Authors: Wang J et al.
Anesthesiology 144(4):886–897, April 2026
Summary:
This large retrospective cohort study evaluates whether critical closing pressure (Pcc) and tissue perfusion pressure (TPP) provide better prognostic insight than mean arterial pressure (MAP) alone in patients with sepsis. While MAP has traditionally been the primary target for resuscitation, it does not fully capture the complexity of microcirculatory blood flow.
Using data from over 6,700 septic patients across multiple centers—with external validation in an additional cohort—the authors estimated Pcc and calculated TPP (MAP − Pcc). Patients were stratified into four groups based on combinations of high and low TPP and Pcc.
The findings showed clear outcome differences. Patients with both low TPP and low Pcc had the worst outcomes, including the highest ICU mortality (~35%), while those with high TPP and high Pcc had the best outcomes (~20% mortality). Importantly, even after adjusting for MAP, a U-shaped relationship was observed—indicating that both inadequate perfusion pressure and abnormal vascular tone contribute to worse outcomes.
These results suggest that MAP alone is insufficient to assess tissue perfusion in sepsis. Instead, TPP better reflects the true driving force of blood flow, while Pcc captures downstream vascular resistance that can limit perfusion even when MAP appears adequate.
Although these measurements are currently derived from modeling rather than direct bedside tools, the study supports a shift toward more physiologically meaningful parameters for risk stratification and potentially future management strategies.
Key Points:
- MAP alone does not fully reflect tissue perfusion in sepsis
- Tissue perfusion pressure (TPP = MAP − Pcc) is a more relevant physiologic metric
- Low TPP–low Pcc patients had the highest mortality (~35%)
- High TPP–high Pcc patients had the lowest mortality (~20%)
- Pcc and TPP provide independent prognostic value beyond MAP
- Suggests a U-shaped relationship between vascular tone, perfusion, and outcomes
What You Should Know:
This reinforces a big shift: a “normal” MAP doesn’t mean the patient is perfusing. The problem may be downstream. If this holds up clinically, we may stop targeting MAP alone and start thinking in terms of true perfusion pressure.
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