- This trial of permissive hypotension in elderly ICU patients with vasodilatory hypotension did not find that the strategy lowered mortality.
- However, confidence intervals and adjusted analyses meant minimizing exposure to vasopressors “was unlikely to be harmful and might have been beneficial.”
- Editorial : “the signal suggests that this deliberate intervention [of giving pressors] may be harmful…clinicians could be reassured in the finding that assiduously targeting an arbitrary blood pressure is not helpful.”
Why this matters
- Vasopressor risks and benefits are difficult to balance, especially in the elderly.
- SEPSISPAM and OVATION tentatively linked pressors to mortality in this subgroup.
- Permissive hypotension vs usual care:
- Median total dose (norepinephrine equivalent), 17.7 vs 26.4 mg (difference, −8.7 [95% CI, −12.8 to −4.6] mg).
- Mortality: 41.0% vs 43.8%;
- Absolute risk difference, −2.85% (95% CI, −6.75% to 1.05%).
- Pragmatic, open, multicenter, parallel group, randomized clinical trial in 65 UK ICUs (n=2463).
- Adults age ≥65 years with vasodilatory hypotension receiving vasopressors were randomly assigned to a permissive-hypotension MAP target (60-65 mmHg) vs clinician discretion.
- Outcome: 90-day all-cause mortality.
- Prespecified superiority criterion: 6% absolute risk reduction.
- Funding: National Institute for Health Research (UK).
- Not a noninferiority trial.