Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial

RCT (n=2600) found among patients aged ≥65 years on vasopressors for vasodilatory hypotension, permissive hypotension (mean arterial pressure target, 60-65mmHg) compared with usual vasopressor exposure did not result in statistically significant reduction in mortality at 90 days.

SPS commentary:

An editorial discusses how the results of the trial should be incorporated into clinical practice. It notes that from a scientific perspective, the trial was indeterminate, as it failed to support its primary hypothesis, although it generated findings that were consistent with that hypothesis and suggested that further work might well be informative. For the clinician caring for a patient with vasodilatory shock, however, it suggests the message is different, as nothing in the results suggests that artificially raising the blood pressure by administering more vasopressors provides benefit for patients It adds that clinicians could be reassured in the finding that assiduously targeting an arbitrary blood pressure is not helpful, though clearly, caution must be exercised in avoiding a blood pressure that is too low to enable perfusion. It concludes that the message of the trial is not that all patients should be treated the same, rather that treatment decisions can be individualised around a somewhat lower mean MAP comfort point, with a MAP target of 60 to 65 mm Hg appearing to be more than adequate for most older patients with vasodilatory shock, and, contrary to conventional wisdom, it is possible that a lower target threshold may be more beneficial in older patients with preexisting hypertension.


Journal of the American Medical Association

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