Permissive blood pressure target in paediatric intensive care: less vasopressor, same outcomes

Design

Pragmatic, unblinded, randomised trial in 23 PICUs

Population

1,900 ventilated children receiving vasoactive drugs for hypotension

Primary outcome

Composite of 30-day mortality and duration of invasive ventilation

Effect

Probabilistic index 0.52 (95% CI 0.49 to 0.54); vasopressor dose 37.5% lower

PRESSURE was a pragmatic, unblinded randomised trial in 23 paediatric intensive care units in three countries. It enrolled 1,900 ventilated children (median age 4) receiving vasoactive drugs for hypotension. The permissive group aimed only for a mean arterial pressure above the 5th centile for age; the control group's target was left to the treating clinician.

Mean arterial pressure on vasoactive drugs ran slightly lower in the permissive group (median 58 vs 61 mmHg), and the total vasopressor dose was 37.5% lower. The primary outcome, combining 30-day death and duration of ventilation, did not differ (probabilistic index 0.52, 95% CI 0.49 to 0.54). PICU stay in survivors was slightly shorter, and kidney replacement therapy and adverse events were similar.

The finding is that higher targets bought nothing except more drug. For units, including Indian PICUs where vasopressor supply and central access can be limiting, a lower, age-based floor is a defensible default. The result applies to ventilated children; whether it holds in specific groups, such as raised intracranial pressure, was not the question.

• Consider a mean arterial pressure target above the 5th centile for age in ventilated children on vasopressors.
• Use an age-appropriate centile chart at the bedside so the target is explicit rather than left to habit.
• Expect lower vasopressor exposure without a rise in kidney replacement therapy.
• Children with raised intracranial pressure or other conditions needing higher perfusion pressure need individual targets.

Why it matters

It removes a reason to escalate vasopressors in children whose pressure is low but adequate for age.

Don't overread it

The permissive target did not improve survival or ventilation time; it matched usual care with less drug.

The statistics, in plain English

A probabilistic index of 0.5 means neither group tends to do better. The observed 0.52, with an interval from 0.49 to 0.54 that includes 0.5, means no clear difference. The shorter PICU stay was a secondary outcome and its interval just touches 0.5, so treat it as supportive rather than established.

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