What is the impact of chronic hypertension on sepsis (Systemic Inflammatory Response Syndrome)?

From the Guidelines

Chronic hypertension in sepsis requires careful management to balance organ perfusion and avoid hypotension, with a recommended mean arterial pressure (MAP) target of 65 mmHg, as supported by the Surviving Sepsis Campaign guidelines 1. The management of chronic hypertension in sepsis is complex and requires consideration of the patient's individual circumstances.

• For patients with pre-existing hypertension who develop sepsis, antihypertensive medications should be continued if the MAP remains above 65 mmHg.
• However, if the patient becomes hypotensive (MAP < 65 mmHg), antihypertensive medications, particularly ACE inhibitors, ARBs, and diuretics, should be temporarily held, as they can exacerbate hypotension in sepsis 1.
• Once hemodynamic stability is achieved with fluid resuscitation and vasopressors if needed, typically norepinephrine starting at 0.05-0.1 mcg/kg/min, antihypertensives can be gradually reintroduced.
• Beta-blockers may be continued at reduced doses if the patient has coronary artery disease or tachyarrhythmias, unless contraindicated by bradycardia or heart failure.
• Calcium channel blockers can often be safely continued if blood pressure permits.
• When restarting antihypertensives during recovery, the dose should be started at approximately half the previous dose and titrated based on blood pressure readings every 4-6 hours, as recommended by the Surviving Sepsis Campaign guidelines 1. This approach acknowledges the physiologic changes in sepsis, including vasodilation and capillary leak, which can dramatically alter a patient's response to their usual antihypertensive regimen. Key considerations in the management of chronic hypertension in sepsis include:
• Individualizing the MAP target based on the patient's circumstances, such as previous hypertension or atherosclerosis.
• Monitoring regional and global perfusion, such as blood lactate concentrations, skin perfusion, mental status, and urine output.
• Adequate fluid resuscitation as a fundamental aspect of hemodynamic management.
• Early use of vasopressors as an emergency measure in patients with severe shock, with efforts to wean vasopressors with continuing fluid resuscitation.

From the Research

Impact of Chronic Hypertension on Sepsis

• Chronic hypertension can affect the management of sepsis, particularly in terms of blood pressure targets 2, 3, 4, 5.
• Studies suggest that patients with chronic hypertension may require higher mean arterial pressure (MAP) targets to minimize renal injury, with a target of 80-85 mmHg recommended 3, 4, 5.
• However, achieving high MAP targets may require higher doses of vasopressors, which can have harmful effects due to sympathetic over-stimulation 4.
• The SEPSISPAM Trial found that targeting a high MAP (80-85 mmHg) in patients with septic shock and chronic hypertension resulted in significantly less renal failure compared to a low MAP target (65-70 mmHg) 4.
• Individualized approaches to blood pressure management may be necessary, taking into account the patient's baseline condition and underlying health status 6.

Blood Pressure Targets in Sepsis

• The Surviving Sepsis Campaign Guidelines recommend a MAP higher than 65 mmHg for patients with septic shock 4.
• However, the optimal MAP target for patients with chronic hypertension is still debated, with some studies suggesting a higher target of 75-85 mmHg may be beneficial 3, 4, 5.
• Organ-specific perfusion pressure targets may also be important to consider, including 50-70 mmHg for the brain, 65 mmHg for renal perfusion, and >50 mmHg for hepato-splanchnic flow 3.

Clinical Implications

• Early administration of norepinephrine may be beneficial for septic shock patients to restore organ perfusion, with individualized MAP targets based on the patient's underlying condition 2.
• The use of vasopressin may be considered in cases of refractory hypotension, as it acts on different vascular receptors than α1-adrenergic receptors 2.
• Further research is needed to determine the optimal blood pressure targets and management strategies for patients with septic shock and chronic hypertension 5, 6.