton Griffith M, Lesmes González de Aledo A, González Fernandez M, Gutiérrez Gutiérrez J, Sánchez Izquierdo Riera JÁ. Postoperative Blood Pressure Deficit and Acute Kidney Injury After Liver Transplant. EXP CLIN TRANSPLANT 2022; 20:992-999. [PMID: 36524885 DOI: 10.6002/ect.2022.0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Acute kidney injury is a common cause of morbidity in liver transplant recipients. In critically ill patients who received an orthotopic liver transplant, we examined whether those with acute kidney injury had a greater deficit between pretransplant and posttransplant hemodynamic pressure-related parameters compared with those without acute kidney injury in the early postoperative period. MATERIALS AND METHODS We included patients who underwent an orthotopic liver transplant during the study period. We obtained premorbid and intensive care unit time-weighted average values for hemodynamic pressure-related parameters (systolic, diastolic, and mean arterial pressure; central venous pressure; mean perfusion pressure; and diastolic perfusion pressure) and calculated deficits in those values. We defined acute kidney injury progression as an increase of ≥1 Kidney Disease: Improving Global Outcomes stage. RESULTS We included 150 eligible transplantrecipients, with 88 (59%) having acute kidney injury progression. Acute kidney injury was associated with worse clinical outcomes. All achieved pressure-related values were similar between transplant recipients with or without acute kidney injury progression. However, those with acute kidney injury versus those without progression had greater diastolic perfusion pressure deficit at 12 hours (-8.33% vs 1.93%; P = .037) and 24 hours (-7.38% vs 5.11%; P = .002) and increased central venous pressure at 24 hours (46.13% vs 15%; P = .043) and 48 hours (40% vs 20.87%; P = .039). CONCLUSIONS Patients with acute kidney injury progression had a greater diastolic perfusion pressure deficit and increased central venous pressure compared with patients without progression. Such deficits might be modifiable risk factors for the prevention of acute kidney injury progression.
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Peros T, Ricciardi F, Booth J, Ray S, Peters MJ. Evaluation of blood pressure trajectories and outcome in critically ill children with initial hypertension on admission to Paediatric Intensive Care. Anaesth Crit Care Pain Med 2022; 41:101149. [PMID: 36075563 DOI: 10.1016/j.accpm.2022.101149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/07/2022] [Accepted: 08/15/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Hypertension on paediatric intensive care (PICU) is associated with adverse outcomes. Management is complex; hypertension often represents a physiological adaptive response and exposure to hypertension could lead to altered pressure-flow autoregulation. International treatment consensus is to avoid rapid blood pressure (BP) reduction. Our aim was to examine if the rate and magnitude of BP reduction in hypertensive patients was correlated with harm. PATIENTS AND METHODS We performed a single centre, retrospective, observational study in a quaternary PICU analysing the first 24 h post admission high resolution BP profiles of children with admission BP above the 95th centile. Individual BP profiles were analysed regarding both time spent and magnitude below a threshold; 75% of the admission BP in the first 24 h. Outcomes were organ support-free days at day 28, change in serum creatinine and PICU mortality. MAIN FINDINGS Of 3069 admissions in a 36-month period (2016-2018), 21.7% had initial hypertension on admission to PICU. A total of 3,259,111 BP measurements (99.4% invasive) were available. Pre-existing hypertension was documented in 4.9% of patients. Both time spent and magnitude below threshold BP was poorly correlated with duration of required organ support and risk of death after adjusting for PIM score, pre-existing hypertension and raised intracranial pressure. We did find an association with a rise in serum creatinine on both uni- and multivariable analysis. CONCLUSIONS The risk of harm due to early and significant reduction of raised blood pressure in critically ill children appears to be limited.
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Affiliation(s)
- Thomas Peros
- Great Ormond Street Hospital - Paediatric Intensive Care Unit, London, United Kingdom; Amsterdam University Medical Centre - Paediatric Intensive Care Unit, Amsterdam, the Netherlands.
| | - Federico Ricciardi
- University College London - Department of Statistical Science, London, United Kingdom
| | - John Booth
- Great Ormond Street Hospital - Digital Research Informatics and Virtual Environments Unit, London, United Kingdom
| | - Samiran Ray
- Great Ormond Street Hospital - Paediatric Intensive Care Unit, London, United Kingdom; UCL Great Ormond Street Institute of Child Health - Infection, Immunity and Inflammation Research & Teaching Department, London, United Kingdom
| | - Mark J Peters
- Great Ormond Street Hospital - Paediatric Intensive Care Unit, London, United Kingdom; UCL Great Ormond Street Institute of Child Health - Infection, Immunity and Inflammation Research & Teaching Department, London, United Kingdom
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Panwar R, Van Haren F, Cazzola F, Nourse M, Brinkerhoff G, Quail A. Standard care versus individualized blood pressure targets among critically ill patients with shock: A multicenter feasibility and preliminary efficacy study. J Crit Care 2022; 70:154052. [PMID: 35525132 DOI: 10.1016/j.jcrc.2022.154052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/16/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Emerging evidence suggests that minimizing mean perfusion pressure (MPP) deficit during vasopressor therapy for shock can potentially reduce adverse kidney-related outcomes in ICU. We assessed feasibility and preliminary efficacy of individualizing MPP targets based on patients' own pre-illness basal-MPP among vasopressor-treated patients with shock. MATERIAL AND METHODS In this prospective before-and-after trial, 31 patients during the 'before'/observational phase and 31 patients during the 'after'/intervention phase were enrolled at two tertiary-level Australian ICUs. Feasibility endpoint was time-weighted average MPP-deficit during vasopressor therapy. Preliminary efficacy outcomes were new significant AKI, major adverse kidney events within 14 days (MAKE-14), and 90-day mortality. RESULTS Patients in the after group had lower MPP-deficit (median 18%, [interquartile range [IQR]: 11-23] vs. 4%, [IQR: 2-9], p < 0.001) and lower incidence of new significant AKI (8/31 [26%] vs. 1/31 [3%], p = 0.01) than the before group. The between-group differences in MAKE-14 (9/31 [29%] vs. 4/31 [13%], p = 0.12) and 90-day mortality (6/31 [19%] vs. 2/31 [6%], p = 0.13) were not statistically significant. CONCLUSIONS An individualized blood pressure target strategy during vasopressor therapy in ICU was feasible and appeared to be efficacious in this preliminary study. Testing this strategy in a larger randomized controlled trial is warranted. STUDY REGISTRATION ACTRN12617001459314.
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Affiliation(s)
- Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia; School of Medicine and Public Health, University of Newcastle, Australia.
| | - Frank Van Haren
- Intensive Care Unit, St George Hospital, Sydney, Australia; University of New South Wales Medicine and Health, Sydney, Australia; Australian National University, College of Health and Medicine, Canberra, Australia
| | | | - Mary Nourse
- Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | | | - Anthony Quail
- School of Medicine and Public Health, University of Newcastle, Australia
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The impact of relative hypotension on acute kidney injury progression after cardiac surgery: a multicenter retrospective cohort study. Ann Intensive Care 2021; 11:178. [PMID: 34928430 PMCID: PMC8686086 DOI: 10.1186/s13613-021-00969-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/10/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cardiac surgery is performed worldwide, and acute kidney injury (AKI) following cardiac surgery is a risk factor for mortality. However, the optimal blood pressure target to prevent AKI after cardiac surgery remains unclear. We aimed to investigate whether relative hypotension and other hemodynamic parameters after cardiac surgery are associated with subsequent AKI progression. METHODS We retrospectively enrolled adult patients admitted to 14 intensive care units after elective cardiac surgery between January and December 2018. We defined mean perfusion pressure (MPP) as the difference between mean arterial pressure (MAP) and central venous pressure (CVP). The main exposure variables were time-weighted-average MPP-deficit (i.e., the percentage difference between preoperative and postoperative MPP) and time spent with MPP-deficit > 20% within the first 24 h. We defined other pressure-related hemodynamic parameters during the initial 24 h as exploratory exposure variables. The primary outcome was AKI progression, defined as one or more AKI stages using Kidney Disease: Improving Global Outcomes' creatinine and urine output criteria between 24 and 72 h. We used multivariable logistic regression analyses to assess the association between the exposure variables and AKI progression. RESULTS Among the 746 patients enrolled, the median time-weighted-average MPP-deficit was 20% [interquartile range (IQR): 10-27%], and the median duration with MPP-deficit > 20% was 12 h (IQR: 3-20 h). One-hundred-and-twenty patients (16.1%) experienced AKI progression. In the multivariable analyses, time-weighted-average MPP-deficit or time spent with MPP-deficit > 20% was not associated with AKI progression [odds ratio (OR): 1.01, 95% confidence interval (95% CI): 0.99-1.03]. Likewise, time spent with MPP-deficit > 20% was not associated with AKI progression (OR: 1.01, 95% CI 0.99-1.04). Among exploratory exposure variables, time-weighted-average CVP, time-weighted-average MPP, and time spent with MPP < 60 mmHg were associated with AKI progression (OR: 1.12, 95% CI 1.05-1.20; OR: 0.97, 95% CI 0.94-0.99; OR: 1.03, 95% CI 1.00-1.06, respectively). CONCLUSIONS Although higher CVP and lower MPP were associated with AKI progression, relative hypotension was not associated with AKI progression in patients after cardiac surgery. However, these findings were based on exploratory investigation, and further studies for validating them are required. Trial Registration UMIN-CTR, https://www.umin.ac.jp/ctr/index-j.htm , UMIN000037074.
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Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2020. Am J Emerg Med 2021; 50:683-692. [PMID: 34879487 PMCID: PMC8485063 DOI: 10.1016/j.ajem.2021.09.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Given the dramatic increase in critically ill patients who present to the emergency department for care, along with the persistence of boarding of critically ill patients, it is imperative for the emergency physician to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2020 that pertain to the resuscitation and care of select critically ill patients. These articles have been selected based on the authors annual review of key critical care, emergency medicine and medicine journals and their opinion of the importance of study findings as it pertains to the care of critically ill ED patients. Several key findings from the studies discussed in this paper include the administration of dexamethasone to patients with COVID-19 infection who require mechanical ventilation or supplemental oxygen, the use of lower levels of positive end-expiratory pressure for patients without acute respiratory distress syndrome, and early initiation of extracorporeal membrane oxygenation for out-of-hospital cardiac arrest patients with refractory ventricular fibrillation if resources are available. Furthermore, the emergency physician should not administer tranexamic acid to patients with acute gastrointestinal bleeding or administer the combination of vitamin C, thiamine, and hydrocortisone for patients with septic shock. Finally, the emergency physician should titrate vasopressor medications to more closely match a patient's chronic perfusion pressure rather than target a mean arterial blood pressure of 65 mmHg for all critically ill patients.
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Affiliation(s)
- Michael E Winters
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Kami Hu
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph P Martinez
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Haney Mallemat
- Departments of Critical Care Medicine and Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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Panwar R, Tarvade S, Lanyon N, Saxena M, Bush D, Hardie M, Attia J, Bellomo R, Van Haren F. Relative Hypotension and Adverse Kidney-related Outcomes among Critically Ill Patients with Shock. A Multicenter, Prospective Cohort Study. Am J Respir Crit Care Med 2020; 202:1407-1418. [PMID: 32614244 DOI: 10.1164/rccm.201912-2316oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rationale: There are no prospective observational studies exploring the relationship between relative hypotension and adverse kidney-related outcomes among critically ill patients with shock.Objectives: To investigate the magnitude of relative hypotension during vasopressor support among critically ill patients with shock and to determine whether such relative hypotension is associated with new significant acute kidney injury (AKI) or major adverse kidney events (MAKE) within 14 days of vasopressor initiation.Methods: At seven multidisciplinary ICUs, 302 patients, aged ≥40 years and requiring ≥4 hours of vasopressor support for nonhemorrhagic shock, were prospectively enrolled. We assessed the time-weighted average of the mean perfusion pressure (MPP) deficit (i.e., the percentage difference between patients' preillness basal MPP and achieved MPP) during vasopressor support and the percentage of time points with an MPP deficit > 20% as key exposure variables. New significant AKI was defined as an AKI-stage increase of two or more (Kidney Disease: Improving Global Outcome creatinine-based criteria).Measurements and Main Results: The median MPP deficit was 19% (interquartile range, 13-25), and 54% (interquartile range, 19-82) of time points were spent with an MPP deficit > 20%. Seventy-three (24%) patients developed new significant AKI; 86 (29%) patients developed MAKE. For every percentage increase in the time-weighted average MPP deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 5.6% (95% confidence interval, 2.2-9.1; P = 0.001) and 5.9% (95% confidence interval, 2.2-9.8; P = 0.002), respectively. Likewise, for every one-unit increase in the percentage of time points with an MPP deficit > 20%, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 1.2% (0.3-2.2; P = 0.008) and 1.4% (0.4-2.4; P = 0.004), respectively.Conclusions: Vasopressor-treated patients with shock are often exposed to a significant degree and duration of relative hypotension, which is associated with new-onset, adverse kidney-related outcomes.Study registered with Australian New Zealand Clinical Trial Registry (ACTRN 12613001368729).
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Affiliation(s)
- Rakshit Panwar
- ICU, John Hunter Hospital, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Sanjay Tarvade
- Intensive Care Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nicholas Lanyon
- Department of Anaesthesia, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom
| | - Manoj Saxena
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Dustin Bush
- ICU, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Miranda Hardie
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Frank Van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, Australia.,Medical School, Australian National University, Canberra, Australia; and.,Faculty of Health, University of Canberra, Canberra, Australia
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What's New in Shock, May 2018? Shock 2018; 49:483-485. [PMID: 29652787 DOI: 10.1097/shk.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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