A permissive blood pressure target in ventilated children cut vasoactive drug use without worse outcomes

Design

Multicentre, pragmatic, unblinded randomised trial

Population

1,900 ventilated children on vasoactive drugs for hypotension, 23 PICUs in 3 countries

Primary outcome

Composite of 30-day mortality and duration of invasive ventilation

Effect

Probabilistic index 0.52 (0.49–0.54); noradrenaline-equivalent dose −37.5%

PRESSURE, a pragmatic unblinded trial in 23 paediatric intensive care units in three countries, published in JAMA on 27 October, randomised 1,900 ventilated children receiving vasoactive drugs for hypotension. The intervention group had a permissive mean arterial pressure (MAP) target: above the fifth centile for age. The control group's target was set by the treating doctor. Median age was 4 years.

Achieved MAP on vasoactive drugs was 58 mm Hg in the permissive group and 61 mm Hg with usual care, and the total noradrenaline-equivalent dose fell by 37.5%. The primary outcome, a composite of 30-day mortality and duration of ventilation, did not differ (probabilistic index 0.52, 95% CI 0.49–0.54). Survivors in the permissive group left intensive care slightly sooner (median 159 vs 166 hours). Kidney replacement therapy and adverse events were similar.

The trial did not show benefit on its primary outcome, but it does show that accepting a lower pressure, and giving substantially less vasoactive drug, did not cause harm. That is useful where drug exposure, central access and nursing time are constrained.

• In ventilated children on vasoactive drugs, a MAP target just above the fifth centile for age appears safe.
• Reassess perfusion clinically — capillary refill, lactate, urine output, conscious level — rather than chasing a number.
• Lower targets may allow less vasoactive drug, which matters when infusions run through peripheral lines.
• Know the age-specific fifth-centile MAP for children in your unit; it is lower than many clinicians assume.

Why it matters

It shows that a third less vasoactive drug, at a lower pressure, did not worsen survival or ventilation time in critically ill children.

Don't overread it

No difference in the primary outcome: this does not show a permissive target improves survival.

The statistics, in plain English

A probabilistic index of 0.52 means a random child in the permissive group had a 52% chance of a better composite outcome than a random child in the usual-care group — close to the 50% expected if there is no difference. The interval (0.49–0.54) includes 0.5.

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