Optimal target mean arterial pressure for patients with sepsis-associated encephalopathy: a retrospective cohort study.
Cerebral blood flow
Intensive care unit
Mean arterial pressure
Mortality
Sepsis associated encephalopathy
Journal
BMC infectious diseases
ISSN: 1471-2334
Titre abrégé: BMC Infect Dis
Pays: England
ID NLM: 100968551
Informations de publication
Date de publication:
02 Sep 2024
02 Sep 2024
Historique:
received:
29
05
2024
accepted:
21
08
2024
medline:
3
9
2024
pubmed:
3
9
2024
entrez:
2
9
2024
Statut:
epublish
Résumé
Sepsis-associated encephalopathy (SAE) patients often experience changes in intracranial pressure and impaired cerebral autoregulation. Mean arterial pressure (MAP) plays a crucial role in cerebral perfusion pressure, but its relationship with mortality in SAE patients remains unclear. This study aims to investigate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients, providing clinicians with the optimal MAP target. We retrospectively collected clinical data of patients diagnosed with SAE on the first day of ICU admission from the MIMIC-IV (v2.2) database. Patients were divided into four groups based on MAP quartiles. Kruskal-Wallis H test and Chi-square test were used to compare clinical characteristics among the groups. Restricted cubic spline and segmented Cox regression models, both unadjusted and adjusted for multiple variables, were employed to elucidate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients and to identify the optimal MAP. Subgroup analyses were conducted to assess the stability of the results. A total of 3,816 SAE patients were included. The Q1 group had higher rates of acute kidney injury and vasoactive drug use on the first day of ICU admission compared to other groups (P < 0.01). The Q1 and Q4 groups had longer ICU and hospital stays (P < 0.01). The 28-day and in-hospital mortality rates were highest in the Q1 group and lowest in the Q3 group. Multivariable adjustment restricted cubic spline curves indicated a nonlinear relationship between MAP and mortality risk (P for nonlinearity < 0.05). The MAP ranges associated with HRs below 1 for 28-day and in-hospital mortality were 74.6-90.2 mmHg and 74.6-89.3 mmHg, respectively.The inflection point for mortality risk, determined by the minimum hazard ratio (HR), was identified at a MAP of 81.5 mmHg. The multivariable adjusted segmented Cox regression models showed that for MAP < 81.5 mmHg, an increase in MAP was associated with a decreased risk of 28-day and in-hospital mortality (P < 0.05). In Model 4, each 5 mmHg increase in MAP was associated with a 15% decrease in 28-day mortality risk (HR: 0.85, 95% CI: 0.79-0.91, p < 0.05) and a 14% decrease in in-hospital mortality risk (HR: 0.86, 95% CI: 0.80-0.93, p < 0.05). However, for MAP ≥ 81.5 mmHg, there was no significant association between MAP and mortality risk (P > 0.05). Subgroup analyses based on age, congestive heart failure, use of vasoactive drugs, and acute kidney injury showed consistent results across different subgroups.Subsequent analysis of SAE patients with septic shock also showed results similar to those of the original cohort.However, for comatose SAE patients (GCS ≤ 8), there was a negative correlation between MAP and the risk of 28-day and in-hospital mortality when MAP was < 81.5 mmHg, but a positive correlation when MAP was ≥ 81.5 mmHg in adjusted models 2 and 4. There is a nonlinear relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients. The optimal MAP target for SAE patients in clinical practice appears to be 81.5 mmHg.
Sections du résumé
BACKGROUND
BACKGROUND
Sepsis-associated encephalopathy (SAE) patients often experience changes in intracranial pressure and impaired cerebral autoregulation. Mean arterial pressure (MAP) plays a crucial role in cerebral perfusion pressure, but its relationship with mortality in SAE patients remains unclear. This study aims to investigate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients, providing clinicians with the optimal MAP target.
METHODS
METHODS
We retrospectively collected clinical data of patients diagnosed with SAE on the first day of ICU admission from the MIMIC-IV (v2.2) database. Patients were divided into four groups based on MAP quartiles. Kruskal-Wallis H test and Chi-square test were used to compare clinical characteristics among the groups. Restricted cubic spline and segmented Cox regression models, both unadjusted and adjusted for multiple variables, were employed to elucidate the relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients and to identify the optimal MAP. Subgroup analyses were conducted to assess the stability of the results.
RESULTS
RESULTS
A total of 3,816 SAE patients were included. The Q1 group had higher rates of acute kidney injury and vasoactive drug use on the first day of ICU admission compared to other groups (P < 0.01). The Q1 and Q4 groups had longer ICU and hospital stays (P < 0.01). The 28-day and in-hospital mortality rates were highest in the Q1 group and lowest in the Q3 group. Multivariable adjustment restricted cubic spline curves indicated a nonlinear relationship between MAP and mortality risk (P for nonlinearity < 0.05). The MAP ranges associated with HRs below 1 for 28-day and in-hospital mortality were 74.6-90.2 mmHg and 74.6-89.3 mmHg, respectively.The inflection point for mortality risk, determined by the minimum hazard ratio (HR), was identified at a MAP of 81.5 mmHg. The multivariable adjusted segmented Cox regression models showed that for MAP < 81.5 mmHg, an increase in MAP was associated with a decreased risk of 28-day and in-hospital mortality (P < 0.05). In Model 4, each 5 mmHg increase in MAP was associated with a 15% decrease in 28-day mortality risk (HR: 0.85, 95% CI: 0.79-0.91, p < 0.05) and a 14% decrease in in-hospital mortality risk (HR: 0.86, 95% CI: 0.80-0.93, p < 0.05). However, for MAP ≥ 81.5 mmHg, there was no significant association between MAP and mortality risk (P > 0.05). Subgroup analyses based on age, congestive heart failure, use of vasoactive drugs, and acute kidney injury showed consistent results across different subgroups.Subsequent analysis of SAE patients with septic shock also showed results similar to those of the original cohort.However, for comatose SAE patients (GCS ≤ 8), there was a negative correlation between MAP and the risk of 28-day and in-hospital mortality when MAP was < 81.5 mmHg, but a positive correlation when MAP was ≥ 81.5 mmHg in adjusted models 2 and 4.
CONCLUSION
CONCLUSIONS
There is a nonlinear relationship between MAP and the risk of 28-day and in-hospital mortality in SAE patients. The optimal MAP target for SAE patients in clinical practice appears to be 81.5 mmHg.
Identifiants
pubmed: 39223467
doi: 10.1186/s12879-024-09789-w
pii: 10.1186/s12879-024-09789-w
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
902Subventions
Organisme : This study was funded by Guangzhou Health Science and Technology Project
ID : 20231A011031
Informations de copyright
© 2024. The Author(s).
Références
Chen J, Shi X, Diao M, et al. A retrospective study of sepsis-associated encephalopathy: epidemiology, clinical features and adverse outcomes. BMC Emerg Med. 2020;20(1):77. https://doi.org/10.1186/s12873-020-00374-3 .
doi: 10.1186/s12873-020-00374-3
pubmed: 33023479
pmcid: 7539509
Griton M, Dhaya I, Nicolas R, et al. Experimental sepsis-associated encephalopathy is accompanied by altered cerebral blood perfusion and water diffusion and related to changes in cyclooxygenase-2 expression and glial cell morphology but not to blood-brain barrier breakdown[J]. Brain Behav Immun. 2020;83:200–13. https://doi.org/10.1016/j.bbi.2019.10.012 .
doi: 10.1016/j.bbi.2019.10.012
pubmed: 31622656
Gao Q, Hernandes MS. Sepsis-associated encephalopathy and blood-brain barrier dysfunction[J]. Inflammation. 2021;44(6):2143–50. https://doi.org/10.1007/s10753-021-01501-3 .
doi: 10.1007/s10753-021-01501-3
pubmed: 34291398
Qin N, Miao Y, Xie L, et al. Sepsis-associated encephalopathy: autophagy and mirnas regulate microglial activation[J]. Physiol Rep. 2024;12(5):e15964. https://doi.org/10.14814/phy2.15964 .
doi: 10.14814/phy2.15964
pubmed: 38439741
pmcid: 10912956
Algebaly H, Elsherbini S, Galal A, et al. Transcranial doppler can predict development and outcome of sepsis-associated encephalopathy in pediatrics with severe sepsis or septic shock[J]. Front Pediatr. 2020;8:450. https://doi.org/10.3389/fped.2020.00450 .
doi: 10.3389/fped.2020.00450
pubmed: 32974238
pmcid: 7468380
Crippa IA, Subira C, Vincent JL, et al. Impaired cerebral autoregulation is associated with brain dysfunction in patients with sepsis[J]. Crit Care. 2018;22(1):327. https://doi.org/10.1186/s13054-018-2258-8 .
doi: 10.1186/s13054-018-2258-8
pubmed: 30514349
pmcid: 6280405
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021[J]. Intensive Care Med. 2021;47(11):1181–247. https://doi.org/10.1007/s00134-021-06506-y .
doi: 10.1007/s00134-021-06506-y
pubmed: 34599691
pmcid: 8486643
Jouan Y, Seegers V, Meziani F, et al. Effects of mean arterial pressure on arousal in sedated ventilated patients with septic shock: a sepsispam post hoc exploratory study[J]. Ann Intensive Care. 2019;9(1):54. https://doi.org/10.1186/s13613-019-0528-5 .
doi: 10.1186/s13613-019-0528-5
pubmed: 31073873
pmcid: 6509319
Erickson SL, Killien EY, Wainwright M, et al. Mean arterial pressure and discharge outcomes in severe pediatric traumatic brain injury[J]. Neurocrit Care. 2021;34(3):1017–25. https://doi.org/10.1007/s12028-020-01121-z .
doi: 10.1007/s12028-020-01121-z
pubmed: 33108627
Lin YH, Liu HM. Update on cerebral hyperperfusion syndrome[J]. J Neurointerv Surg. 2020;12(8):788–93. https://doi.org/10.1136/neurintsurg-2019-015621 .
doi: 10.1136/neurintsurg-2019-015621
pubmed: 32414892
pmcid: 7402457
Ge C, Deng F, Chen W, et al. Machine learning for early prediction of sepsis-associated acute brain injury[J]. Front Med (Lausanne). 2022;9:962027. https://doi.org/10.3389/fmed.2022.962027 .
doi: 10.3389/fmed.2022.962027
pubmed: 36262275
Yang Y, Liang S, Geng J, et al. Development of a nomogram to predict 30-day mortality of patients with sepsis-associated encephalopathy: a retrospective cohort study[J]. J Intensive Care. 2020;8:45. https://doi.org/10.1186/s40560-020-00459-y .
doi: 10.1186/s40560-020-00459-y
pubmed: 32637121
pmcid: 7331133
Zhao L, Wang Y, Ge Z, et al. Mechanical learning for prediction of sepsis-associated encephalopathy[J]. Front Comput Neurosci. 2021;15:739265. https://doi.org/10.3389/fncom.2021.739265 .
doi: 10.3389/fncom.2021.739265
pubmed: 34867250
pmcid: 8636425
Lu X, Qin M, Walline JH, et al. Clinical phenotypes of sepsis-associated encephalopathy: a retrospective cohort study[J]. Shock. 2023;59(4):583–90. https://doi.org/10.1097/SHK.0000000000002092 .
doi: 10.1097/SHK.0000000000002092
pubmed: 36821412
pmcid: 10082059
Pei J, Wang X, Xing Z, et al. Association between admission systolic blood pressure and major adverse cardiovascular events in patients with acute myocardial infarction[J]. PLoS ONE. 2020;15(6):e234935. https://doi.org/10.1371/journal.pone.0234935 .
doi: 10.1371/journal.pone.0234935
Zhang H, Xu Y, Xu Y. The association of the platelet/high-density lipoprotein cholesterol ratio with self-reported stroke and cardiovascular mortality: a population-based observational study[J]. Lipids Health Dis. 2024;23(1):121. https://doi.org/10.1186/s12944-024-02115-y .
doi: 10.1186/s12944-024-02115-y
pubmed: 38659020
pmcid: 11040779
Beloncle F, Radermacher P, Guerin C, et al. Mean arterial pressure target in patients with septic shock[J]. Minerva Anestesiol. 2016;82(7):777–84.
pubmed: 26967829
Dari MA, Fayaz A, Sharif S, et al. Comparison of high-normal versus low-normal mean arterial pressure at target on outcomes in sepsis or shock patients: a meta-analysis of randomized control trials[J]. Cureus. 2024;16(1):e52258. https://doi.org/10.7759/cureus.52258 .
doi: 10.7759/cureus.52258
pubmed: 38352092
pmcid: 10863627
Zhong X, Li H, Chen Q, et al. Association between different map levels and 30-day mortality in sepsis patients: a propensity-score-matched, retrospective cohort study[J]. BMC Anesthesiol. 2023;23(1):116. https://doi.org/10.1186/s12871-023-02047-7 .
doi: 10.1186/s12871-023-02047-7
pubmed: 37024806
pmcid: 10077659
Cao B, Chen Q, Tang T, et al. Non-linear relationship between baseline mean arterial pressure and 30-day mortality in patients with sepsis: a retrospective cohort study based on the mimic-iii database[J]. Ann Transl Med. 2022;10(16):872. https://doi.org/10.21037/atm-22-3457 .
doi: 10.21037/atm-22-3457
pubmed: 36111019
pmcid: 9469146
Lamontagne F, Richards-Belle A, Thomas K, et al. Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension: a randomized clinical trial[J]. JAMA. 2020;323(10):938–49. https://doi.org/10.1001/jama.2020.0930 .
doi: 10.1001/jama.2020.0930
pubmed: 32049269
pmcid: 7064880
Marshall JC. Choosing the best blood pressure target for vasopressor therapy[J]. JAMA. 2020;323(10):931–3. https://doi.org/10.1001/jama.2019.22526 .
doi: 10.1001/jama.2019.22526
pubmed: 32049266
Meng L, Wang Y, Zhang L, et al. Heterogeneity and variability in pressure autoregulation of organ blood flow: lessons learned over 100 + years[J]. Crit Care Med. 2019;47(3):436–48. https://doi.org/10.1097/CCM.0000000000003569 .
doi: 10.1097/CCM.0000000000003569
pubmed: 30516567
Maiwall R, Rao PS, Hidam AK, et al. A randomised-controlled trial (target-c) of high vs. low target mean arterial pressure in patients with cirrhosis and septic shock[J]. J Hepatol. 2023;79(2):349–61. https://doi.org/10.1016/j.jhep.2023.04.006 .
doi: 10.1016/j.jhep.2023.04.006
pubmed: 37088310
Zhu X, Hou J, Zhang Q, et al. [Effects of treatment based on different target mean arterial pressure on gastrointestinal function in septic shock patients with hypertension][J]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2021;33(5):517–22. https://doi.org/10.3760/cma.j.cn121430-20200713-00515 .
doi: 10.3760/cma.j.cn121430-20200713-00515
pubmed: 34112285
Khanna AK, Maheshwari K, Mao G, et al. Association between mean arterial pressure and acute kidney injury and a composite of myocardial injury and mortality in postoperative critically ill patients: a retrospective cohort analysis[J]. Crit Care Med. 2019;47(7):910–7. https://doi.org/10.1097/CCM.0000000000003763 .
doi: 10.1097/CCM.0000000000003763
pubmed: 30985388
Taccone FS, Su F, He X, et al. Effects of reversal of hypotension on cerebral microcirculation and metabolism in experimental sepsis[J]. Biomedicines. 2022;10(4). https://doi.org/10.3390/biomedicines10040923 .
Taccone FS, Su F, Pierrakos C, et al. Cerebral microcirculation is impaired during sepsis: an experimental study[J]. Crit Care. 2010;14(4):R140. https://doi.org/10.1186/cc9205 .
doi: 10.1186/cc9205
pubmed: 20667108
pmcid: 2945121
Rosenblatt K, Walker KA, Goodson C, et al. Cerebral autoregulation-guided optimal blood pressure in sepsis-associated encephalopathy: a case series[J]. J Intensive Care Med. 2020;35(12):1453–64. https://doi.org/10.1177/0885066619828293 .
doi: 10.1177/0885066619828293
pubmed: 30760173
Kow CY, Harley B, Li C, et al. Escalating mean arterial pressure in severe traumatic brain injury: a prospective, observational study[J]. J Neurotrauma. 2021;38(14):1995–2002. https://doi.org/10.1089/neu.2020.7289 .
doi: 10.1089/neu.2020.7289
pubmed: 33280492
Dietvorst S, Depreitere B, Meyfroidt G. Beyond intracranial pressure: monitoring cerebral perfusion and autoregulation in severe traumatic brain injury[J]. Curr Opin Crit Care. 2023;29(2):85–8. https://doi.org/10.1097/MCC.0000000000001026 .
doi: 10.1097/MCC.0000000000001026
pubmed: 36762674
Claassen J, Thijssen D, Panerai RB, et al. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation[J]. Physiol Rev. 2021;101(4):1487–559. https://doi.org/10.1152/physrev.00022.2020 .
doi: 10.1152/physrev.00022.2020
pubmed: 33769101
pmcid: 8576366
Crippa IA, Vincent JL, Zama CF, et al. Estimated cerebral perfusion pressure and intracranial pressure in septic patients[J]. Neurocrit Care. 2024;40(2):577–86. https://doi.org/10.1007/s12028-023-01783-5 .
doi: 10.1007/s12028-023-01783-5
pubmed: 37420137
Taccone FS, Scolletta S, Franchi F, et al. Brain perfusion in sepsis[J]. Curr Vasc Pharmacol. 2013;11(2):170–86. https://doi.org/10.2174/1570161111311020007 .
doi: 10.2174/1570161111311020007
pubmed: 23506496
Pan S, Lv Z, Wang R et al. Sepsis-induced brain dysfunction: pathogenesis, diagnosis, and treatment[J]. Oxid Med Cell Longev, 2022,2022: 1328729. https://doi.org/10.1155/2022/1328729
Figaji AA, Zwane E, Fieggen AG, et al. Pressure autoregulation, intracranial pressure, and brain tissue oxygenation in children with severe traumatic brain injury[J]. J Neurosurg Pediatr. 2009;4(5):420–8. https://doi.org/10.3171/2009.6.PEDS096 .
doi: 10.3171/2009.6.PEDS096
pubmed: 19877773
Osteresch R, Diehl K, Dierks P, et al. Influence of the ratio of mean arterial pressure to right atrial pressure on outcome after successful percutaneous edge-to-edge repair for severe mitral valve regurgitation[J]. Int J Cardiol Heart Vasc. 2021;37:100903. https://doi.org/10.1016/j.ijcha.2021.100903 .
doi: 10.1016/j.ijcha.2021.100903
pubmed: 34805479
pmcid: 8585619
Lamontagne F, Day AG, Meade MO, et al. Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock[J]. Intensive Care Med. 2018;44(1):12–21. https://doi.org/10.1007/s00134-017-5016-5 .
doi: 10.1007/s00134-017-5016-5
pubmed: 29260272
Zhao L, Fan Y, Wang Z, et al. The blood pressure targets in sepsis patients with acute kidney injury: an observational cohort study of multiple icus[J]. Front Immunol. 2022;13:1060612. https://doi.org/10.3389/fimmu.2022.1060612 .
doi: 10.3389/fimmu.2022.1060612
pubmed: 36591259
pmcid: 9797512