Lamontagne Francois, Cook Deborah J, Meade Maureen O, Seely Andrew, Day Andrew G, Charbonney Emmanuel, Serri Karim, Skrobik Yoanna, Hebert Paul, St-Arnaud Charles, Quiroz-Martinez Hector, Mayette Michaël, Heyland Daren K
Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
Centre de Recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada.
PLoS One. 2017 Jan 20;12(1):e0167840. doi: 10.1371/journal.pone.0167840. eCollection 2017.
The optimal approach to titrate vasopressor therapy is unclear. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines.
In a multicenter prospective cohort study of critically ill adults with severe hypotension, we recorded MAP and vasopressor doses hourly. We investigated variability across patients and centres using multivariable regression models and Analysis of variance (ANOVA), respectively.
We included data from 56 patients treated in 6 centers. The mean (standard deviation [SD]) age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were 64 (14) and 25 (8). Half (28 of 56) of the patients were at least 65 years old, and half had chronic hypertension. The patient-averaged MAP while receiving vasopressors was 75 mm Hg (6) and the median (1st quartile, 3rd quartile) duration of vasopressor therapy was 43 hours (23, 84). MAP achieved was not associated with history of underlying hypertension (p = 0.46) but did vary by center (p<0.001).
In this multicenter, prospective observational study, the patient-level average MAP while receiving vasopressors for severe hypotension was 75 mmHg, approximately 10 mmHg above current recommendations and stated practices. Moreover, our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but MAP achieved while receiving vasopressors varied by site.
滴定血管升压药治疗的最佳方法尚不清楚。近期的脓毒症指南建议，慢性高血压患者的平均动脉压（MAP）目标为65 mmHg及以上。随着比较血管升压药治疗血压目标的临床试验数据的出现，需要对常规治疗进行准确描述以解释研究结果。我们的目的是测量加拿大重症监护病房（ICU）中血管升压药治疗期间的MAP值，并将其与既定做法和指南进行比较。
在一项针对患有严重低血压的危重症成年患者的多中心前瞻性队列研究中，我们每小时记录MAP和血管升压药剂量。我们分别使用多变量回归模型和方差分析（ANOVA）研究患者和中心之间的变异性。
我们纳入了6个中心治疗的56例患者的数据。平均（标准差[SD]）年龄和急性生理与慢性健康状况评估（APACHE）II评分分别为64（14）和25（8）。一半（56例中的28例）患者年龄至少65岁，一半患有慢性高血压。接受血管升压药治疗期间患者的平均MAP为75 mmHg（6），血管升压药治疗的中位（第1四分位数，第3四分位数）持续时间为43小时（23，84）。达到的MAP与潜在高血压病史无关（p = 0.46），但因中心而异（p<0.001）。
在这项多中心前瞻性观察研究中，严重低血压患者接受血管升压药治疗期间患者水平的平均MAP为75 mmHg，比当前建议和既定做法高出约10 mmHg。此外，我们的结果不支持临床医生根据个体患者特征（如潜在慢性高血压）调整血管升压药治疗的观点，但接受血管升压药治疗期间达到的MAP因地点而异。
