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Zuin M, Henkin S, Harder EM, Piazza G. Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients. J Thromb Thrombolysis 2024; 57:918-928. [PMID: 38762710 DOI: 10.1007/s11239-024-02998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, Ferrara, 44124, Italy.
| | | | - Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Endo A, Yamakawa K, Tagami T, Umemura Y, Takahashi K, Nagasawa H, Araki Y, Kojima M, Sera T, Yagi M, Yamamoto R, Takahashi J, Nakane M, Takeda C, Narita C, Kazuma S, Okura H, Takahashi H, Wada T, Tahara S, Matsuoka A, Masaki T, Shiraishi A, Shimoyama K, Yokokawa Y, Nakamura R, Sageshima H, Yanagida Y, Takahashi K, Otomo Y. Optimal target blood pressure in elderly with septic shock (OPTPRESS) trial: study protocol for a randomized controlled trial. Trials 2022; 23:799. [PMID: 36153530 PMCID: PMC9509562 DOI: 10.1186/s13063-022-06732-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hemodynamic stabilization is a core component in the resuscitation of septic shock. However, the optimal target blood pressure remains debatable. Previous randomized controlled trials suggested that uniformly adopting a target mean arterial pressure (MAP) higher than 65 mmHg for all adult septic shock patients would not be beneficial; however, it has also been proposed that higher target MAP may be beneficial for elderly patients, especially those with arteriosclerosis.
Methods
A multicenter, pragmatic single-blind randomized controlled trial will be conducted to compare target MAP of 80–85 mmHg (high-target) and 65–70 mmHg (control) in the resuscitation of septic shock patients admitted to 28 hospitals in Japan. Patients with septic shock aged ≥65 years are randomly assigned to the high-target or control groups. The target MAP shall be maintained for 72 h after randomization or until vasopressors are no longer needed to improve patients’ condition. To minimize the adverse effects related to catecholamines, if norepinephrine dose of ≥ 0.1 μg/kg/min is needed to maintain the target MAP, vasopressin will be initiated. Other therapeutic approaches, including fluid administration, hydrocortisone use, and antibiotic choice, will be determined by the physician in charge based on the latest clinical guidelines. The primary outcome is all-cause mortality at 90 days after randomization.
Discussion
The result of this trial will provide great insight on the resuscitation strategy for septic shock in the era of global aged society. Also, it will provide the better understanding on the importance of individualized treatment strategy in hemodynamic management in critically ill patients.
Trial registration
UMIN Clinical Trials Registry; UMIN000041775. Registered 13 September 2020.
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Yoshimoto H, Fukui S, Higashio K, Endo A, Takasu A, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: A systematic review and meta-analysis. Front Physiol 2022; 13:962670. [PMID: 36051909 PMCID: PMC9424848 DOI: 10.3389/fphys.2022.962670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
While the Surviving Sepsis Campaign guidelines recommend an initial target value of 65 mmHg as the mean arterial pressure (MAP) in patients with septic shock, the optimal MAP target for improving outcomes remains controversial. We performed a meta-analysis to evaluate the optimal MAP for patients with vasodilatory shock, which included three randomized controlled trials that recruited 3,357 patients. Between the lower (60–70 mmHg) and higher (>70 mmHg) MAP target groups, there was no significant difference in all-cause mortality (risk ratio [RR], 1.06; 95% confidence intervals [CI], 0.98–1.16) which was similar in patients with chronic hypertension (RR, 1.10; 95% CI, 0.98–1.24) and patients aged ≥65 years (RR, 1.10; 95% CI, 0.99–1.21). No significant difference in adverse events was observed between the different MAP groups (RR, 1.04; 95% CI, 0.87–1.24); however, supraventricular arrhythmia was significantly higher in the higher MAP group (RR, 1.73; 95% CI, 1.15–2.60). Renal replacement therapy was reduced in the higher MAP group of patients with chronic hypertension (RR, 0.83; 95% CI, 0.71–0.98). Though the higher MAP control did not improve the mortality rate, it may be beneficial in reducing renal replacement therapy in patients with chronic hypertension. Systematic review registration: UMIN Clinical Trials Registry, identifier UMIN000042624
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Affiliation(s)
- Hidero Yoshimoto
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Satoshi Fukui
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- *Correspondence: Kazuma Yamakawa,
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Khemani RG, Lee JT, Wu D, Schenck EJ, Hayes MM, Kritek PA, Mutlu GM, Gershengorn HB, Coudroy R. Update in Critical Care 2020. Am J Respir Crit Care Med 2021; 203:1088-1098. [PMID: 33734938 DOI: 10.1164/rccm.202102-0336up] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jessica T Lee
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Wu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York.,NewYork-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patricia A Kritek
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Washington Seattle, Washington
| | - Gökhan M Mutlu
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Rémi Coudroy
- Institut National de la Santé et de la Recherche Médicale, Poitiers, France; and.,Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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Fukui S, Higashio K, Murao S, Endo A, Akira T, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: a protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e048512. [PMID: 33741676 PMCID: PMC7986773 DOI: 10.1136/bmjopen-2020-048512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The optimal target of mean arterial pressure (MAP) for better outcomes in patients with vasodilatory shock remains a matter of debate. Although catecholamines are generally used to maintain target blood pressure in hypotensive patients with vasodilatory shock, the adverse effects of catecholamines must also be considered. We will perform a systematic review and meta-analysis of randomised controlled trials (RCTs) to assess the certainty of evidence determining the optimal target of MAP control for patients with vasodilatory shock in critically ill settings. METHODS AND ANALYSIS This study protocol was registered in the University Hospital Medical Information Network Clinical Trials Registry. We will include only RCTs that evaluated the two different comparators for target MAP to be maintained for clinical outcomes of all-cause mortality: organ dysfunction and adverse events in critically ill adult patients with vasodilatory shock. We will search the electronic bibliographic databases of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials in November 2020. Two reviewers will independently screen titles and abstracts, perform full article reviews and extract study data. We will report study characteristics and assess methodological quality using the Cochrane Risk-of-Bias 2 tool. If pooling is appropriate, we will calculate relative risks with 95% CIs for all outcome measures. Clinical and methodological subgroup and sensitivity analyses will be performed to explore heterogeneity. Overall certainty of evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION This study will not involve primary data collection, and formal ethics approval will therefore not be required. We aim to publish this systematic review in a peer-reviewed journal. TRIAL REGISTRATION NUMBER UMIN000042624.
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Affiliation(s)
- Satoshi Fukui
- Faculty of Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Shuhei Murao
- Department of Traumatology and Acute Critical Medicine, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Takasu Akira
- Department of Emergency Medicne, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicne, Osaka Medical College, Takatsuki, Osaka, Japan
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