PACUPod is your trusted source for AI-infused evidence-based insights tailored to advanced clinical pharmacists and physicians. Each episode dives into the latest primary literature, covering medication-focused studies across emergency medicine and critical care. We break down study designs, highlight key findings, and objectively discuss clinical implications—without the hype—so you stay informed and ready to apply new evidence in practice. Whether you’re preparing for board certification or striving for excellence in patient care, PACUPod helps you make sense of the data, one study at a time.
Britany: Welcome back to PACULit. Today, we’re discussing the OPTPRESS trial, which evaluated targeting high mean arterial pressure (MAP) in older patients with septic shock. Seth, great to have you here.
Seth: Thanks, Britany. Septic shock is a major challenge, especially in older adults. OPTPRESS fills a gap by focusing on patients aged 65 and older, often underrepresented in research.
Britany: Septic shock is a leading cause of ICU mortality. Older adults are vulnerable due to physiological changes and comorbidities. The 2021 Surviving Sepsis Campaign recommends an initial MAP target of at least 65 mmHg.
Seth: That 65 mmHg target has been standard, but there’s debate about whether higher MAP targets improve organ perfusion, especially in patients with chronic hypertension or stiffer vasculature.
Britany: The SEPSISPAM trial in 2014 compared high MAP (80–85 mmHg) versus standard (65–70 mmHg) in septic shock. No overall mortality benefit was found, but subgroup analyses suggested possible renal protection in hypertensive patients.
Seth: However, SEPSISPAM didn’t focus on older adults, who may respond differently to vasopressors. OPTPRESS specifically enrolled patients 65 and older to address this.
Britany: Older adults are a growing proportion of septic shock admissions. Higher MAP might improve organ perfusion but risks vasopressor-related adverse effects like arrhythmias or ischemia.
Seth: Balancing these risks and benefits was the rationale for OPTPRESS: to see if targeting MAP 80–85 mmHg improves outcomes or causes harm in older patients.
Britany: OPTPRESS was a multicenter, pragmatic, open-label randomized trial in Japan ICUs, reflecting real-world practice.
Seth: Inclusion criteria: patients ≥65 years with septic shock per Sepsis-3—requiring vasopressors to maintain MAP ≥65 mmHg and lactate >2 mmol/L despite fluids.
Britany: They excluded patients with vasopressor contraindications, advanced directives limiting care, and other confounders to ensure a homogenous group.
Seth: Intervention: vasopressors titrated to MAP 80–85 mmHg; comparator: usual care targeting 65–70 mmHg per guidelines.
Britany: Vasopressors continued until shock resolution or ICU discharge. Primary outcome was 90-day all-cause mortality.
Seth: Secondary outcomes included renal replacement therapy incidence, organ dysfunction scores, vasopressor dose/duration, and adverse events like arrhythmias and ischemia. Subgroup analyses considered hypertension and comorbidities.
Britany: Analysis was intention-to-treat with adequate power and interim safety monitoring due to vasopressor risks.
Seth: Results were striking. The high MAP group had higher 90-day mortality—39.3% versus 28.6% in usual care—leading to early trial termination for harm.
Britany: This suggests targeting MAP 80–85 mmHg in older septic shock patients is harmful, contrasting with SEPSISPAM’s neutral mortality findings in a broader population.
Seth: OPTPRESS provides strong evidence that conservative MAP targets remain appropriate for older adults, who may be more vulnerable to vasopressor adverse effects at higher pressures.
Britany: No significant reduction in renal replacement therapy was seen with higher MAP, challenging the idea that higher pressures protect renal function in this group.
Seth: This aligns with Li et al.’s 2022 review showing higher MAP doesn’t improve mortality but may reduce renal replacement therapy in hypertensive patients. OPTPRESS suggests this benefit may not apply broadly to older adults.
Britany: It highlights the need to individualize MAP targets, considering hypertension and renal risk. Pharmacists and clinicians should collaborate closely to titrate vasopressors carefully.
Seth: Clinically, this trial warns against aggressively pushing vasopressors to achieve higher MAPs in elderly patients due to increased arrhythmia and ischemia risk.
Britany: Also, drug interactions matter. Older patients often take beta-blockers or calcium channel blockers, affecting vasopressor response and hemodynamics.
Seth: The open-label design may introduce performance bias, but the significant mortality difference and early stopping strengthen the findings.
Britany: The study population was exclusively Japanese, which may limit generalizability, though physiological principles likely apply broadly.
Seth: The trial focused on short-term outcomes; longer-term functional status and quality of life weren’t assessed, important in older adults.
Britany: To summarize, OPTPRESS fills a key gap by showing that targeting MAP 80–85 mmHg in older septic shock patients increases mortality without renal benefit. Current guidelines targeting MAP ≥65 mmHg remain appropriate.
Seth: It reinforces individualized blood pressure management, considering age, comorbidities, and baseline blood pressure rather than a one-size-fits-all approach.
Britany: For clinical pharmacists, this means advocating careful vasopressor titration, monitoring adverse effects, and collaborating with critical care teams to optimize hemodynamics.
Seth: It also highlights the need for ongoing research to refine MAP targets, possibly using biomarkers or hemodynamic monitoring for precision.
Britany: Thanks for the discussion, Seth. OPTPRESS offers valuable guidance for managing older septic shock patients.
Seth: My pleasure, Britany. It’s great to see research impacting bedside care in this challenging population.
Britany: Thanks to our listeners for joining PACULit. Stay tuned for more clinical literature updates. Until next time!
Seth: Take care, everyone!
Britany: Before we wrap up, Seth, what do you think are the practical takeaways for ICU teams when managing older patients with septic shock, especially regarding vasopressor use?
Seth: Great question, Britany. First, it’s crucial to recognize that older patients often have altered vascular responsiveness and comorbidities that can increase their susceptibility to vasopressor side effects. So, while maintaining adequate perfusion pressure is essential, pushing MAP targets too high can do more harm than good. Clinicians should aim for the standard MAP target of around 65 mmHg and carefully monitor for signs of ischemia or arrhythmias.
Britany: That makes sense. And from a pharmacist’s perspective, it’s important to review the patient’s medication history, right? Since many older adults are on antihypertensives or other cardiovascular drugs that might interact with vasopressors.
Seth: Exactly. Beta-blockers, calcium channel blockers, and even some antiarrhythmics can blunt the response to vasopressors or increase the risk of adverse cardiac events. Adjusting vasopressor dosing with these factors in mind is key. Also, frequent reassessment is necessary because the hemodynamic status in septic shock can change rapidly.
Britany: Do you think future research might explore personalized MAP targets based on individual patient characteristics or advanced monitoring techniques?
Seth: Absolutely. There’s growing interest in using dynamic assessments like pulse pressure variation, echocardiography, or even biomarkers of tissue perfusion to tailor blood pressure goals. The one-size-fits-all approach is becoming outdated, especially in heterogeneous populations like older adults with septic shock.
Britany: That would be a significant advancement. It could help avoid both under- and overtreatment with vasopressors, improving outcomes and reducing complications.
Seth: Definitely. Also, integrating multidisciplinary care—including pharmacists, nurses, and physicians—can optimize vasopressor management and ensure early detection of adverse effects.
Britany: Thanks for those insights, Seth. It’s clear that OPTPRESS not only informs us about MAP targets but also emphasizes the complexity of managing septic shock in the elderly.
Seth: Agreed. It’s a reminder that evidence-based practice must always be balanced with clinical judgment and individualized patient care.
Britany: Well, that’s all for today’s episode of PACULit. Thanks again, Seth, for sharing your expertise.
Seth: Thank you, Britany. Looking forward to our next discussion.
Britany: And thanks to our listeners for tuning in. Stay safe and keep up the great work in critical care!
Seth: Take care, everyone!