For critically ill and hemodynamically unstable patients , goal-directed therapy for blood pressure with continuous daily monitoring is needed. The mortality rate for those who experience hypertensive emergencies can reach 50% within 12 months of the episode. The incidence of perioperative hypertension in patients undergoing cardiac surgery is approximately 50%, with this figure dropping to 25% for non-cardiac surgery.
Hypotension is a common clinical manifestation of shock and the most frequently monitored measure in the intensive care unit (ICU) . Hypovolemic shock accounts for 16% of all shock patients admitted to the ICU, primarily due to endogenous or exogenous blood volume loss, which can lead to tissue and organ hypoperfusion.
Therefore, it remains a challenge to standardize blood pressure control and medication use in critically ill patients, control it within an ideal range, restore tissue and organ perfusion, correct microcirculation disorders, and reduce events. related adverse events
To further optimize blood pressure control and regulation in critically ill patients, the Chinese Society of Critical Care Medicine (CSCCM) commissioned a panel of experts to discuss, summarize and formulate relevant content using the GRADE Grading of Recommendations Assessment Development and Evaluation scale to develop the Expert Consensus on Blood Pressure Control in Critically Ill Patients ( Table 1 ).
Table 1. GRADE recommendation levels (Classification of recommendations, assessment, development and evaluation)
| Qualification | Recommendation | Evidence |
| Grade 1+ | Highly recommended | High quality evidence |
| Grade 2+ | Weakly recommended | Low quality evidence |
| Expert opinion | Expert advice | Insufficient evidence |
| Grade 2- | Weakly recommended | Low quality evidence |
| Grade 1- | Totally not recommended | High quality evidence |
| Scope and definition of consensus |
This consensus proposes recommendations focused mainly on:
A- The implementation of blood pressure monitoring in critically ill patients.
B- Goal-directed blood pressure therapy for patients in shock.
C- Hypertension in seriously ill patients and emergency treatment of hypertension.
D- Management of blood pressure in severe patients in different disease states.
| A- Monitoring methods and medications for blood pressure in critically ill patients. |
Question 1: What are appropriate blood pressure monitoring methods for critically ill patients?
| Recommendation 1: For patients with hypotension requiring vasopressors or hypertensive emergencies requiring emergency intervention, the authors suggest that invasive blood pressure monitoring be the first option (Grade 2+, weak recommendation). |
Question 2: Which site should be selected for invasive blood pressure monitoring?
| Recommendation 2: The radial artery is suggested as the preferred site for invasive blood pressure monitoring (grade 2+, weak recommendation). |
| Intravenous pharmacological treatment for blood pressure control in critically ill patients |
The blood pressure of critically ill patients fluctuates considerably and medications must exert a rapid and strong effect to control blood pressure. Therefore, intravenous administration is often used.
| B- Blood pressure management in patients with shock |
Blood pressure management in patients with septic shock:
In septic shock, hypotension leads to inadequate oxygen delivery and tissue perfusion. Therefore, blood pressure control is necessary to restore the balance between systemic oxygen supply and oxygen consumption as quickly as possible.
Question 3: What is the target blood pressure for initial resuscitation in patients with septic shock?
| Recommendation 3: For patients with septic shock requiring vasopressors, experts recommend an initial target mean arterial pressure (MAP) ≥65 mmHg (Grade 1+, strong recommendation). |
Question 4: What is the initial resuscitation blood pressure goal for septic shock patients with chronic hypertension?
| Recommendation 4: For septic shock patients with chronic hypertension, the authors suggest that baseline MAP be maintained between 80 and 85 mmHg or normal levels (Grade 2+, Weak Recommendation). |
Question 5: What diastolic blood pressure (DBP) goal should be maintained in patients with septic shock?
| Recommendation 5: For patients with septic shock, the authors recommend that diastolic blood pressure be maintained at >50 mmHg (Grade 2+, weak recommendation). |
Question 6: For patients with septic shock, which vasopressor should be selected to maintain target blood pressure?
| Recommendations 6: (a) For patients with septic shock, norepinephrine is recommended as the preferred vasopressor (Grade 1+, strong recommendation); and (b) for patients with septic shock requiring norepinephrine, if target MAP cannot be achieved, we suggest coadministration of vasopressin instead of increasing the norepinephrine dose (Grade 2+, weak recommendation). |
| Blood pressure management in patients with hemorrhagic shock |
Hemorrhagic shock should be treated by stopping bleeding as quickly as possible, eliminating the etiology and restoring blood volume. An appropriate pressure level is essential to maintain tissue perfusion, but an excessively high target blood pressure can lead to aggravated bleeding during treatment of hemorrhagic shock.
Question 7: What is the target blood pressure in patients with hemorrhagic shock with uncontrolled bleeding?
| Recommendation 7: (a) For patients with traumatic hemorrhagic shock without traumatic brain injury (TBI), a permissive hypotension strategy (systolic blood pressure [SBP] ≥70 mmHg, MAP 50–60 mmHg) is recommended until bleeding is controlled (Grade 2+, weak recommendation). (b) For hemorrhagic shock patients with severe TBI (Glasgow Coma Scale [GCS] ≤8), we suggest maintaining SBP >90 mmHg (Grade 2+, weak recommendation). |
Question 8: What is the target blood pressure in the initial resuscitation of patients with hemorrhagic shock?
| Recommendation 8: For patients with hemorrhagic shock, we suggest a relatively lower target MAP of 60 to 70 mmHg for initial resuscitation (grade 2+, weak recommendation). |
| Management of blood pressure in patients with cardiogenic shock |
Cardiogenic shock is a state of low cardiac output resulting in life-threatening end-organ hypoperfusion and hypoxia. Acute myocardial infarction with left ventricular dysfunction is the most common cause of the condition, and other causes include severe valvular disease, pericardial disease, arrhythmias, and myocarditis.
Question 9: What is the initial blood pressure goal in patients with cardiogenic shock?
| Recommendation 9: For patients with cardiogenic shock requiring vasopressors, we suggest a target MAP of 65–70 mmHg (Grade 2+, Weak recommendation). |
Question 10: For patients with cardiogenic shock, at what level should DBP be maintained?
| Recommendation 10: It is suggested to maintain the target DBP >60 mmHg for patients with cardiogenic shock. |
Question 11 : What is the initial blood pressure goal for patients with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO)?
| Recommendation 11: We suggest a MAP ≥65 mmHg as the initial blood pressure goal for patients with cardiogenic shock requiring VAECMO (Expert opinion). |
| C- Management of hypertension in critical patients and hypertensive emergencies |
Question 12: Which patients with acutely and severely elevated blood pressure should be admitted to the ICU?
| Recommendation 12: The authors indicate that patients with acute onset SBP >180 mmHg and/or DBP >110 mmHg accompanied by organ dysfunction should be admitted to the ICU (Grade 2+, Weak recommendation). |
Question 13: Should antihypertensive therapy be the routine treatment for patients admitted to the ICU with severe hypertension?
| Recommendation 13: It is recommended that antihypertensive therapy be administered intravenously for patients with SBP > 180 mmHg and/or DBP > 110 mmHg with organ dysfunction (Grade 2+, Weak Recommendation). |
Question 14: For patients with severe acute hypertension admitted to the ICU, how should the rate of blood pressure reduction be established?
| Recommendation 14: For patients with severe acute hypertension, we suggest a gradual strategy for antihypertensive therapy. Except in acute aortic dissection, SBP should be reduced by no more than 25% in the first hour, then reduced to 160/100-110 mmHg over the next 2-6 hours and cautiously reduced to normal over the next 24-48 hours. hours (Grade 2+, Weak Recommendation). |
| D- Management of hypertension in special types of critically ill patients |
| Management of blood pressure in patients with abdominal compartment syndrome |
Question 15: Can intraperitoneal perfusion pressure instead of MAP be used as an endpoint of shock resuscitation in patients with intra-abdominal hypertension (IAH) during shock resuscitation?
| Recommendation 15: For patients with IAH, we suggest maintaining intraperitoneal perfusion pressure at 60 mmHg based on control of increased intra-abdominal pressure (Expert opinion). |
| Blood pressure management |
Question 16: What is the target blood pressure in patients with moderate to severe TBI?
| Recommendation 16: For patients with hypotension, we suggest maintaining SBP >100 mmHg and MAP >80 mmHg (GRADE 2+, weak recommendation). For patients with hypertension, we suggest maintaining SBP <160 mmHg, focusing on the etiology and treatment of inductive factors (Expert opinion). |
Question 17: How is target blood pressure individualized in patients with TBI?
| Recommendation 17: Targeting individualized blood pressure based on increased intracranial pressure and cerebral perfusion pressure is recommended for patients with TBI. Multimodal monitoring can be performed in experienced medical units (Expert opinion). |
| Blood pressure management in stroke patients |
Question 18: What is the target blood pressure in patients with acute ischemic stroke without intravenous thrombolysis or mechanical thrombectomy?
| Recommendation 18: For patients with acute ischemic stroke without intravenous thrombolysis and mechanical thrombectomy, the authors indicate starting antihypertensive therapy if SBP ≥220 mmHg and/or DBP ≥120 mmHg and reducing SBP by 10-25% in 24 h ( Grade 2+, weak recommendation). |
Question 19: What is the target blood pressure in patients with acute ischemic stroke receiving intravenous thrombolysis?
| Recommendation 19: Before intravenous thrombolysis, it is suggested to start antihypertensive therapy if BP ≥180/105 mmHg. After thrombolytic recanalization, we suggest maintaining SBP within 130-140 mmHg (Grade 2+, Weak recommendation). |
Question 20: What is the target blood pressure after mechanical thrombectomy in patients with acute ischemic stroke?
| Recommendation 20: We suggest maintaining SBP between 130 and 140 mmHg within 24 h after mechanical thrombectomy (grade 2+, weak recommendation). |
Question 21: What is the target blood pressure in patients with acute intracerebral hemorrhage (ICH)?
| Recommendation 21: The authors recommend maintaining SBP between 130 and 140 mmHg if SBP is 150 to 220 mmHg and maintaining SBP between 140 and 180 mmHg if SBP >220 mmHg (Grade 2+, weak recommendation). |
Question 22: Does SBP variability affect prognosis in hypertensive patients with acute ICH?
| Recommendation 22: High SBP variability is associated with poor prognosis. Therefore, we suggest constant and continuous antihypertensive therapy (grade 2+, weak recommendation). |
| Blood pressure management in patients with subarachnoid hemorrhage (SAH) |
Question 23: What is the blood pressure goal in patients with SAH?
Recommendation 23: There is no definitive evidence to support the magnitude of blood pressure reduction and optimal blood pressure levels in acute SAH, and the recommended control goals before aneurysm management are to maintain SBP <160 mmHg and MAP about 80 mmHg; Blood pressure management after aneurysm management should be individualized with reference to baseline blood pressure and multimodal brain monitoring to determine optimal divided blood pressure. In the case of delayed cerebral ischemia (DCI), blood pressure can increase by 20% depending on the situation. (Grade 2+, strong recommendation, Level of evidence B); We do not recommend the routine use of ’triple H therapy’ to prevent and treat ICD. (Grade 2-, strong recommendation, Level of evidence B) |
| Management of blood pressure in patients with acute renal failure (AKI) |
Question 24: What is the blood pressure goal in patients with ARF without a history of hypertension?
| Recommendation 24: We suggest maintaining MAP ≥65 mmHg for patients with ARF without a history of hypertension (Grade 2+, weak recommendation). |
Question 25: What is the target MAP for AKI patients with a history of hypertension?
| Recommendation 25: We suggest maintaining MAP between 80 and 85 mmHg or at baseline blood pressure levels for ARF patients with a history of hypertension (grade 2+, weak recommendation). |
Question 26: To prevent the onset or progression of AKI, what renal perfusion pressure (RPP) should be targeted in critically ill patients?
| Recommendation 26: PRR should be maintained at ≥60 mmHg in critically ill patients to avoid the onset or progression of AKI. We suggest titrating the blood pressure level according to the PPR, if possible (Grade 2+, weak recommendation). |
Question 27: What is the target blood pressure for critically ill patients on continuous renal replacement therapy (CRRT)?
| Recommendation 27: Hypotension is associated with a high risk of mortality during CRRT. Therefore, we suggest keeping PPR ≥60 mmHg as a reasonable goal (Expert Opinion). |
| Perioperative management of blood pressure in cardiac surgery |
Question 28: What is the target blood pressure after coronary artery bypass grafting (CABG)?
| Recommendation 28: It is recommended to maintain MAP ≥70 mmHg in post-CABG patients to ensure adequate myocardial perfusion (Expert opinion). |
Question 29: What is the target blood pressure during the perioperative period in patients with aortic dissection?
| Recommendation 29: The authors suggest that the perioperative SBP of patients with aortic dissection be controlled between 100 and 120 mmHg. Heart rate should be controlled at approximately 60 beats/min. Perfusion of vital organs must be maintained with the premise of preventing rupture and bleeding (Grade 2+, Weak recommendation). |
Question 30: What is the target blood pressure after left ventricular assist device (LVAD) implantation?
| Recommendation 30: We suggest maintaining MAP between 70 and 80 mmHg after LVAD implantation because high blood pressure may be related to poor neurological prognosis (Grade 2+, weak recommendation). |
| Postoperative blood pressure management |
Question 31: Do non-cardiac surgery patients need postoperative blood pressure monitoring?
| Recommendation 31: For hemodynamically stable patients, routine noninvasive blood pressure monitoring (NIBP) is recommended. For hemodynamically unstable patients, invasive blood pressure (IP) monitoring should be performed (Expert opinion). |
Question 32: What is the threshold for starting blood pressure management?
| Recommendation 32: For hypotensive patients, the threshold for initiating blood pressure management is MAP <65 mmHg (Grade 2+, weak recommendation). For hypertensive patients, the threshold for initiating blood pressure management is SBP >180 mmHg or DBP >110 mmHg, whichever is greater (Expert opinion). |
Question 33: How should postoperative blood pressure be managed in patients undergoing non-cardiac surgery?
| Recommendation 33: For hypotensive patients, volume responsiveness should be evaluated after excluding residual effects of anesthesia-related medications. For hypertensive patients, predisposing factors (e.g., pain, dyspnea, and anxiety) should be eliminated before blood pressure management (expert opinion). |
| Blood pressure management |
Question 34: What are the indications for transfer to the ICU in patients with postsurgical pheochromocytoma?
| Recommendation 34: For patients who experience intraoperative hemorrhage or severe hemodynamic fluctuations (MAP <65 mmHg), and/or still require vasoactive drugs to maintain blood pressure after pheochromocytoma surgery, transfer to the ICU for monitoring and treatment is recommended. additional (BPS). |
Question 35: How should patients with postoperative hypotension be managed?
| Recommendation 35: (a) For patients with a significant drop in blood pressure or hypotension, rapid fluid resuscitation and immediate administration of vasoactive drugs should be performed immediately (expert opinion); b) Immediate glucocorticoid supplementation is needed when patients develop intractable hypotension (Grade 2+, weak recommendation); and (c) Intra-aortic balloon counterpulsation (IABP) or ECMO should be considered when treatments (a) and (b) above are not effective (expert opinion) |
| Blood pressure management in critically ill patients with severe heart disease |
Question 36: What is the target blood pressure for acute coronary syndrome (ACS)?
| Recommendation 36: For patients with ACS combined with hypertension, we suggest that SBP be controlled within 120-130 mmHg and DBP ≥60 mmHg to maintain coronary artery blood flow (Grade 2+, weak recommendation). |
Question 37: What is the target blood pressure for patients with acute heart failure (AHF)?
| Recommendation 37: For patients with AHF combined with hypertension, we suggest that SBP be controlled within 120-130 mmHg (Grade 2+, weak recommendation). |
| Summary |
Controlling blood pressure in critically ill patients is essential. The task force summarized the results of recent trials, performed a GRADE classification based on evidence-based medical data, and formulated a national expert consensus on blood pressure control in critically ill patients, including shock, hypertension, SCA, complicated head injury, severe kidney disease, perioperative period and severe heart disease. The objectives of this consensus were to clarify optimal approaches to blood pressure monitoring, clinical management, and related pharmacotherapy options for critically ill patients. However, there are still limitations to this consensus. A systematic review was not performed, but GRADE-based recommendations still provide strong evidence to guide clinicians. Several recent and important trials were not included due to time constraints. The authors welcome further suggestions to advance the development of the next version of the consensus and hope to add more evidence-based medical data in the future for optimal updating. |
