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01-01-2018 | What's New in Intensive Care
Permissive hypotension during shock resuscitation: equipoise in all patients?
Published in: Intensive Care Medicine | Issue 1/2018
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Recently, the idea that treatment of severely ill patients hinges on correction of deranged physiology has been challenged. Several trials have found benefit from “abnormal” or more permissive resuscitation targets for such interventions as oxygen, feeding, ventilation, blood transfusion, insulin, and hemodynamic support in trauma (Table 1). Similarly, targeting a normal blood pressure during resuscitation has been a core element of shock management, but trials are now evaluating the effects of permissive hypotension. The rationale for such trials is that adequate perfusion may not depend on “normal” blood pressure and that autoregulatory capacity may differ among organs and patient subgroups defined by age and cardiovascular comorbidity.
Table 1
Selected trials of lower intensity vs higher intensity interventions for critically ill patients
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First author, yeara
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Patient population
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Restrictive intervention
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Findings
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|---|---|---|---|
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Oxygen
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|||
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Girardis, 2016
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General critical illness
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Target PaO2 between 70 and 100 mmHg and SpO2 94–98% vs. usual care of PaO2 150 mmHg and SpO2 of 97–100%
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Restricting oxygen therapy improves survival
|
|
Feeding
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|||
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Arabi, 2015
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General critical illness
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Permissive underfeeding (40–60% of calculated caloric requirements) vs. standard enteral feeding (70–100%), with similar protein intake
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Restricting non-protein calories does not worsen outcomes
|
|
Rice, 2012
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Acute lung injury
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Trophic vs. full enteral feeding for 6 days
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Restricting enteral feeding for 6 days does not worsen outcomes and reduces gastrointestinal intolerance
|
|
Mechanical ventilation
|
|||
|
ARDSNet, 2000
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Acute lung injury
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Tidal volumes of 6 mL/kg predicted body weight and a plateau pressure of 30 cmH2O vs. tidal volume of 12 mL/kg predicted body weight and a plateau pressure of 50 cmH2O
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Low tidal volumes worsen gas exchange but improve survival
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Intravenous fluids
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|||
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Bickell, 1994
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Penetrating trauma and hypotension
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Delayed administration of intravenous fluids until reaching the operating room vs. standard fluid resuscitation before reaching the hospital
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Delayed fluid therapy and permissive hypotension improve survival
|
|
Maitland, 2011
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Severe pediatric febrile illness and hypoperfusion in Africa
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No intravenous fluid boluses vs. intravenous boluses (either saline or albumin)
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Maintenance intravenous fluid therapy without boluses improves survival
|
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Blood transfusion
|
|||
|
Hebert, 1999
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General critical illness
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Transfusion to target hemoglobin value of 70 vs. 90 g/L
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Restricting blood transfusions does not worsen outcomes
|
|
Villanueva, 2013
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Severe acute upper gastrointestinal bleeding
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Transfusion to target hemoglobin value of 70 vs. 90 g/L
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Restricting blood transfusions improves survival
|
|
Carson, 2011
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High-risk surgery hip fracture surgery
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Transfusion to target hemoglobin value of 80 vs. 100 g/L
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Restricting blood transfusions does not worsen outcomes
|
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Holst, 2014
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Septic shock
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Transfusion to target hemoglobin value of 70 vs. 90 g/L
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Restricting blood transfusions does not worsen outcomes
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Insulin
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|||
|
Finfer, 2009
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General critical illness
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Target blood glucose value of 10.0 mmol/L or less vs. 4.5 to 6.0 mmol/L
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Restricting insulin therapy raises blood glucose values but improves survival
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