Personalized Pressors – REACT Study Group

Written by Clay Smith

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A personalized approach to vasopressor management may improve kidney outcomes. Read on to see how this works.

Why does this matter?
We know outright hypotension is bad for the kidneys. But a one-size-fits-all mean arterial pressure (MAP) cut off also may not be best. Could we tailor pressors to match an individual’s need?

Personalized pressors
This was a multicenter prospective study with 302 critically ill patients ≥40 years old with non-hemorrhagic, largely septic shock, who needed at least 4 hours of vasopressor support. They measured the association of relative hypotension and acute kidney injury (AKI) or major adverse kidney event (MAKE-14) within 14 days. Relative hypotension was measured by comparing pre-illness baseline mean perfusion pressure (MPP) and MPP achieved during the critical illness with vasopressor support; a ≥20% MPP deficit was the key variable. MPP = MAP – CVP. Basal MPP was estimated using prior BP readings in the chart and prior right-heart catheterization or echocardiographic data to determine CVP (or mean values stratified for +/- heart disease if no echo or RHC). For every percentage increase in time-weighted average MPP deficit, the adjusted odds of significant AKI increased 5.6%, and odds of MAKE-14 increased 5.9%. Practically, it can be hard to estimate baseline MPP. An easier method may be to use baseline MAP. A MAP deficit also correlated significantly with AKI (aOR 1.059; 95%CI 1.021–1.099) and MAKE-14 (aOR 1.062; 1.021–1.105). The editorialist compared personalized pressor management to ventilator settings based on ideal body weight instead of a one-size-fits-all tidal volume. When you think of it like that, personalized pressors makes sense.

Relative Hypotension and Adverse Kidney-related Outcomes among Critically Ill Patients with Shock. A Multicenter, Prospective Cohort Study. Am J Respir Crit Care Med. 2020 Nov 15;202(10):1407-1418. doi: 10.1164/rccm.201912-2316OC.

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