High versus low mean arterial pressure targets do not produce significant differences in mortality among critically ill patients (RR 1.06; 95% CI 0.98-1.15; p=0.12).
Does a high target mean arterial pressure reduce mortality in critically ill adult patients with shock compared to a low target?
Current evidence suggests no overall mortality benefit for high versus low MAP targets in critically ill patients with shock, though higher targets may reduce the need for renal replacement therapy in those with chronic hypertension.
Relative Risk: 1.06 (95% CI 0.98–1.15)
p-value: p=0.12
Adult critical illness is one of the conditions that generates the substantial burden of disease and is expensive globally.Sepsis, acute lung injury, and mechanical ventilation are the most representative conditions in this specialty 1 .The barriers and deficiencies of health systems in low-and middle-income countries make the approach to this type of disease even more complex, forcing the reproduction of the best evidence-based decision-making with the least use of resources 1 .This contemplates the ongoing discussion of emerging evidence and the evolution of traditionally used clinical concepts that are essential in the pathophysiology and health care of critically ill patients.Systemic mean arterial pressure (MAP) is a hemodynamic parameter that reflects the perfusion pressure of vital organs.In critically ill patients with resolution therapy, supportive care is essential to ensure survival, reduce morbidity, and reduce the risk of sequelae 2,3 .There has been much discussion on the MAP value that is most appropriate to maintain in critically ill patients 2,3 .However, the scientific evidence shows that this may vary depending on the baseline characteristics of the patients, the disease being treated, and the goal the intensivist wants to achieve.Some guidelines differ between these values, recommending values ranging from 65-70 mmHg to 80-85 mmHg but relying mainly on 30-or 90-day mortality outcome 2-4 .Then, is there a difference between high and low target?What does the evidence say about it?Recently, Carayannopoulos et al. 4 conducted a meta-analysis of randomized controlled trials, including six trials with a total of 3,690 patients, in order to assess whether the target of higher vs. lower MAP in adults with shock produces significant differences in outcomes in critically ill patients.The authors found that high vs. low target MAP does not produce significant differences in mortality outcome (RR: 1.06; 95%CI: 0.98-1.15,I2=0%, p=0.12), nor in renal replacement therapy (RR: 0.96; 95%CI: 0.83-1.11,I2=24%, p=0.57).However, it was evident that a high target MAP in patients with a history of arterial hypertension may reduce the risk of renal replacement therapy (RR: 0.83; 95%CI: 0.71-0.98,I2=0%, p=0.02) compared to those without arterial hypertension (RR: 0.83; 95%CI: 0.71-0.98,I2=0%, p=0.02).Thus, the authors concluded that there is no difference between the MAP targets in terms of mortality, but a higher MAP can be considered in patients with arterial hypertension 4 .Another similar meta-analysis 5 , which evaluated additional outcomes in 3,753 patients with the same conditions, showed that there was no significant difference between MAP targets and duration of mechanical ventilation (SMD: 0.51; 95%CI: -0.29 to 1.31, p=0.21), or length of stay in intensive care (SMD: 0.22; 95%CI: -0.07 to 0.5, p=0.14).However, there was a statistically significant difference in the reduction of ICU length of stay in post-cardiac arrest patients with high MAP targets (SMD: 0.55; 95%CI: 0.31-0.80,p<0.000001) 5 .Other recent studies useful in understanding the impact of MAP variation on outcomes in critically ill patients include those by How et al. 6 and Yoshimoto et al. 7 In the first one, the authors explored the relationship between MAP variability and short-and medium-term mortality in a cohort study.They included a total of 12,867 patients (1,320 died in-hospital, 1,399 died within the first 28 days, and 2,734 died within 1 year), finding that the average real variability of MAP ≥7. 2 mmHg was associated with higher in-hospital (OR: 1.44; 95%CI: 1.21-1.72),28-day (HR: 1.28; 95%CI: 1.1-1.5),and 1-year mortality (HR: 1.27; 95%CI: 1.14-1.42) 6.This association was maintained independently of the sequential organ failure assessment (SOFA) score.In the Yoshimoto et al.'s 7 study, in which three randomized controlled trials on 3,357 patients with vasodilator shock were meta-analyzed and the optimal
Palacios et al. (Sun,) conducted a review in Critically ill patients. High mean arterial pressure target vs. Low mean arterial pressure target was evaluated on Mortality (RR 1.06, 95% CI 0.98-1.15, p=0.12). High versus low mean arterial pressure targets do not produce significant differences in mortality among critically ill patients (RR 1.06; 95% CI 0.98-1.15; p=0.12).
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