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Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial.
Intensive Care Med 2016; 42(4):542-550IC

Abstract

PURPOSE

In shock, hypotension may contribute to inadequate oxygen delivery, organ failure and death. We conducted the Optimal Vasopressor Titration (OVATION) pilot trial to inform the design of a larger trial examining the effect of lower versus higher mean arterial pressure (MAP) targets for vasopressor therapy in shock.

METHODS

We randomly assigned critically ill patients who were presumed to suffer from vasodilatory shock regardless of admission diagnosis to a lower (60-65 mmHg) versus a higher (75-80 mmHg) MAP target. The primary objective was to measure the separation in MAP between groups. We also recorded days with protocol deviations, enrolment rate, cardiac arrhythmias and mortality for prespecified subgroups.

RESULTS

A total of 118 patients were enrolled from 11 centres (2.3 patients/site/month of screening). The between-group separation in MAP was 9 mmHg (95% CI 7-11). In the lower and higher MAP groups, we observed deviations on 12 versus 8% of all days on vasopressors (p = 0.059). Risks of cardiac arrhythmias (20 versus 36%, p = 0.07) and hospital mortality (30 versus 33%, p = 0.84) were not different between lower and higher MAP arms. Among patients aged 75 years or older, a lower MAP target was associated with reduced hospital mortality (13 versus 60%, p = 0.03) but not in younger patients.

CONCLUSIONS

This pilot study supports the feasibility of a large trial comparing lower versus higher MAP targets for shock. Further research may help delineate the reasons for vasopressor dosing in excess of prescribed targets and how individual patient characteristics modify the response to vasopressor therapy.

Authors+Show Affiliations

Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca. Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca. Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada. francois.lamontagne@usherbrooke.ca.Department of Medicine, McMaster University, Hamilton, ON, Canada. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.Department of Medicine and Research Centre, Université de Montréal, Montreal, QC, Canada.Department of Medical Intensive Care Medicine, University Hospital Angers, Angers, France.Department of Medicine, Université Laval, Quebec, QC, Canada. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada. CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Université Laval, Quebec, QC, Canada.Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ottawa, ON, Canada. Ottawa Hospital Research Institute, Ottawa, ON, Canada.Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada.Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.Department of Medicine, McMaster University, Hamilton, ON, Canada. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.Ottawa Hospital Research Institute, Ottawa, ON, Canada.Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada. CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Université Laval, Quebec, QC, Canada.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.Department of Critical Care Medicine, Mercy St John's Medical Center, St Louis, MO, USA.Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.Department of Medicine, McMaster University, Hamilton, ON, Canada.McGill University, Montreal, QC, Canada.Department of Surgery, McMaster University, Hamilton, ON, Canada. Population Health Research Institute, McMaster University, Hamilton, ON, Canada.Department of Critical Care, Dalhousie University, Halifax, NS, Canada.Department of Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA.Canadian Association of Critical Care Nurses, London, ON, Canada.McGill University, Montreal, QC, Canada.Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.No affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

26891677

Citation

Lamontagne, François, et al. "Higher Versus Lower Blood Pressure Targets for Vasopressor Therapy in Shock: a Multicentre Pilot Randomized Controlled Trial." Intensive Care Medicine, vol. 42, no. 4, 2016, pp. 542-550.
Lamontagne F, Meade MO, Hébert PC, et al. Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Med. 2016;42(4):542-550.
Lamontagne, F., Meade, M. O., Hébert, P. C., Asfar, P., Lauzier, F., Seely, A. J. E., ... Heyland, D. K. (2016). Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Medicine, 42(4), pp. 542-550. doi:10.1007/s00134-016-4237-3.
Lamontagne F, et al. Higher Versus Lower Blood Pressure Targets for Vasopressor Therapy in Shock: a Multicentre Pilot Randomized Controlled Trial. Intensive Care Med. 2016;42(4):542-550. PubMed PMID: 26891677.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. AU - Lamontagne,François, AU - Meade,Maureen O, AU - Hébert,Paul C, AU - Asfar,Pierre, AU - Lauzier,François, AU - Seely,Andrew J E, AU - Day,Andrew G, AU - Mehta,Sangeeta, AU - Muscedere,John, AU - Bagshaw,Sean M, AU - Ferguson,Niall D, AU - Cook,Deborah J, AU - Kanji,Salmaan, AU - Turgeon,Alexis F, AU - Herridge,Margaret S, AU - Subramanian,Sanjay, AU - Lacroix,Jacques, AU - Adhikari,Neill K J, AU - Scales,Damon C, AU - Fox-Robichaud,Alison, AU - Skrobik,Yoanna, AU - Whitlock,Richard P, AU - Green,Robert S, AU - Koo,Karen K Y, AU - Tanguay,Teddie, AU - Magder,Sheldon, AU - Heyland,Daren K, AU - ,, Y1 - 2016/02/18/ PY - 2015/10/26/received PY - 2016/01/20/accepted PY - 2016/2/20/entrez PY - 2016/2/20/pubmed PY - 2017/1/5/medline KW - Blood pressure targets KW - Resuscitation KW - Shock KW - Vasopressors SP - 542 EP - 550 JF - Intensive care medicine JO - Intensive Care Med VL - 42 IS - 4 N2 - PURPOSE: In shock, hypotension may contribute to inadequate oxygen delivery, organ failure and death. We conducted the Optimal Vasopressor Titration (OVATION) pilot trial to inform the design of a larger trial examining the effect of lower versus higher mean arterial pressure (MAP) targets for vasopressor therapy in shock. METHODS: We randomly assigned critically ill patients who were presumed to suffer from vasodilatory shock regardless of admission diagnosis to a lower (60-65 mmHg) versus a higher (75-80 mmHg) MAP target. The primary objective was to measure the separation in MAP between groups. We also recorded days with protocol deviations, enrolment rate, cardiac arrhythmias and mortality for prespecified subgroups. RESULTS: A total of 118 patients were enrolled from 11 centres (2.3 patients/site/month of screening). The between-group separation in MAP was 9 mmHg (95% CI 7-11). In the lower and higher MAP groups, we observed deviations on 12 versus 8% of all days on vasopressors (p = 0.059). Risks of cardiac arrhythmias (20 versus 36%, p = 0.07) and hospital mortality (30 versus 33%, p = 0.84) were not different between lower and higher MAP arms. Among patients aged 75 years or older, a lower MAP target was associated with reduced hospital mortality (13 versus 60%, p = 0.03) but not in younger patients. CONCLUSIONS: This pilot study supports the feasibility of a large trial comparing lower versus higher MAP targets for shock. Further research may help delineate the reasons for vasopressor dosing in excess of prescribed targets and how individual patient characteristics modify the response to vasopressor therapy. SN - 1432-1238 UR - https://www.unboundmedicine.com/medline/citation/26891677/full_citation L2 - https://dx.doi.org/10.1007/s00134-016-4237-3 DB - PRIME DP - Unbound Medicine ER -