JMIR Publications

ABSTRACT

Background:

Sepsis affects nearly 20 million individuals annually, with hemodynamic resuscitation central to its management. While guidelines recommend a MAP target of 65 mmHg, the optimal threshold remains debated.

Objective:

This systematic review evaluates the effect of elevated MAP targets on mortality, splanchnic perfusion, renal outcomes, and vasoactive agent toxicity in septic resuscitation.

Methods:

Following PRISMA 2020 guidelines, we systematically searched PubMed, Embase, and Cochrane databases for studies comparing higher versus standard MAP targets in septic shock patients. Ten studies were included encompassing randomized controlled trials and observational cohorts. Data were synthesized narratively, with a random-effects meta-analysis performed for 28-day mortality. Study quality was assessed using RoB 2 and Newcastle-Ottawa Scale.

Results:

Ten studies enrolling 2,089 patients were included. No randomized trial demonstrated a statistically significant mortality benefit from elevated MAP targets, with pooled meta-analysis confirming no significant difference between higher and standard MAP groups (OR 1.16; 95% CI 0.92–1.46; P = 0.21; I² = 0%). Direct physiological evidence consistently demonstrated that MAP augmentation above 65 mmHg improves microcirculatory parameters without improving splanchnic perfusion, lactate clearance, or microcirculatory flow. Observational evidence identified a renal-protective MAP zone of 72–75 mmHg specifically in patients with chronic hypertension, chronic kidney disease, and early AKI. Vasopressor load emerged as the strongest independent predictor of multiorgan complications and mortality, surpassing MAP level itself. Elevated MAP targets were consistently associated with higher rates of atrial fibrillation and overall adverse events across multiple studies.

Conclusions:

Elevated MAP targets above 65 mmHg confer no mortality or perfusion benefit in unselected septic shock populations. Individualized MAP targeting in high-risk subgroups and vasopressor-sparing strategies warrant prioritization in future research.