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Permissive Hypotension in Elderly – Is a MAP 60-65 mm Hg Safe?

March 20, 2020

Written by Clay Smith

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It was safe to allow older patients with vasodilatory shock to have a lower target MAP of 60-65 mm Hg but not clearly superior to usual care.

Why does this matter?
Surviving Sepsis 2012 recommended a MAP target of 65 mm Hg, in general, and a higher target in elderly patients and those with chronic hypertension or coronary artery disease. Yet, SEPSISPAM (awesome study name!) and the OVATION pilot study seemed to signal this could lead to higher mortality in the elderly. Does allowing permissive hypotension in patients ≥65 years and only using vasopressors to maintain a MAP target of 60-65 mm Hg vs usual care improve 90-day mortality?

How low can you go…
This was a RCT, the 65 Trial, with 2,463 patients ≥65 years who were randomized into well matched, unblinded groups receiving usual care or permissive hypotension, with a lower MAP target of 60-65 mm Hg. There was no difference in 90-day mortality, which was the primary outcome: 41% permissive hypotension vs 43.8% usual care; difference -2.85% (95%CI -6.75 to 1.05). There was a lower total dose and less time on vasopressors in the permissive hypotension group. Serious adverse events, like renal failure or SVT, were similar among the groups. Counterintuitively, the subgroup with chronic hypertension was found to have statistically significant improvement in mortality with a permissive hypotension approach; but with no statistical correction for multiple comparisons, this may have been due to chance. It is unlikely this approach would cause harm. What I take home is that permissive hypotension in elderly patients who need vasopressors for shock appears safe and may even benefit select patients.

Source
Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA. 2020 Feb 12. doi: 10.1001/jama.2020.0930. [Epub ahead of print]

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What are your thoughts?