Should we target blood pressure in sepsis?

Abstract

Objective: To review blood pressure targets and their implementation in sepsis.

Design: Review of the hemodynamic intervention trials in sepsis.

Main results and conclusions: Explicit blood pressure targets have been recommended for septic patients. The Surviving Sepsis Guidelines recommend vasopressors to achieve and maintain a mean arterial blood pressure of at least 65 mm Hg in patients not responding to initial fluid resuscitation. Patients remaining hypotensive despite efforts to increase blood pressure have up to twice as high mortality as those whose hypotension can be corrected with fluids and vasopressors. The actual blood pressure targets and their implementation are the main determinants of the patient's exposure to vasopressors. Several randomized controlled trials on hemodynamic interventions in septic shock show that patients continue to receive vasopressors despite the fact that blood pressure targets have been exceeded, and thus vasopressors should be reduced. Accordingly, patients are likely to be exposed to higher amounts of vasopressors and over longer periods of time than would be necessary if the predefined targets would be strictly implemented. Post hoc analyses suggest that in patients without refractory hypotension, the cumulative vasopressor load is independently associated with mortality. Accordingly, reduction of exposure to vasopressors has the potential of improving outcomes. This can be achieved by adhering to the lower currently proposed blood pressure limits. In addition, the lowest tolerable blood pressure levels should be reevaluated.