3 Key Takeaways
Plain English Summary- 01Core Finding
To evaluate whether adopting a permissive MAP target, and thereby potentially reducing exposure to vasoactive drugs, improves outcomes in hypotensive critically ill children.
- 02Study Evidence
Tested in a randomized controlled trial (n = 957) at the randomized clinical trial stage.
- 03Practical Meaning
Controlled trial findings show causal benefit under protocol rules; real-world effectiveness can vary across patients.
What This Means for You
Adopting a permissive MAP target resulted in no significant difference in mortality and duration of invasive ventilation at 30 days compared with usual care.
Published in JAMA, these peer-reviewed pharmacology findings provide quantitative clinical evidence to inform risk stratification, therapeutic decision-making, and follow-up validation.
The Discovery
Vasoactive drugs are often given to critically ill children to treat hypotension. However, optimal mean arterial pressure (MAP) targets are unknown. To evaluate whether adopting a permissive MAP target, and thereby potentially reducing exposure to vasoactive drugs, improves outcomes in hypotensive critically ill children. 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. 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. 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. 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. 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 meaningful 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.
How It Works, Simply
This pharmacology research focuses on selective receptor binding & pharmacokinetic optimization. Researchers evaluated it using a randomized controlled trial (n = 957) at the randomized clinical trial stage of medical research.
3 Key Takeaways
Clinical Takeaways- 01Core Finding
To evaluate whether adopting a permissive MAP target, and thereby potentially reducing exposure to vasoactive drugs, improves outcomes in hypotensive critically ill children.
- 02Study Evidence
Tested in a randomized controlled trial (n = 957) at the randomized clinical trial stage.
- 03Practical Meaning
Controlled trial findings show causal benefit under protocol rules; real-world effectiveness can vary across patients.
Key Numbers
Biological Mechanism & Study Design
Study Design & Cohort
Randomized controlled trial
Randomized controlled trial (n = 957) · Randomized Clinical Trial
Biological Pathway & Modality
Selective receptor binding & pharmacokinetic optimization
Intervention: Permissive Blood Pressure Targets in Pediatric Critical Care: The PRESSURE
Experimental Findings & Endpoints
Vasoactive drugs are often given to critically ill children to treat hypotension.
However, optimal mean arterial pressure (MAP) targets are unknown. To evaluate whether adopting a permissive MAP target, and thereby potentially reducing exposure to vasoactive drugs, improves outcomes in hypotensive critically ill children.
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. 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. 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. 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. 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 meaningful 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.
Clinical Translation & Practice Context
Adopting a permissive MAP target resulted in no significant difference in mortality and duration of invasive ventilation at 30 days compared with usual care.
Published in JAMA, these peer-reviewed pharmacology findings provide quantitative clinical evidence to inform risk stratification, therapeutic decision-making, and follow-up validation.
The Bottom Line · Clinical Pearl
“Adopting a permissive MAP target resulted in no significant difference in mortality and duration of invasive ventilation at 30 days compared with usual care.”
Published in JAMA · Current Stage: Randomized Clinical Trial