A systematic review of vasopressor blood pressure targets in critically ill adults with hypotension

  • Mathieu Hylands
  • Morten Hylander Moller
  • Pierre Asfar
  • Augustin Toma
  • Anne Julie Frenette
  • Nicolas Beaudoin
  • Émilie Belley-Côté
  • Frédérick D’Aragon
  • Jon Henrik Laake
  • Reed Alexander Siemieniuk
  • Emmanuel Charbonney
  • François Lauzier
  • Joey Kwong
  • Bram Rochwerg
  • Per Olav Vandvik
  • Gordon Guyatt
  • François Lamontagne
Reports of Original Investigations

Abstract

Purpose

Clinicians must balance the risks from hypotension with the potential adverse effects of vasopressors. Experts have recommended a mean arterial pressure (MAP) target of at least 65 mmHg, and higher in older patients and in patients with chronic hypertension or atherosclerosis. We conducted a systematic review of randomized-controlled trials comparing higher vs lower blood pressure targets for vasopressor therapy administered to hypotensive critically ill patients.

Methods

We searched MEDLINE®, EMBASE™, and the Cochrane Central Register of Controlled Trials for studies of higher vs lower blood pressure targets for vasopressor therapy in critically ill hypotensive adult patients. Two reviewers independently assessed trial eligibility based on titles and abstracts, and they then selected full-text reports. Outcomes, subgroups, and analyses were prespecified. We used GRADE (Grading of Recommendations Assessment, Development and Evaluation) to rate the overall confidence in the estimates of intervention effects.

Results

Of 8001 citations, we retrieved 57 full-text articles and ultimately included two randomized-controlled trials (894 patients). Higher blood pressure targets were not associated with lower mortality (relative risk [RR], 1.05; 95% confidence interval [CI], 0.90 to 1.23; P = 0.54), and neither age (P = 0.17) nor chronic hypertension (P = 0.32) modified the overall effect. Nevertheless, higher blood pressure targets were associated with a greater risk of new-onset supraventricular cardiac arrhythmia (RR, 2.08; 95% CI, 1.28 to 3.38; P < 0.01).

Conclusion

Current evidence does not support a MAP target > 70 mmHg in hypotensive critically ill adult patients requiring vasopressor therapy.

Une revue systématique des cibles de tension artérielle sous vasopresseurs chez des adultes gravement malades atteints d’hypotension

Résumé

Objectif

Les cliniciens doivent équilibrer les risques liés à l’hypotension aux complications potentielles des vasopresseurs. Des experts ont recommandé de cibler une tension artérielle moyenne (TAM) d’au moins 65 mmHg, et une TAM plus élevée chez les patients atteints d’hypertension chronique, d’athérosclérose ou plus âgés. Nous avons réalisé une revue systématique des études randomisées contrôlées comparant des cibles de tension artérielle plus élevées à plus basses chez des patients hypotendus en état critique recevant un traitement vasopresseur.

Méthode

Nous avons fait des recherches dans les bases de données Medline, EMBASE et dans le registre central des études contrôlées Cochrane afin d’en extraire les études comparant des cibles de tension artérielle plus élevées ou plus basses chez des patients adultes hypotendus et en état critique recevant un traitement vasopresseur. Deux examinateurs ont évalué de façon indépendante l’éligibilité des études selon leur titre et leur résumé, puis sélectionné les articles intégraux. Les critères d’évaluation, sous-groupes et analyses étaient spécifiés au préalable. Nous avons utilisé le système GRADE (Grading of Recommendations Assessment, Development and Evaluation) afin d’évaluer la confiance globale dans les estimations des effets de l’intervention.

Résultats

Parmi les 8001 citations, nous avons extrait 57 articles intégraux et finalement inclus deux études randomisées contrôlées (894 patients). Les cibles de tension artérielle plus élevées n’étaient pas associées à une mortalité plus basse (risque relatif [RR] 1,05; intervalle de confiance [IC] 95 %, 0,90 à 1,23; P = 0,54), et ni l’âge (P = 0,17) ni l’hypertension chronique (P = 0,32) n’ont modifié l’effet global. Cependant, les cibles de tension artérielle plus élevées étaient associées à un risque plus élevé de nouvelle apparition d’une arythmie cardiaque supraventriculaire (RR, 2,08; IC 95 %, 1,28 à 3,38; P < 0,01).

Conclusion

Les données probantes actuelles n’appuient pas une cible de TAM supérieure à 70 mmHg chez les patients adultes hypotendus et gravement malades nécessitant un traitement vasopresseur.

References

  1. 1.
    Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010; 376: 1339-46.CrossRefPubMedGoogle Scholar
  2. 2.
    Lamontagne F, Cohen D, Herridge M. Understanding patient-centredness: contrasting expert versus patient perspectives on vasopressor therapy for shock. Intensive Care Med 2016. DOI:10.1007/s00134-016-4518-x.Google Scholar
  3. 3.
    Andreis DT, Singer M. Catecholamines for inflammatory shock: a Jekyll-and-Hyde conundrum. Intensive Care Med 2016; 42: 1387-97.CrossRefPubMedGoogle Scholar
  4. 4.
    Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580-637.CrossRefPubMedGoogle Scholar
  5. 5.
    Schmittinger CA, Torgersen C, Luckner G, Schroder DC, Lorenz I, Dunser MW. Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012; 38: 950-8.CrossRefPubMedGoogle Scholar
  6. 6.
    D’Aragon F, Belley-Cote EP, Meade MO, et al. Blood pressure targets for vasopressor therapy: a systematic review. Shock 2015; 43: 530-9.CrossRefPubMedGoogle Scholar
  7. 7.
    Institute of Medicine; Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011.Google Scholar
  8. 8.
    Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO. Introduction to BMJ rapid recommendations. BMJ 2016; 354: i5191.CrossRefPubMedGoogle Scholar
  9. 9.
    Moher D, Liberati A, Tetzlaff J. Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006-12.CrossRefPubMedGoogle Scholar
  10. 10.
    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-88.CrossRefPubMedGoogle Scholar
  11. 11.
    Deeks JJ. Issues in the selection of a summary statistic for meta-analysis of clinical trials with binary outcomes. Stat Med 2002; 21: 1575-600.CrossRefPubMedGoogle Scholar
  12. 12.
    ARISE Investigators; ANZICS Clinical Trials Group; Peake SL, Delaney A, Bailey M, et al. Goal-directed resuscitation for patients with early septic shock. The New England journal of medicine 2014; 371: 1496-506.CrossRefGoogle Scholar
  13. 13.
    Bassler D, Briel M, Montori VM, et al. Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysis. JAMA 2010; 303: 1180-7.CrossRefPubMedGoogle Scholar
  14. 14.
    Guyatt G, Busse J. Modification of Cochrane Tool to assess risk of bias in randomized trials. 2016. Available from URL: http://distillercer.com/resources/ (accessed March 2017).
  15. 15.
    Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-6.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Cochrane Handbook. Recommendations on testing for funnel plot asymmetry. Available from URL: http://handbook.cochrane.org/chapter_10/10_4_3_1_recommendations_on_testing_for_funnel_plot_asymmetry.htm (accessed March 2017).
  17. 17.
    Guyatt GH, Oxman AD, Vist G, et al. GRADE guidelines: 4. Rating the quality of evidence–study limitations (risk of bias). J Clin Epidemiol 2011; 64: 407-15.CrossRefPubMedGoogle Scholar
  18. 18.
    Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines 6. Rating the quality of evidence–imprecision. J Clin Epidemiol 2011; 64: 1283-93.CrossRefPubMedGoogle Scholar
  19. 19.
    Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 7. Rating the quality of evidence–inconsistency. J Clin Epidemiol 2011; 64: 1294-302.CrossRefPubMedGoogle Scholar
  20. 20.
    Guyatt GH, Oxman AD, Kunz R, et al. GRADE guidelines: 8. Rating the quality of evidence–indirectness. J Clin Epidemiol 2011; 64: 1303-10.CrossRefPubMedGoogle Scholar
  21. 21.
    Guyatt GH, Oxman AD, Montori V, et al. GRADE guidelines: 5. Rating the quality of evidence–publication bias. J Clin Epidemiol 2011; 64: 1277-82.CrossRefPubMedGoogle Scholar
  22. 22.
    Brok J, Thorlund K, Gluud C, Wetterslev J. Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses. J Clin Epidemiol 2008; 61: 763-9.CrossRefPubMedGoogle Scholar
  23. 23.
    Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014; 370: 1583-93.CrossRefPubMedGoogle Scholar
  24. 24.
    Lamontagne F, Meade MO, Hebert PC, et al. Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Med 2016; 42: 542-50.CrossRefPubMedGoogle Scholar
  25. 25.
    Alonso-Coello P, Oxman AD, Moberg J, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ 2016; 353: i2089.CrossRefPubMedGoogle Scholar
  26. 26.
    Rochwerg B, Hylands M, Moller M, et al. CCCS-SSAI WikiRecs Clinical Practice Guideline: vasopressor blood pressure targets in critically ill adults with hypotension. Can J Anesth 2017; 64: this issue. DOI: 10.1007/s12630-017-0878-0
  27. 27.
    Rochwerg B, Hylands M, Moller M, et al. CCCS-SSAI WikiRecs Clinical Practice Guideline: vasopressors in early traumatic shock. Can J Anesth 2017; 64: this issue. DOI: 10.1007/s12630-017-0879-z
  28. 28.
    Russell JA, Walley KR, Singer J, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 2008; 358: 877-87.CrossRefPubMedGoogle Scholar
  29. 29.
    Lamontagne F, Cook DJ, Meade MO, et al. Vasopressor use for severe hypotension-a multicentre prospective observational study. PloS One 2017; 12: e0167840.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Canadian Anesthesiologists' Society 2017

Authors and Affiliations

  • Mathieu Hylands
    • 1
  • Morten Hylander Moller
    • 2
  • Pierre Asfar
    • 3
  • Augustin Toma
    • 4
  • Anne Julie Frenette
    • 5
  • Nicolas Beaudoin
    • 6
  • Émilie Belley-Côté
    • 4
    • 7
  • Frédérick D’Aragon
    • 6
    • 8
  • Jon Henrik Laake
    • 9
  • Reed Alexander Siemieniuk
    • 4
  • Emmanuel Charbonney
    • 5
  • François Lauzier
    • 10
  • Joey Kwong
    • 11
  • Bram Rochwerg
    • 4
    • 12
  • Per Olav Vandvik
    • 13
  • Gordon Guyatt
    • 4
  • François Lamontagne
    • 7
    • 8
  1. 1.Department of SurgeryUniversité de SherbrookeSherbrookeCanada
  2. 2.Copenhagen University Hospital RigshospitaletCopenhagenDenmark
  3. 3.Centre Hospitalier Universitaire d’AngersAngersFrance
  4. 4.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  5. 5.Centre de recherche de l’Hôpital du Sacré-Coeur de MontréalUniversité de MontréalMontréalCanada
  6. 6.Department of AnesthesiologyUniversité de SherbrookeSherbrookeCanada
  7. 7.Department of MedicineUniversité de SherbrookeSherbrookeCanada
  8. 8.Centre de recherche du CHU de SherbrookeUniversité de SherbrookeSherbrookeCanada
  9. 9.Oslo Universitetssykehus UllevalOsloNorway
  10. 10.Centre de Recherche du CHU de Québec - Université Laval, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine)QuebecCanada
  11. 11.Wuhan UniversityCenter for Evidence-Based and Translational Medicine Zhongnan HospitalWuhanChina
  12. 12.Department of Medicine, Faculty of Health SciencesMcMaster UniversityHamiltonCanada
  13. 13.Norwegian Knowledge Centre for the Health ServicesOsloNorway

Personalised recommendations