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Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France

Ideal MAP for resuscitation A moving target. Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France. Questions. 1- Why do we use vasopressors in septic shock?. 2- Which first-line agent ?. 3- When to start?. 4- Which therapeutic target ?.

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Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France

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  1. Ideal MAP for resuscitation A moving target Prof. Jean-Louis TEBOUL Medical ICU Bicetre hospital University Paris-South France

  2. Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When to start? 4- Which therapeutic target?

  3. Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When to start? 4- Which therapeutic target?

  4. Hypotension Hypoperfusion worsening Why do we use vasopressors in septic shock? Septic shock is characterized by a decreased vascular tone (inducible NO synthase activation, etc)

  5. organ blood flow mean arterial pressure Autoregulation of organ blood flow

  6. Why do we use vasopressors in septic shock? 1- Septic shock is characterized by a decreased vascular tone (inducible NO synthase activation, etc) 2- Profound hypotension worsens organ hypoperfusion …… and represents an independent risk of death

  7. 48 hrs 65 mmHg

  8. Why do we use vasopressors in septic shock? 1- Septic shock is characterized by a decreased vascular tone (inducible NO synthase activation, etc) 2- Profound hypotension worsens organ hypoperfusion …… and represents an independent risk of death 3- Correction of hypotension with a vasopressor allows improving organ perfusion

  9. Probable “arterial pressure” effect 54 mmHg 72 mmHg 73 mmHg while cardiac output did not change Urine flow Creatinine clearance Blood lactate(meq/l) (ml/h) 60 * * * * * 30 baseline 4 hrs 8 hrs 0-2 hrs 4-6 hrs baseline 4 hrs 8 hrs 54 mmHg 72 mmHg 73 mmHg 54 mmHg 72 mmHg

  10. renal blood flow mean arterial pressure Autoregulation of renal blood flow 54 72

  11. Why do we use vasopressors in septic shock? 1- Septic shock is characterized by a decreased vascular tone (inducible NO synthase activation, etc) 2- Profound hypotension worsens organ hypoperfusion …… and represents an independent risk of death 3- Correction of hypotension with a vasopressor allows improving organ perfusion and microcirculation

  12. % StO2 95 90 85 80 75 70 65 60 55 before NE with NE p < 0.05 StO2: 75 ± 9% healthy volunteers 82 ± 4 *

  13. NIRS technology

  14. Vascular Occlusion Test StO2 (%) Inflation of the pneumatic cuff Deflation of the pneumatic cuff AUC 90 Start point : 0.98 x baseline StO2 End point : 0.85 x baseline StO2 80 Recovery slope 70 Desaturation slope 60 Index of recruitment of microvessels 50 Start point : 1.05 x minimal StO2 40 Time Occlusion time

  15. Restoration of a “good” MAP with early introduction of NE resulted in recruitment of microvessels and better tissue oxygenation StO2 recovery slope (%/s) 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 with NE before NE p < 0.05

  16. Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When to start? 4- Which therapeutic target?

  17. Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When to start? 4- Which therapeutic target?

  18. 140 120 140 100 120 80 100 60 80 40 60 20 40 20 SAP MAP DAP vasodilatation reflects the vascular tone low DAP Consider vasopressors When to start vasopressors? • whenMAP is < 65 mmHgdespite “adequate” fluid resuscitation • or whenMAP is < 65 mmHgandDAP is low • even if the patient has not been yet fully fluid resuscitated

  19. Questions 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When to start? 4- Which therapeutic target?

  20. organ blood flow mean arterial pressure Autoregulation of organ blood flow 65 mmHg? ?

  21. MAP:65mmHg MAP:75mmHg MAP:85mmHg % 150 100 13 50 urine output capillary flow tonometry PCO2 gap red cell velocity

  22. organ blood flow Autoregulation of organ blood flow 65 75 85 Mean Arterial Pressure (mmHg)

  23. Crit Care Med 2000; 28:2729-2732 Crit Care Med 2005; 33:780 –786 increasing MAP above 65 mmHg results in little benefit

  24. 48 hrs 65 mmHg

  25. Crit Care Med 2000; 28:2729-2732 Crit Care Med 2005; 33:780 –786 MAP target value:65mmHg

  26. Probably higher target value if: • History of chronic hypertension

  27. 10 patients none with history of severe hypertension MAP:65mmHg MAP:75mmHg MAP:85mmHg % 150 100 13 50 urine output capillary flow tonometry PCO2 gap red cell velocity

  28. with prior hypertension no prior hypertension Organ Blood flow 65 mmHg Mean arterial pressure

  29. pts with chronic hypertension pts with no chronic hypertension

  30. Probably higher target value if: • History of chronic hypertension • High CVP

  31. Probably higher target value if: • History of chronic hypertension • High CVP • Increased abdominal pressure

  32. Is it dangerous to target a MAP value up to “normal values” (around 85 mmHg) in septic shock?

  33. 13 pts with septic shock * * Recovery slope %/min 65 75 85 65 MAP mmHg

  34. 6 pts with septic shock No worsening but improvement of microcirculation for MAP target up to 85 mmHg with NE Perfused Vessel Density Microvascular Flow Index

  35. 20 pts with septic shock

  36. Highly variableresponse among patients

  37. 20 pts with septic shock Perfused capillary density improved in pts with an altered sublingual perfusion at baseline, and decreased in patients with preserved basal microvascular perfusion.

  38. Conclusion 1- Why do we use vasopressors in septic shock? 2- Which first-line agent? 3- When to start? 4-Which therapeutic target? • at least 65 mmHg • probably higher value if: • History of chronic hypertension • High CVP • Increased abdominal pressure 65-85 mmHg seems to be a safe range Thank you

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