What is the target mean arterial pressure (MAP) in patients with cirrhosis?

From the Guidelines

The target mean arterial pressure (MAP) in patients with cirrhosis should be maintained at 65 mmHg, as recommended by the most recent guidelines. This target is based on the latest evidence from the American Association for the Study of Liver Diseases (AASLD) practice guidance on acute-on-chronic liver failure and the management of critically ill patients with cirrhosis 1. The guidance suggests that a MAP of 65 mmHg is appropriate for patients with cirrhosis and septic shock, with ongoing assessment of end-organ perfusion.

Key Considerations

• The optimal approach is to use an individualized MAP target based on frequent assessment of end-organ perfusion, including mental status, capillary refill, urine output, extremity perfusion, lactate, central venous oxygen saturation, and end-organ function 1.
• Norepinephrine is recommended as the first-line vasopressor agent to maintain adequate organ perfusion pressure in patients with septic shock, starting at a dose of 0.01-0.5 μg/kg/min 1.
• Vasopressin deficiency has been documented in cirrhosis, and the Surviving Sepsis Campaign Guidelines suggest considering its use in patients with refractory shock requiring high-dose vasopressors.

Management Strategies

• Careful volume resuscitation with balanced crystalloids, such as lactated Ringer's, or albumin (in select indications) is recommended to optimize volume status in critically ill patients with cirrhosis and shock 1.
• Bedside echocardiography can be useful to evaluate volume status and cardiac function in patients with cirrhosis and hypotension or shock 1.
• Invasive hemodynamic monitoring, including arterial and central venous catheterization, may be necessary for adequate assessment of cardiac function and titration of vasopressors and fluid resuscitation 1.

From the Research

Target Mean Arterial Pressure in Cirrhosis

The target mean arterial pressure (MAP) in patients with cirrhosis is a critical aspect of their management, particularly in the context of septic shock or hepatorenal syndrome. Several studies have investigated the optimal MAP targets in these patients.

• A study published in the Journal of Hepatology 2 compared the efficacy of a high (80-85 mmHg) vs. low (60-65 mmHg) target MAP strategy in patients with cirrhosis and septic shock. The results showed that a higher MAP strategy does not confer a survival benefit but improves tolerance to dialysis, lactate clearance, and renal recovery.
• Another study published in Critical Care Medicine 3 suggested that maintaining a MAP of greater than 65 mmHg may be a reasonable target in patients with cirrhosis admitted to the ICU. The study found that time-weighted-average-mean arterial pressure and cumulative-time-below mean arterial pressure thresholds were associated with ICU mortality.
• A study published in Hepatology 4 found that an increase in mean arterial pressure of ≥5 mmHg at day 3 of treatment with terlipressin and albumin was an independent predictive factor of response to therapy in patients with type 1 hepatorenal syndrome.
• A study published in the Scandinavian Journal of Gastroenterology 5 analyzed the arterial pressure curve in patients with cirrhosis and found that the arterial pulsation in cirrhosis is qualitatively changed with reduced pulse reflections.
• A recent study published in Liver Transplantation 6 found that outpatient MAP was associated with cirrhosis-related outcomes, including stage 2 acute kidney injury, a 5-point increase in the MELD-Na score, and waitlist mortality. The study identified an outpatient MAP of 82 mmHg as the threshold most associated with these outcomes.

Key Findings

• A higher MAP target strategy may be recommended for patients with cirrhosis and septic shock, with close monitoring of adverse events 2.
• Maintaining a MAP of greater than 65 mmHg may be a reasonable target in patients with cirrhosis admitted to the ICU 3.
• An increase in mean arterial pressure of ≥5 mmHg at day 3 of treatment with terlipressin and albumin is an independent predictive factor of response to therapy in patients with type 1 hepatorenal syndrome 4.
• Outpatient MAP is associated with cirrhosis-related outcomes, and an outpatient MAP of 82 mmHg may be the threshold most associated with these outcomes 6.