December 2025

Question

- should we target a higher MAP target for older patients with sepsis

Title

- Efficacy of targeting high mean arterial pressure for older patients with septic shock (OPTPRESS): a multicentre, pragmatic, open-label, randomised controlled trial

Author

- Akira Endo et al 2025 ICM

Background

- yay sepsis... lots of it around, it's been fairly hammered into us through training and it keeps me employed in the intensive care unit.

- we commonly use vasopressors like noradrenaline to maintain mean arterial pressure as we think (though interestingly we have never proved) that this is good for patients. The perfusing pressure of almost organ beds in the body is around 65.

- the theory is that older people with stiffer vasculature or perhaps used to a higher perfusing pressure would benefit from a higher MAP target. This is not a new question and previous RCT (the aply named 65 trial) suggest a standard 60-65mmHg is just fine

- enter the OPTPRESS trial to look at the question in elderly japanese patients.

Methods

- included people admitted to the ICU (only randomised once in the unit, not in the ED) with septic shock per sepsis 3 definitions.

- fluid was given sensibly rather than the mandatory 3L bolus

- randomised 80-85 vs 65-70mmHg. maintained for 72 hrs or till they got better - allowed to drop the MAP target in higher group if they thought the higher dose was causing problems - norad and vasopressin used

- all cause mortality at 90 days as outcome

- they hypothesised that they would find a 10% absolute mortality benefit on a baseline of 45% which is a little mad. But this is typical in RCTs were your sample size is determined by resources and reality rather than by what is clinically likely

Results

- aiming for 800 or so but stopped early for potential harm in the high target group. stopped at 180 patients

- 40% vs 30% mortality faouring the lower target - not entirely clear what they were dying of more frequently (for example it does not seem to be more dead hut in the high MAP group)

Thoughts

- stick with 65 as your target whether older or young. not sure you have to have a japanese patient to implement this recommendation

- good example of how things we do commonly can have unanticipated harms. Pressors are not benign it seems

- it does seem to beg the question "how low can you go". If high is bad then maybe low is good?

Guidelines 2025 - English

NHS England » Urgent and emergency care plan 2025/26

https://aace.org.uk/wp-content/uploads/2025/02/202526-Ambulance-Commissioning-Guidance-FINAL.pdf

Overview | Overweight and obesity management | Guidance | NICE

Overview | Suspected sepsis in people aged 16 or over: recognition, assessment and early management | Guidance | NICE
Overview | Suspected sepsis in under 16s: recognition, diagnosis and early management | Guidance | NICE
Overview | Suspected sepsis in pregnant or recently pregnant people: recognition, diagnosis and early management | Guidance | NICE

Facing the Future - standards for children and young people in emergency care settings
GPEMS - Guidelines for the Provision of Emergency Medical Services - RCEM

Author

- Andy Neill

- Dave McCreary

Question

- should we give prophylactic antibiotics to patients with facial fractures

Title

- Prophylactic antibiotic use in trauma patients with non-operative facial fractures: A prospective AAST multicenter trial

Author - Mian et al Journal Trauma 2024

Background - facial fractures are really common. We have progressed beyond the early noughties squinting at plain films trying to see if there was an opaue sinus or if one of the innumerable lines on the film represetned an xray. Now we do CT scans and even i can see the subtle fractures. So I suspect we're diagnosing these a lot more than we used to. Hence there are probably a lot more (potentially unnecesary) referrals to a max fax person who will inevitably tell us it's non surgical (and they're right) and they shouldn't blow their nose and they need some co amox for 5 days and on OPD appointment.

- it's difficult to know if the antibiotics are needed and I suspect the pre test probability here for such low risk injuries is that prophylaxis is not likely to be helpful.

- Indeed a 2020 Surgical Infection Society guideline recommended against prophylaxis in these cases.

- this paper attempts to provide some much needed data

Methods

- prospective observatonal data

- included non op facial fracture patients

- outcome was infectious complications within 30 days (not sure how they assessed this - in person or chart?)

Results

- 1900 pts - median age 50, 2 thirds male (a little older but typically male)

- only a 1% infection rate noted. there was not a significant association between antibiotic use and infection

- 2 thirds did not get antibiotics

Thoughts

- as noted we already thought giving antibiotics here was low yield and this cohort (where large numbers did not get antibiotics) suggests the natural history of these fractures is a low infection rate.

- it is not an RCT but it is still helpful

- of note 50% of the fractures here were nasal bone fractures and to be fair I don't think we are giving these injuries antibiotics anyhow so a more focussed cohort on maxillary and orbital would have been nice