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Fifth Centile Versus 50th Centile Mean Blood Pressure Targets in Pediatric Septic Shock: A Randomized Controlled
Sachin Shah1, Amita Kaul, Ganesh Shiwarkar
1All authors: Neonatal and Pediatric Intensive Care Services, Surya Mother and Child Superspecialty Hospital, Pune, Maharashtra, India.
Insights
Targeting a lower mean blood pressure (MBP) percentile in pediatric septic shock did not increase 28-day mortality. This approach may safely reduce vasoactive agent use and associated adverse events in critically ill children.
Area of Science:
- Pediatric critical care medicine
- Pediatric intensive care
- Septic shock management
Background:
- Hypotension is common in pediatric septic shock, necessitating vasoactive agent titration guided by mean blood pressure (MBP).
- Current guidelines lack consensus on optimal MBP targets (5th vs. 50th percentile) for vasoactive agent titration in pediatric septic shock.
Purpose of the Study:
- To compare the efficacy and safety of targeting the 5th versus the 50th MBP percentile for vasoactive agent titration in children with septic shock.
Main Methods:
- A single-center, open-label, randomized noninferiority trial was conducted in a tertiary care pediatric intensive care unit (PICU) in India.
- 144 children aged 1 month to 16 years with fluid-unresponsive septic shock requiring vasopressors were randomized to either the 5th or 50th MBP percentile target group.
- Vasopressor treatment was adjusted to maintain the assigned MBP target, with 28-day all-cause mortality as the primary outcome.
Main Results:
- No significant difference in 28-day all-cause mortality was observed between the 5th percentile group (16.9%) and the 50th percentile group (23.2%) (p = 0.41).
- The 50th percentile group required higher norepinephrine use (85% vs. 67%), longer vasoactive agent duration (30.4 vs. 18.8 days), and had a higher prevalence of acute respiratory distress syndrome (ARDS) (32.8% vs. 16.9%).
- No significant differences were found in PICU/hospital stay, duration of ventilation, need for continuous renal replacement therapy (CRRT), or vasopressor-related adverse events.
Conclusions:
- Targeting a lower MBP (5th percentile) in pediatric septic shock is non-inferior to targeting a higher MBP (50th percentile) regarding 28-day mortality.
- A lower MBP target may be a safe strategy, potentially reducing vasoactive drug requirements and associated complications like ARDS.
Objectives:
Hypotension is common in septic children, mean blood pressure (MBP) guides vasoactive agent titration. However, the Surviving Sepsis Guidelines for children were unable to recommend whether to target the 5th or 50th MBP percentile for septic shock. We aim to compare two MBP targets (5th vs. 50th percentile) for titrating vasoactive agents in septic shock patients.
Design:
Single-center, open-label, randomized noninferiority trial.
Setting:
It was conducted in a tertiary care PICU in India from April 2021 to March 2024.
Patients:
Patients 1 month to 16 years old with septic shock unresponsive to fluids and requiring vasopressors.
Interventions:
Children with septic shock were randomly assigned to either the 5th or 50th percentile MBP group, with vasopressor treatment adjusted to maintain the target blood pressure (BP) for each group.
Measurements And Main Results:
The primary outcome was 28-day all-cause mortality. Secondary outcomes included PICU/hospital stay, duration of vasoactive use, vasopressor-related adverse events, need for continuous renal replacement therapy (CRRT), invasive ventilation, and prevalence of acute respiratory distress syndrome (ARDS). A total of 144 children were enrolled. At 28 days, mortality did not differ significantly between groups: 16.9% (12/71) in the 5th centile group vs. 23.2% (17/73) in the 50th centile group ( p = 0.41; risk difference, 6.3; 95% CI, -6.9 to 19.2). Norepinephrine use was higher in the 50th centile group (85% vs. 67%; p = 0.04). Vasoactive duration was longer in the 50th centile group (30.4 ± 13.3 vs. 18.8 ± 10.8; p = 0.001). The Vasoactive-Inotropic Score was also higher (64.0 ± 35.7 vs. 45.2 ± 29.6; p = 0.001). ARDS prevalence was significantly higher in the 50th centile group (32.8% vs. 16.9%; p = 0.02). No significant differences were found in other secondary outcomes like length of stay, ventilation duration, need for CRRT, or adverse events.
Conclusions:
Targeting a lower MBP (5th vs. 50th centile) in septic shock showed no significant difference in 28-day mortality. This suggests a lower BP target may be safe, reducing vasoactive drug use and related side effects.
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