Authors: Wang J-Y et al.
Journal: Anesthesiology, December 5, 2025. DOI: 10.1097/ALN.0000000000005881
Summary
This large retrospective cohort study evaluated whether critical closing pressure (Pcc) and tissue perfusion pressure (TPP) improve prognostication and risk stratification in patients with sepsis beyond mean arterial pressure (MAP) alone. While MAP is the cornerstone hemodynamic target in sepsis management, it does not directly account for microvascular flow cessation or effective tissue driving pressure.
Using two independent Chinese datasets encompassing 18 hospitals and more than 6,700 adult sepsis patients, the investigators estimated Pcc from routinely available physiologic data and calculated TPP as MAP minus Pcc. Patients were stratified into four physiologic phenotypes based on early Pcc and TPP values within 24 hours of sepsis diagnosis. Outcomes included ICU mortality and early acute kidney injury, with external validation performed in the MIMIC-IV cohort.
Patients with both low TPP and low Pcc experienced the highest mortality, whereas those with high TPP and high Pcc had the best outcomes. Importantly, after adjustment for MAP, the combination of elevated Pcc with reduced TPP demonstrated a U-shaped relationship with mortality and acute kidney injury, indicating that both excessive vascular tone and inadequate effective perfusion pressure contribute to organ dysfunction. These associations were robust and reproducible across datasets.
The study highlights that MAP alone may mask clinically important differences in microcirculatory perfusion. Incorporating Pcc and TPP into hemodynamic assessment may better identify high-risk sepsis phenotypes and guide more individualized blood pressure targets.
Key Points
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Critical closing pressure reflects the arterial pressure at which flow ceases and contributes to the vascular waterfall effect.
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Tissue perfusion pressure (MAP minus Pcc) represents the true driving pressure for organ blood flow.
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Low TPP combined with unfavorable Pcc identifies patients at highest risk for mortality and acute kidney injury.
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Risk relationships persisted even after adjustment for MAP, underscoring limitations of MAP-only targeting.
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Findings were consistent across multiple datasets, including external validation in MIMIC-IV.
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Pcc and TPP may enhance sepsis risk stratification and individualized hemodynamic management.
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