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Canadian Journal of Anesthesia/Journal canadien d'anesthésie

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01-07-2017 | Reports of Original Investigations

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

Authors: Mathieu Hylands, MD, MSc, Morten Hylander Moller, MD, Pierre Asfar, MD, PhD, Augustin Toma, BSc, Anne Julie Frenette, BPharm, MSc, Nicolas Beaudoin, MD, MSc, Émilie Belley-Côté, MD, MSc, Frédérick D’Aragon, MD, MSc, Jon Henrik Laake, MD, PhD, Reed Alexander Siemieniuk, MD, Emmanuel Charbonney, MD, PhD, François Lauzier, MD, MSc, Joey Kwong, PhD, Bram Rochwerg, MD, MSc, Per Olav Vandvik, MD, PhD, Gordon Guyatt, MD, MSc, François Lamontagne, MD, MSc

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 7/2017

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.

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Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010; 376: 1339-46.CrossRefPubMed

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.

Andreis DT, Singer M. Catecholamines for inflammatory shock: a Jekyll-and-Hyde conundrum. Intensive Care Med 2016; 42: 1387-97.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

D’Aragon F, Belley-Cote EP, Meade MO, et al. Blood pressure targets for vasopressor therapy: a systematic review. Shock 2015; 43: 530-9.CrossRefPubMed

Institute of Medicine; Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011.

Siemieniuk RA, Agoritsas T, Macdonald H, Guyatt GH, Brandt L, Vandvik PO. Introduction to BMJ rapid recommendations. BMJ 2016; 354: i5191.CrossRefPubMed

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.CrossRefPubMed

10.

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-88.CrossRefPubMed

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.CrossRefPubMed

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.CrossRef

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.CrossRefPubMed

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.

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.CrossRefPubMedPubMedCentral

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.

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.CrossRefPubMed

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.

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.

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.CrossRefPubMed

29.

Lamontagne F, Cook DJ, Meade MO, et al. Vasopressor use for severe hypotension-a multicentre prospective observational study. PloS One 2017; 12: e0167840.CrossRefPubMedPubMedCentral

Title: A systematic review of vasopressor blood pressure targets in critically ill adults with hypotension
Authors: Mathieu Hylands, MD, MSc
Morten Hylander Moller, MD
Pierre Asfar, MD, PhD
Augustin Toma, BSc
Anne Julie Frenette, BPharm, MSc
Nicolas Beaudoin, MD, MSc
Émilie Belley-Côté, MD, MSc
Frédérick D’Aragon, MD, MSc
Jon Henrik Laake, MD, PhD
Reed Alexander Siemieniuk, MD
Emmanuel Charbonney, MD, PhD
François Lauzier, MD, MSc
Joey Kwong, PhD
Bram Rochwerg, MD, MSc
Per Olav Vandvik, MD, PhD
Gordon Guyatt, MD, MSc
François Lamontagne, MD, MSc
Publication date: 01-07-2017
Publisher: Springer US
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 7/2017
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI: https://doi.org/10.1007/s12630-017-0877-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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