Blood Pressure Goals in Children With Septic Shock

Pediatric sepsis is a leading cause of death worldwide, with reported mortality rates between 7% and 28%.¹ Most children who succumb to sepsis die from unremitting shock and/or multiorgan failure. The Society of Critical Care Medicine published the evidence-based Surviving Sepsis Campaign guidelines in 2020 for the management of sepsis and septic shock.² Despite many iterations of the guidelines, specific recommendations regarding blood pressure (BP) goals when using inotropes or vasopressors are lacking. The guidelines state only that the mean arterial blood pressure (MAP) goal for children with septic shock should be between 5% and 50% for age. Maintenance of higher MAP goals in septic children with certain clinical conditions characterized by increased intracranial pressure or intra-abdominal pressure has been recommended in the past but, to date, there have been no studies specifically comparing outcomes using different hemodynamic targets.³

In this single-center, randomized noninferiority study, Shah et al sought to compare outcomes after using different target MAPs in children with septic shock needing vasoactive medications.⁴ The authors recruited children between ages one month and 16 years who presented with septic shock needing vasoactive medications. The children were divided into a low-normal group and a high-normal group. The target MAP range for the low-normal group was 5% for age to 5% plus 5 mm Hg. The target range for the high-normal group was 50% for age to 50% plus 5 mm Hg. A specific protocol was used to escalate vasoactive agents or to wean these agents once the goal MAP had been achieved. The study’s primary outcome was death by 28 days. Secondary outcomes included length of pediatric intensive care unit (PICU) and hospital stays, maximum vasoactive inotropic score (VIS), adverse events, and need for renal replacement therapy.

The authors used a generated block sequence to randomize 144 patients, 71 in the low-normal group and 73 in the high-normal group. Demographics and baseline characteristics (including admission Pediatric Logistic Organ Dysfunction scores) were similar between the two groups, except that pneumonia was more common in the high-normal group. The high-normal group had higher VIS scores, required more stress-dose hydrocortisone, and were on vasoactive drugs for longer, as expected. Overall, there was no difference between the groups in mortality, length of PICU or hospital stay, need for renal replacement therapy, or adverse events due to the vasoactive agents. The development of acute respiratory distress syndrome (ARDS) and subsequent longer duration of mechanical ventilation was significantly demonstrated in the high-normal group.

The authors found no difference in mortality when they compared the two different BP targets. More patients in the high-normal group developed ARDS, which the authors suggest may be a result of higher BP targeting since an association has been shown in adults with traumatic brain injury. It is also likely that more patients in this group had pneumonia as a diagnosis. The authors acknowledge that titration of a vasoactive to maintain a single BP target may not be appropriate for all children. Each organ carries its own perfusion pressure, and specific infections may require a higher target BP. For example, a child with meningitis may need a higher BP to maintain an appropriate cerebral perfusion pressure. A child with septic shock will also need measures of organ perfusion (e.g., lactate or urine output) in addition to BP monitoring. In their single center, the authors found that acceptance of BP above 5% for age is safe. A multicenter trial under way across 18 PICUs in the UK looking at permissive BP will help boost these findings.⁵


References

1. Schlapbach LJ, Watson RS, Sorce LR, et al. International consensus criteria for pediatric sepsis and septic shock. JAMA. 2024 Feb 27;331(8):665-674.
2. Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med. 2020 Feb;21(2):e52-e106.
3. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009 Feb;37(2):666-688.
4. Shah S, Kaul A, Shiwarkar G, Nare R, Khandare J. Fifth centile versus 50th centile mean blood pressure targets in pediatric septic shock: a randomized controlled trial. Crit Care Med. 2025 Aug 1;53(8):e1581-e1589.
5. Darnell R, Brown A, Laing E, et al; Protocolised Evaluation of Permissive Blood Pressure Targets Versus Usual Care (PRESSURE) Trial Investigators on behalf of the U.K. Paediatric Critical Care Society Study Group (PCCS-SG). Protocol for a randomized controlled trial to evaluate a permissive blood pressure target versus usual care in critically ill children with hypotension (PRESSURE). Pediatr Crit Care Med. 2024 July 1;25(7):629-637.