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. 2018 Jun;44(6):857-867.
doi: 10.1007/s00134-018-5218-5. Epub 2018 Jun 5.

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

Kamal Maheshwari  1   2 , Brian H Nathanson  3 , Sibyl H Munson  4 , Victor Khangulov  4 , Mitali Stevens  5 , Hussain Badani  4 , Ashish K Khanna  6 , Daniel I Sessler  7
Affiliations

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

Kamal Maheshwari et al. Intensive Care Med. 2018 Jun.

Abstract

Purpose: Current guidelines recommend maintaining a mean arterial pressure (MAP) ≥ 65 mmHg in septic patients. However, the relationship between hypotension and major complications in septic patients remains unclear. We, therefore, evaluated associations of MAPs below various thresholds and in-hospital mortality, acute kidney injury (AKI), and myocardial injury.

Methods: We conducted a retrospective analysis using electronic health records from 110 US hospitals. We evaluated septic adults with intensive care unit (ICU) stays ≥ 24 h from 2010 to 2016. Patients were excluded with inadequate blood pressure recordings, poorly documented potential confounding factors, or renal or myocardial histories documented within 6 months of ICU admission. Hypotension exposure was defined by time-weighted average mean arterial pressure (TWA-MAP) and cumulative time below 55, 65, 75, and 85 mmHg thresholds. Multivariable logistic regressions determined the associations between hypotension exposure and in-hospital mortality, AKI, and myocardial injury.

Results: In total, 8,782 patients met study criteria. For every one unit increase in TWA-MAP < 65 mmHg, the odds of in-hospital mortality increased 11.4% (95% CI 7.8%, 15.1%, p < 0.001); the odds of AKI increased 7.0% (4.7, 9.5%, p < 0.001); and the odds of myocardial injury increased 4.5% (0.4, 8.7%, p = 0.03). For mortality and AKI, odds progressively increased as thresholds decreased from 85 to 55 mmHg.

Conclusions: Risks for mortality, AKI, and myocardial injury were apparent at 85 mmHg, and for mortality and AKI risk progressively worsened at lower thresholds. Maintaining MAP well above 65 mmHg may be prudent in septic ICU patients.

Keywords: Acute kidney injury; Blood pressure monitoring; Hypotension; Mortality; Myocardial injury; Sepsis.

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Conflict of interest statement

Drs. Maheshwari and Sessler work as consultants for Edwards Lifesciences. Dr. Khanna consults for La Jolla pharmaceuticals. Drs. Khangulov, Munson and Badani work as consultants for Boston Strategic Partners, Inc. who received funds from Edwards Lifesciences to perform the research. Dr. Nathanson is an employee of OptiStatim, LLC, which received consulting fees from Boston Strategic Partners, Inc.

Figures

Fig. 1
Fig. 1
Patient attrition diagram. AKI acute kidney injury
Fig. 2
Fig. 2
Association of hypotension exposure with in-hospital mortality, AKI and myocardial injury. Adjusted odds ratios and 95% confidence intervals for a 1 mmHg increase in TWA-MAP, below different thresholds are shown for the primary outcome of in-hospital mortality and secondary outcomes of acute kidney injury and myocardial injury
Fig. 3
Fig. 3
Predicted mortality outcome for time-weighted average (TWA)-MAP below 65 mmHg and cumulative hours of MAP below 65 mmHg. Predicted probability of mortality from the TWA-MAP < 65 mmHg threshold and cumulative hours of MAP < 65 mmHg are represented in panels a and b, respectively
Fig. 4
Fig. 4
Predicted marginal probability for AKI and myocardial injury for TWA-MAP below 65 mmHg threshold. AKI and myocardial injury predicted probability from the TWA-MAP below 65 mmHg threshold are shown in panels a and b, respectively. Both exposures showed a linear relationship with the secondary outcomes of AKI and myocardial injury. AKI acute kidney injury
See this image and copyright information in PMC

Comment in

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