BP target in ICU

1. Blood pressure target in ICU
Evidence and Practice
Natthida Owattanapanich, MD
Division of Trauma Surgery, Surgery department
Faculty of Medicine, Siriraj hospital

2. Outline
Physiology of blood pressure
How important to keep target MAP
Blood pressure target
 Hypertension
 Hypotension

3. Blood pressure
Systolic blood pressure
Diastolic blood pressure
Mean arterial pressurePulse pressure
Stroke volume

4. Mean arterial pressure: how important?
 MAP related to cardiac output and oxygen delivery
 MAP related regional circulation

5. MAP and Oxygen delivery
RA LA
RV LV
CVP
MAP
Cardiac
output
Venous
return
Pulmonary circulation
Systemic capillary
bed
DO2 = cardiac output x [(1.39 x Hb x SaO2) + (PaO2x 0.003)]

6. MAP and regional perfusion
 Renal, splanchnic, cerebral and coronary beds
 ‘autoregulation’
50-150 mmHg

7. Autoregulation threshold
• Kidney 70 mmHg
• Brain 60-70 mmHg
• Heart 50-55 mmHg
Kidney Brain

8. Normal blood pressure
In general patients: BP 125/75 mmHg (MAP 92 mmHg)
ACS/AHa 2017: normal blood pressure was defined as SBP
<120 mmHg and DBP <80 mmHg
ICU patients: normal MAP was around 75-100 mmHg

9. Blood pressure in ICU
HypertensionHypotension
75-100 mmHg

10. Hypertension in ICU
 Definition: hypertension in general population 130/80 mmHg
 Out patient clinic ≠ ICU patients
 ICU: no tight control
 Need emergency control: 180/110 mmHg
 Specific target blood pressure in specific diseases

11. Specific diseases Target blood pressure
 Aortic dissection
 Congestive heart failure
 Acute coronary syndrome
 Ischemic stroke
 Preeclampsia/
pheochromocytoma
SBP < 120 mmHg, Pulse < 60/min within 30 min
Decrease 25% within 1 hr and BP 160/110 mmHg
within 2-6 hr
BP 160/110 mmHg within 2-6 hr
BP 220/120 mmHg, before rtPA infusion: 185/110
mmHg and 180/105 mmHg after rtPA
BP 160/110 mmHg within 2-6 hr

12. Hypotension in ICU

13. River 2001
2016
‘In sepsis’

14. SEPSISPAM
 High versus Low Blood-Pressure Target in
Patients with Septic Shock
 MAP 65-70 mmHg VS MAP 80-85 mmHg
 No significant difference in 28 day
mortality
 Chronic hypertension: high target was
less likely to have doubling of serum
creatinine and RRT requirement.
N Engl J Med 2014;370:1583-93

15. one size
does not fit all
‘Personalized Medicine’
Target BP >>> Check microcirculation/perfusion

16. Blood pressure target Specific conditions

17. Perioperative period
Walsh et al, Anesthesiology 2013

18. MAP < 55 mmHg
Walsh et al, Anesthesiology 2013
Increase AKI,
cardiac
complication
and MI
In less than
5 min

19. • Baseline BP (+/- 10%) vs
standard treatment
• Significant decrease in
postoperative organ dysfunction
D30
• No significant in mortality and
adverse event
‘Personalized Medicine’

20. Perioperative patients
Keep normal blood pressure
Trend to adjust according to baseline BP
Prompt treatment if MAP < 55 mmHg

21. Traumatic hemorrhagic shock

22. In general:
MAP 50 mmHg
SBP 80 mmHg
To date: Meta-analysis showed the mortality benefit of hypotensive
resuscitation in traumatic hemorrhagic shock patients

23. Prolonged
Shock

24. Postcardiac arrest

26. Laurikkala et al. Resuscitation 2016

27. Russo et al. Resuscitation 2016

28. Postcardiac arrest patients
• Keep MAP > 65 mmHg
• Trend to keep higher target, however there’s
still no strong recommendation
• Need specific monitoring: cerebral perfusion?

29. Neurological patients
CPP MAP ICP

30. Intracranial hemorrhage Traumatic brain injury
• Improve functional outcome
• Neither too fast nor too low
Age 50-69 years old: SBP ≥ 100 mmHg
Age 15-49 or > 70 years old: SBP ≥ 110
mmHg
Target CPP 60-70 mmHg
Monitor ICP , treatment if ICP > 22 mmHg

32. Patient Target SBP or MAP
Hypertension General ICU patients Urgent control if BP >180/100
mmHg then slowly decreased to
SBP ≤ 140 mmHg
ICH Slowly control SBP around 140
mmHg
TBI SBP 100-110 mmHg, keep CPP 60-
70 mmHg
Hypotension ICU patients esp septic
shock
MAP ≥ 65 mmHg
Neurological patients and
chronic hypertension
MAP ≥ 70 mmHg