Abstract
Objective
To evaluate the association between arterial blood pressure (ABP) during the first 24 h and mortality in sepsis.
Design
Retrospective cohort study.
Setting
Multidisciplinary intensive care unit (ICU).
Patients and participants
A total of 274 septic patients.
Interventions
None.
Measurements and results
Hemodynamic, and laboratory parameters were extracted from a PDMS database. The hourly time integral of ABP drops below clinically relevant systolic arterial pressure (SAP), mean arterial pressure (MAP), and mean perfusion pressure (MPP = MAP − central venous pressure) levels was calculated for the first 24 h after ICU admission and compared with 28-day-mortality. Binary and linear regression models (adjusted for SAPS II as a measure of disease severity), and a receiver operating characteristic (ROC) analysis were applied. The areas under the ROC curve were largest for the hourly time integrals of ABP drops below MAP 60 mmHg (0.779 vs. 0.764 for ABP drops below MAP 55 mmHg; P ≤ 0.01) and MPP 45 mmHg. No association between the hourly time integrals of ABP drops below certain SAP levels and mortality was detected. One or more episodes of MAP < 60 mmHg increased the risk of death by 2.96 (CI 95%, 1.06–10.36, P = 0.04). The area under the ROC curve to predict the need for renal replacement therapy was highest for the hourly time integral of ABP drops below MAP 75 mmHg.
Conclusions
A MAP level ≥ 60 mmHg may be as safe as higher MAP levels during the first 24 h of ICU therapy in septic patients. A higher MAP may be required to maintain kidney function.
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References
Mayr VD, Dünser MW, Greil V, Jochberger S, Luckner G, Ulmer H, Friesenecker BE, Takala J, Hasibeder WR (2006) Causes of death and determinants of outcome in critically ill patients. Crit Care 10:R154
Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 34:1589–1596
Bernardin G, Pradier C, Tiger F, Deloffre P, Mattei M (1996) Blood pressure and arterial lactate level are early indicators of short-term survival in human septic shock. Intensive Care Med 22:17–25
Martin C, Viviand X, Leone M, Thirion X (2000) Effect of norepinephrine on the outcome of septic shock. Crit Care Med 28:2758–2765
Dünser MW, Mayr AJ, Ulmer H, Knotzer H, Sumann G, Pajk W, Friesenecker B, Hasibeder WR (2003) Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation 107:2313–2319
Dellinger RP (2003) Cardiovascular management of septic shock. Crit Care Med 31:946–955
Annane D, Bellissant E, Cavaillon JM (2005) Septic shock. Lancet 365:63–78
Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM, Surviving Sepsis Campaign Management Guidelines Committee (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873
Meier-Hellmann A, Reinhart K, Bredle DL, Specht M, Spies CD, Hannemann L (1997) Epinephrine impairs splanchnic perfusion in septic shock. Crit Care Med 25:399–404
Lopez A, Lorente JA, Steingrub J, Bakker J, McLuckie A, Willatts S, Brockway M, Anzueto A, Holzapfel L, Breen D, Silverman MS, Takala J, Donaldson J, Arneson C, Grove G, Grossman S, Grover R (2004) Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med 32:21–30
LeDoux D, Astiz ME, Carpati CM, Rackow EC (2000) Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med 28:2729–2732
Bourgoin A, Leone M, Delmas A, Garnier F, Albanese J, Martin C (2005) Increasing mean arterial pressure in patients with septic shock: effects on oxygen variables and renal function. Crit Care Med 33:780–786
Varpula M, Tallgren M, Saukkonen K, Voipio-Pulkki LM, Pettilä V (2005) Hemodynamic variables related to outcome in septic shock. Intensive Care Med 31:1066–1071
Dünser MW, Daudel F, Luckner G, Mayr V, Jochberger S, Hasibeder WR, Takala J, Jakob S (2007) Arterial blood pressure during early sepsis. Intensive Care Med 33(Suppl 2):A125
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31:1250–1256
Makivirta A, Koski E, Kari A, Sukuvaara T (1991) The median filter as a preprocessor for a patient monitor limit alarm system in intensive care. Comput Methods Programs Biomed 34:139–144
Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963
Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE (1981) APACHE—acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 9:591–597
Jakob SM, Korhonen I, Ruokonen E, Virtanen T, Kogan A, Takala J (2000) Detection of artifacts in monitored trends in intensive care. Comput Methods Programs Biomed 63:203–209
Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the european society of intensive care medicine. Intensive Care Med 22:707–710
DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating curves: a nonparametric approach. Biometrics 44:837–845
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M, Early Goal-Directed Therapy Collaborative Group (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377
Jones AE, Yiannibas V, Johnson C, Kline JA (2006) Emergency department hypotension predicts sudden unexpected in-hospital mortality. A prospective cohort study. Chest 130:941–946
Beale RJ, Hollenberg SM, Vincent JL, Parrillo JE (2004) Vasopressor and inotropic support in septic shock: an evidence-based review. Crit Care Med 32:S455–465
Guyton AC, Hall JE (2000) Urine formation by the kidneys: I. Glomerular filtration, renal blood flow, and their control. In: Guyton AC, Hall JE (eds) Textbook of medical physiology. Saunders, Philadelphia, pp 279–294
Levy B, Gibot S, Franck P, Cravoisy A, Bollaert PE (2005) Relation between muscle Na + K + ATPase activity and raised lactate concentrations in septic shock: a prospective study. Lancet 365:871–875
Rowell LB (1986) Control of individual vascular beds: splanchnic and renal circulations. In: Rowell LB (ed) Human circulation. Regulation during physical stress. Oxford University Press, Oxford, pp 78–95
Bellomo R, Kellum JA, Wisniewski SR, Pinsky MR (1999) Effects of norepinephrine on the renal vasculature in normal and endotoxemic dogs. Am J Respir Crit Care Med 159:1186–1192
Deruddre S, Cheisson G, Mazoit JX, Vicaut E, Benhamou D, Duranteau J (2007) Renal arterial resistance in septic shock: effects of increasing mean arterial pressure with norepinephrine on the renal resistive index with Doppler ultrasonography. Intensive Care Med 33:1557–1562
Acknowledgments
The authors are indebted to Mrs. Pia Burri and Mr. Roy Lanz for their invaluable assistance in extracting the study variables from the database.
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Dünser, M.W., Takala, J., Ulmer, H. et al. Arterial blood pressure during early sepsis and outcome. Intensive Care Med 35, 1225–1233 (2009). https://doi.org/10.1007/s00134-009-1427-2
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DOI: https://doi.org/10.1007/s00134-009-1427-2