Individualized Mean Arterial Pressure Targets Guided by Cerebral Autoregulation in Critically Ill Patients

Abstract

Delirium is common in critically ill patients and is associated with poor in-hospital and post-discharge outcomes. Emerging evidence suggests that delirium may be linked to inadequate cerebral perfusion and impaired cerebral autoregulation. A proposed intervention to address this is the use of individualized optimal mean arterial pressure (MAPopt), derived from each patient’s autoregulatory range based on bedside hemodynamic monitoring in the intensive care unit (ICU). Interest is growing in whether MAPopt-guided management can optimize cerebral perfusion and reduce delirium risk, which is the broad focus of this thesis. To explore this topic, the thesis comprises two components. First, a scoping review was conducted to map the methodologies, feasibility, and clinical evidence surrounding MAPopt in critically ill adult populations. The review identified substantial variability in numerical MAPopt values and calculation methods across studies as well as key feasibility challenges such as poor physiological signal quality and insufficient MAP variation or monitoring duration. While preliminary findings support the potential clinical utility of MAPopt, few randomized controlled trials have been conducted. Further, subgroups such as patients without primary brain injury or those undergoing non-cardiac surgery remain understudied. Second, a prospective single-center pilot study evaluated the feasibility of identifying and targeting NIRS-derived MAPopt values in 16 mechanically ventilated patients in the ICU. MAPopt could be identified in most patients; however, maintaining MAP within narrow individualized targets (typically ≤10 mmHg) was limited. Together, these findings highlight key directions for future research in personalized blood pressure management in the ICU. Priorities include standardizing MAPopt calculation and reporting methods, expanding investigation to broader ICU populations, and developing strategies to improve physiological data capture and the ability to maintain individualized perfusion targets.