A permissive blood pressure target in sick children cut vasopressor use with no harm to outcomes or kidneys

Design

Multicentre, pragmatic, unblinded randomised trial

Population

1,900 ventilated children on vasoactive drugs in 23 PICUs

Primary outcome

Composite of 30-day mortality and duration of invasive ventilation

Effect

Probabilistic index 0.52 (95% CI 0.49–0.54); noradrenaline-equivalent dose −37.5%; no difference in kidney replacement therapy

PRESSURE, a pragmatic unblinded trial in 23 paediatric intensive care units in three countries, randomised 1,900 ventilated children on vasoactive drugs for hypotension to a permissive mean arterial pressure target (above the 5th centile for age) or usual care with the target set by the treating team.

The permissive arm ran a median MAP of 58 versus 61 mmHg and received 37.5% less noradrenaline-equivalent drug. The primary composite of 30-day mortality and duration of ventilation did not differ (probabilistic index 0.52, 95% CI 0.49–0.54). Kidney replacement therapy and adverse events did not differ; PICU stay in survivors was slightly shorter.

The kidney is the organ most often cited to justify higher pressure targets. In this trial, accepting a lower target did not increase kidney replacement therapy. That supports less vasopressor exposure in ventilated children, though the trial does not show a benefit beyond reduced drug use.

• Consider a MAP target just above the 5th centile for age in ventilated children on vasoactive drugs
• Expect substantially less vasopressor use with no increase in kidney replacement therapy
• Individualise for conditions needing higher perfusion pressure, such as raised intracranial pressure
• Monitor urine output and lactate as markers of adequate perfusion

Why it matters

It removes the assumption that higher pressure targets are needed to protect the kidneys of sick children.

Don't overread it

The trial showed no difference in outcomes, not a benefit; it was unblinded and pragmatic.

The statistics, in plain English

A probabilistic index of 0.52 means a randomly chosen child in the permissive arm had only a 52% chance of a better composite outcome than one in the usual-care arm — essentially a coin toss, so no difference.

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