Permissive MAP Target Does Not Significantly Improve Primary Outcome in PRESSURE Trial

A permissive mean arterial pressure (MAP) target did not significantly improve a composite of mortality and duration of invasive ventilation at 30 days compared with usual care in hypotensive critically ill children, according to results of the PRESSURE randomized clinical trial published in JAMA. Vasoactive drugs are often given to critically ill children to treat hypotension, but optimal MAP targets are unknown, the investigators noted.

The multicenter, unblinded, pragmatic trial enrolled 1900 children receiving invasive ventilation and vasoactive drugs for hypotension at 23 pediatric intensive care units (PICUs) in the UK, Republic of Ireland, and Switzerland between November 2021 and May 2026. Patients were randomized to a permissive MAP target greater than the fifth percentile for age (n = 957) or usual care with the target set by the attending physician (n = 943). The primary analysis included 1814 patients with a median age of 4 years. Median MAP while receiving vasoactive drugs was 58 mm Hg with the permissive target and 61 mm Hg with usual care, and the permissive target led to a 37.5% reduction in median norepinephrine-equivalent total dose. The primary outcome did not differ significantly between groups (probabilistic index, 0.52; 95% CI, 0.49-0.54; P=.23); 10.9% and 11.7% of patients died, respectively.

Six of 7 secondary outcomes were similar. PICU length of stay among survivors was shorter with the permissive target (median, 159 vs 166 hours), a finding the authors said must be interpreted in the context of multiple testing. Receipt of kidney replacement therapy and adverse events did not differ between groups.

Patients with acute brain injury, some cardiac diagnoses, and pulmonary hypertension were excluded, and the authors stated that no conclusions can be drawn for these groups. Protocol deviations above the permissive target were more frequent than those below.

Source: Inwald DP, Laing E, Broomhall JM, et al. Permissive blood pressure targets in pediatric critical care: the PRESSURE randomized clinical trial. JAMA. Published online September 28, 2026. doi:10.1001/jama.2026.19747