An unambiguous definition of pediatric hypotension is still lacking: Gaps between two percentile-based definitions and Pediatric Advanced Life Support/Advanced Trauma Life Support guidelines

BACKGROUND Data are lacking to provide cutoffs for hypotension in children based on outcome studies and Pediatric Advanced Life Support (PALS), and Advanced Trauma Life Support (ATLS) definitions are based on normal populations. The goal of this study was to compare different normal population based cutoffs including fifth percentile of systolic blood pressure (P5-SBP) in children and adolescents from the German Health Examination Survey for Children and Adolescents (KiGGS), US population data (Fourth Report), and cutoffs from PALS and ATLS guidelines. METHODS Fifth percentile of systolic blood pressure according to age, sex, and height was modeled based on standardized resting oscillometric BP measurements (12,199 children aged 3–17 years) from KiGGS 2003–2006. In addition, we applied the age-adjusted pediatric shock index in the KiGGS study. RESULTS The KiGGS P5-SBP was on average 7 mm Hg higher than Fourth Report P5-SBP (5–10 mm Hg depending on age-sex group). For children aged 3 to 9 years, KIGGS P5-SBP at median height follows the formula 82 mm Hg + age; for age 10 to 17 years, the increase was not linear and is presented in a simplified table. Pediatric Advanced Life Support/ATLS thresholds were between KiGGS and Fourth Report until age of 11 years. The adult threshold of 90 mm Hg was reached by KiGGS P5-SBP median height at 8 years, PALS/ATLS at age of 10 years, and Fourth Report P5-SBP at 12 years. The pediatric shock index, which is supposed to identify severely injured children, was exceeded by 2.3% nonacutely ill KiGGS participants. CONCLUSION Our study shows that percentile cutoffs vary by reference population. The 90 mm Hg cutoff for adolescents targets only those in the less than 1% of the low SBP range and represents an undertriage compared with P5 at younger ages according to both KiGGS and Fourth Report. Finally, current pediatric shock index cutoffs when applied to a healthy cohort lead to a relevant percentage of false positives. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.