Diastolic arterial blood pressure: a reliable early predictor of survival in human septic shock.
BACKGROUND
Emphasis in therapy of human septic shock is shifting towards reliable end points and predictors of survival. Rationale is to study whether the evolution of cardiovascular reactivity in view of the administered doses of norepinephrine is an early predictor of in-hospital survival and to determine the optimal threshold of norepinephrine therapy and its consequences on renal function.


METHODS
Observational study of a prospective cohort of patients in septic shock, hospitalized in intensive care unit at least 24 hours before requiring norepinephrine. Excluded were patients requiring <72 hours of continuous norepinephrine (16 patients) or who received corticosteroids. Hemodynamic parameters (heart rate, blood pressure, urinary output, and temperature) were continuously monitored.


RESULTS
Of 68 patients, 45 survived [intensive care unit stay of 24 (12-36) days, hospital stay of 36 (27-66) days], and 23 died 5 (3-10) days after septic shock onset and norepinephrine treatment. Multivariate analysis revealed four independent positive predictive factors of short-term (10 days) outcome: Simplified Acute Physiology Score (SAPS) II <50 [odds ratio (OR) 6.4, 95% confidence interval (95% CI) 1.3-30.7, p < 0.011], and on day 3 Logistic Organ Dysfunction System (LODS) score <6 (OR 29.1, 95% CI 2.7-314.3, p = 0.0056), norepinephrine concentration <0.5 mug/kg/min (OR 17.6, 95% CI 2.2-142.0, p < 0.0007), diastolic arterial pressure >50 mm Hg (OR 24.8, 95% CI 2.9-215.9, p < 0.004), but not systolic arterial pressure.


CONCLUSIONS
Septic shock survival increases when dose of 0.5 mug/kg/min of norepinephrine continuously improves vascular tone within the first 48 hours, or when diastolic arterial pressure (>50 mm Hg) is restored. Norepinephrine has beneficial effects on renal function. Predictive value of LODS score on day 3 is demonstrated, while SAPS II is confirmed as the only reliable predictive factor in first 24 hours.
Benchekroune
Samir
S
Department of Anesthesiology and Intensive Care, Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
Karpati
Peter C J
PC
Berton
Christine
C
Nathan
Cédric
C
Mateo
Joaquim
J
Chaara
Mansour
M
Riché
Florence
F
Laisné
Marie-Josèphe
MJ
Payen
Didier
D
Mebazaa
Alexandre
A
D018806:APACHE; D000368:Aged; D001794:Blood Pressure / Q000187:drug effects*; D002316:Cardiotonic Agents / Q000627:therapeutic use; D004280:Dobutamine / Q000627:therapeutic use; D005260:Female; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D007362:Intensive Care Units; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000494:pharmacology / Q000627:therapeutic use*; D011379:Prognosis; D012372:ROC Curve; D012772:Shock, Septic / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality; D016019:Survival Analysis; D014662:Vasoconstrictor Agents / Q000494:pharmacology / Q000627:therapeutic use*
D002316:Cardiotonic Agents; D014662:Vasoconstrictor Agents; D004280:Dobutamine; D009638:Norepinephrine