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Intensive Care Medicine

, Volume 44, Issue 1, pp 12–21 | Cite as

Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock

  • François Lamontagne
  • Andrew G. Day
  • Maureen O. Meade
  • Deborah J. Cook
  • Gordon H. Guyatt
  • Mathieu Hylands
  • Peter Radermacher
  • Jean-Marie Chrétien
  • Nicolas Beaudoin
  • Paul Hébert
  • Frédérick D’Aragon
  • Ferhat Meziani
  • Pierre Asfar
Systematic Review

Abstract

Purpose

Guidelines for shock recommend mean arterial pressure (MAP) targets for vasopressor therapy of at least 65 mmHg and, until recently, suggested that patients with underlying chronic hypertension and atherosclerosis may benefit from higher targets. We conducted an individual patient-data meta-analysis of recent trials to determine if patient variables modify the effect of different MAP targets.

Methods

We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for randomized controlled trials of higher versus lower blood pressure targets for vasopressor therapy in adult patients in shock (until November 2017). After obtaining individual patient data from both eligible trials, we used a modified version of the Cochrane Collaboration’s instrument to assess the risk of bias of included trials. The primary outcome was 28-day mortality.

Results

Included trials enrolled 894 patients. Controlling for trial and site, the OR for 28-day mortality for the higher versus lower MAP targets was 1.15 (95% CI 0.87–1.52). Treatment effect varied by duration of vasopressors before randomization (interaction p = 0.017), but not by chronic hypertension, congestive heart failure or age. Risk of death increased in higher MAP groups among patients on vasopressors > 6 h before randomization (OR 3.00, 95% CI 1.33–6.74).

Conclusions

Targeting higher blood pressure targets may increase mortality in patients who have been treated with vasopressors for more than 6 h. Lower blood pressure targets were not associated with patient-important adverse events in any subgroup, including chronically hypertensive patients.

Keywords

Vasopressors Hypotension Critical care Mean arterial blood pressure Individual patient data meta-analysis 

Notes

Acknowledgements

We would like to thank Qi Zhou for additional input on the statistical analysis plan as well as nurses and physicians who contributed to both trials included in this analysis. We thank the Unité de Recherche Clinique et Épidémiologique (URCE) of the Centre de recherche du CHU de Sherbrooke for their support in coordinating the preparation and revisions of this manuscript.

Author contributions

FL and PA had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: FL, AGD, MOM, DJC, GHG, PA. Acquisition, analysis, or interpretation of data: FL, AGD, MOM, DJC, GHG, MH, PR, J-MC, NB, PH, FD, FM, PA. Drafting the manuscript: FL, PA. Critical revision of the manuscript for important intellectual content: FL, AGD, MOM, DJC, GHG, MH, PR, J-MC, NB, PH, FD, FM, PA. Statistical analysis: FD. Study supervision: FL.

Compliance with ethical standards

Funding

This analysis was funded by a grant from the Fonds de Recherche du Québec - Santé. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Conflicts of interest

The authors declare that they have no conflict of interest. Drs. Lamontagne and Asfar are the Principal Investigators of both trials included in this analysis.

Supplementary material

134_2017_5016_MOESM1_ESM.docx (184 kb)
Supplementary material 1 (DOCX 183 kb)

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2017

Authors and Affiliations

  • François Lamontagne
    • 1
    • 2
  • Andrew G. Day
    • 3
  • Maureen O. Meade
    • 4
    • 5
  • Deborah J. Cook
    • 4
    • 5
  • Gordon H. Guyatt
    • 5
  • Mathieu Hylands
    • 6
  • Peter Radermacher
    • 7
  • Jean-Marie Chrétien
    • 8
  • Nicolas Beaudoin
    • 9
  • Paul Hébert
    • 10
  • Frédérick D’Aragon
    • 1
    • 2
  • Ferhat Meziani
    • 11
  • Pierre Asfar
    • 12
  1. 1.Department of MedicineUniversité de SherbrookeSherbrookeCanada
  2. 2.Centre de recherche du CHU de SherbrookeSherbrookeCanada
  3. 3.Kingston General HospitalKingstonCanada
  4. 4.Interdepartmental Division of Critical CareHamilton Health SciencesHamiltonCanada
  5. 5.Departments of Medicine and Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  6. 6.Department of SurgeryUniversité de SherbrookeSherbrookeCanada
  7. 7.Institute of Anesthesiological Pathophysiology and Process EngineeringUlm University HospitalUlmGermany
  8. 8.Department of Clinical Research and InnovationUniversity Hospital of AngerAngersFrance
  9. 9.Department of AnesthesiologyUniversité de SherbrookeSherbrookeCanada
  10. 10.Department of MedicineUniversity of MontrealMontrealCanada
  11. 11.Service de Réanimation Médicale, Nouvel Hôpital CivilCentre Hospitalo-UniversitaireStrasbourgFrance
  12. 12.Department of Medical Intensive CareUniversity Hospital of AngersAngersFrance

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