Individualized mean arterial pressure targets in critically ill patients guided by non-invasive cerebral-autoregulation: a scoping review

Critical Care volume 29, Article number: 196 Published: 16 May 2025

Background

Current guidelines recommend a uniform mean arterial pressure (MAP) target for resuscitating critically ill patients; for example, 65 mmHg for patients with sepsis and post-cardiac arrest. However, since cerebral autoregulation capacity likely varies widely in patients, uniform target may be insufficient in maintaining cerebral perfusion. Personalized MAP targets, based on a non-invasive determination of cerebral autoregulation, may optimize perfusion and reduce complications.

Objectives

This scoping review summarizes the numerical values, feasibility, and clinical data on personalized MAP targets in critically ill patients. The focus is on non-invasive monitoring, such as near-infrared spectroscopy and transcranial doppler ultrasound, due to their safety, practicality and applicability to patients with- and without brain injury.

Methods

Following PRISMA-ScR guidelines, a systematic search of Ovid MedLine, Embase (Ovid), and the Cochrane Library (Wiley) was conducted on September 28, 2023. Two independent reviewers screened titles, abstracts, and full texts for eligibility and manually reviewed references.

Results

Of 7,738 studies were identified, 49 met the inclusion criteria. Of these, 45 (92%) were observational and 4 (8%) were interventional. Patient populations included cardiac surgery (26, 53%), non-cardiac major surgery (4, 8%), cardiac arrest (8, 16%), brain injury (7, 14%), respiratory failure and shock (3, 6%), and sepsis (3, 6%). Optimal MAP was reported in 24 (49%), lower limit of autoregulation in 23 (47%), and upper limit of autoregulation in 10 studies (20%). Thirty-four studies reported partial data loss due to software failures, anomalous data, insufficient natural MAP fluctuation, and workflow barriers. Available randomized controlled trials (RCT) identified challenges with maintaining patients within their target range. Studies explored the associations between personalized MAP targets and a wide range of neurological and non-neurological outcomes, with the most significant and consistent associations identified for acute kidney injury and major morbidity and mortality. Ten studies investigated demographic predictors identifying only few predictors of personalized targets.

Conclusion

Preliminary investigations suggest considerable variability in personalized MAP targets, which may explain differences in clinical outcomes among critically ill populations. Key gaps remain, including a lack of observational studies in critically ill subpopulations other than cardiac surgery and well-designed RCTs. Resolving identified feasibility barriers might be crucial to successfully carrying out future studies.

Cerebral Oximetry During Cardiac Arrest: A Multicenter Study of Neurologic Outcomes and Survival

Cerebral Oximetry During Cardiac Arrest: A Multicenter Study of Neurologic Outcomes and Survival

Critical Care Medicine:

September 2016 - Volume 44 - Issue 9 - p 1663–1674

 Parnia, Sam et alObjectives: Cardiac arrest is associated with morbidity and mortality because of cerebral ischemia. Therefore, we tested the hypothesis that higher regional cerebral oxygenation during resuscitation is associated with improved return of spontaneous circulation, survival, and neurologic outcomes at hospital discharge. We further examined the validity of regional cerebral oxygenation as a test to predict these outcomes. Design: Multicenter prospective study of in-hospital cardiac arrest. Setting: Five medical centers in the United States and the United Kingdom. Patients: Inclusion criteria are as follows: in-hospital cardiac arrest, age 18 years old or older, and prolonged cardiopulmonary resuscitation greater than or equal to 5 minutes. Patients were recruited consecutively during working hours between August 2011 and September 2014. Survival with a favorable neurologic outcome was defined as a cerebral performance category 1–2. Interventions: Cerebral oximetry monitoring. Measurements and Main Results: Among 504 in-hospital cardiac arrest events, 183 (36%) met inclusion criteria. Overall, 62 of 183 (33.9%) achieved return of spontaneous circulation, whereas 13 of 183 (7.1%) achieved cerebral performance category 1–2 at discharge. Higher mean ± SD regional cerebral oxygenation was associated with return of spontaneous circulation versus no return of spontaneous circulation (51.8% ± 11.2% vs 40.9% ± 12.3%) and cerebral performance category 1–2 versus cerebral performance category 3–5 (56.1% ± 10.0% vs 43.8% ± 12.8%) (both p < 0.001). Mean regional cerebral oxygenation during the last 5 minutes of cardiopulmonary resuscitation best predicted the return of spontaneous circulation (area under the curve, 0.76; 95% CI, 0.69–0.83); regional cerebral oxygenation greater than or equal to 25% provided 100% sensitivity (95% CI, 94–100) and 100% negative predictive value (95% CI, 79–100); regional cerebral oxygenation greater than or equal to 65% provided 99% specificity (95% CI, 95–100) and 93% positive predictive value (95% CI, 66–100) for return of spontaneous circulation. Time with regional cerebral oxygenation greater than 50% during cardiopulmonary resuscitation best predicted cerebral performance category 1–2 (area under the curve, 0.79; 95% CI, 0.70–0.88). Specifically, greater than or equal to 60% cardiopulmonary resuscitation time with regional cerebral oxygenation greater than 50% provided 77% sensitivity (95% CI,:46–95), 72% specificity (95% CI, 65–79), and 98% negative predictive value (95% CI, 93–100) for cerebral performance category 1–2. Conclusions: Cerebral oximetry allows real-time, noninvasive cerebral oxygenation monitoring during cardiopulmonary resuscitation. Higher cerebral oxygenation during cardiopulmonary resuscitation is associated with return of spontaneous circulation and neurologically favorable survival to hospital discharge. Achieving higher regional cerebral oxygenation during resuscitation may optimize the chances of cardiac arrest favorable outcomes.