There have been a few studies that suggested that there may be some neuroprotective effect with a higher MAP goal in post-arrest patients. However, these studies were small and/or observational.
Intervention:
-The BOX trial was a double-blind, dual-center (Denmark), randomized trial
-Study population: >18 yo, OHCA of presumed cardiac cause
-Pts randomized to higher (77 mmHg) vs. lower (63 mmHg) MAP goal
-double-blinded by attaching a module that reported a BP that was 10% higher or lower than the pt’s actual BP
-Notable exclusion criteria:
-unwitnessed asystole or suspected intracranial bleeding/stroke
Results/Primary outcome:
-No sig difference in composite of death + Cerebral Performance Category of 3 or 4 (3= severe disability, 4= coma) within 90 days
-133 patients (34%) in the high-target group vs 127 patients (32%) in the low-target group (hazard ratio, 1.08;95%CI, 0.84 to 1.37; P=0.56)
Caveats/Takeaways:
-Mean difference in BP was 10.7 mmHg (95[CI], 10.0 to 11.4) which is still relatively clinically significant, but was lower than their goal difference of 14 mmHg
-They used IVF to target a CVP of 10 mmHg prior to initiation of norepi and used dopamine "if necessary"
-Consider generalizability given study population was patients with presumed cardiac cause of arrest
-Keeping a lower MAP goal of >65 mmHg is reasonable in post-arrest patients
References
Kjaergaard J, Møller JE, Schmidt H, et al. Blood-pressure targets in comatose survivors of cardiac arrest. N Engl J Med. 2022;387(16):1456-1466.
