Permissive Blood Pressure Targets in Pediatric Critical Care

Importance: Vasoactive drugs are often given to critically ill children to treat hypotension. However, optimal mean arterial pressure (MAP) targets are unknown. Objective: To evaluate whether adopting a permissive MAP target, and thereby potentially reducing exposure to vasoactive drugs, improves outcomes in hypotensive critically ill children. Design, Setting, and Participants: This multicenter, unblinded, pragmatic randomized clinical trial was conducted in 23 pediatric intensive care units (PICUs) in 3 countries. Critically ill children receiving invasive ventilation and vasoactive drugs for hypotension were enrolled between November 2021 and May 2026. Follow-up to the 30-day outcome was completed in June 2026. Interventions: Patients randomized to the intervention (n = 957) were assigned a permissive MAP target greater than the fifth percentile for age. Patients in the control group (n = 943) received usual care with MAP target set by the attending physician. Main Outcomes and Measures: The primary outcome was a composite of mortality and duration of invasive ventilation at 30 days. Secondary outcomes included mortality at PICU discharge, time to cessation of invasive ventilation, receipt and duration of kidney replacement therapy in PICU at 30 days, and length of PICU and hospital stay. Results: Of 1900 randomized patients, 910 in the permissive MAP target group and 904 in the usual care group were included for analysis of the primary outcome. Participants had a median (IQR) age of 4 (0-10) years and 44.8% were female; baseline characteristics were similar between the groups. Median (IQR) MAP while receiving vasoactive drugs was 58 (51-63) mm Hg in the permissive MAP target group and 61 (54-67) mm Hg in the usual care group. A permissive MAP target led to a 37.5% reduction in median norepinephrine-equivalent total dose compared with the usual care group. There was no significant difference between the groups in the primary outcome (probabilistic index, 0.52 [95% CI, 0.49-0.54]; P = .23). Six of the 7 secondary outcomes were similar between the groups, except median (IQR) PICU length of stay was significantly shorter in survivors in the permissive MAP target vs usual care group (159 [79-286] vs 166 [92-319] hours); probabilistic index, 0.53 [95% CI, 0.50-0.56]). Receipt of kidney replacement therapy and adverse events did not differ between the groups. Conclusions and Relevance: Adopting a permissive MAP target resulted in no significant difference in mortality and duration of invasive ventilation at 30 days compared with usual care. Trial Registration: isrctn.org Identifier: ISRCTN20609635; Swiss National Clinical Trial Portal: SNCTP000006590.