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Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial

Authors
  • Lamontagne, François1, 2, 3
  • Meade, Maureen O.4, 5
  • Hébert, Paul C.6
  • Asfar, Pierre7
  • Lauzier, François8, 9, 10
  • Seely, Andrew J.E.11, 12
  • Day, Andrew G.13
  • Mehta, Sangeeta14
  • Muscedere, John15
  • Bagshaw, Sean M.16
  • Ferguson, Niall D.14
  • Cook, Deborah J.4, 5
  • Kanji, Salmaan12
  • Turgeon, Alexis F.9, 10
  • Herridge, Margaret S.14
  • Subramanian, Sanjay17
  • Lacroix, Jacques18
  • Adhikari, Neill K.J.14, 19
  • Scales, Damon C.14, 19
  • Fox-Robichaud, Alison4
  • And 7 more
  • 1 Université de Sherbrooke, Department of Medicine, Sherbrooke, QC, Canada , Sherbrooke (Canada)
  • 2 Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada , Sherbrooke (Canada)
  • 3 Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada , Sherbrooke (Canada)
  • 4 McMaster University, Department of Medicine, Hamilton, ON, Canada , Hamilton (Canada)
  • 5 McMaster University, Department of Clinical Epidemiology and Biostatistics, Hamilton, ON, Canada , Hamilton (Canada)
  • 6 Université de Montréal, Department of Medicine and Research Centre, Montreal, QC, Canada , Montreal (Canada)
  • 7 University Hospital Angers, Department of Medical Intensive Care Medicine, Angers, France , Angers (France)
  • 8 Université Laval, Department of Medicine, Quebec, QC, Canada , Quebec (Canada)
  • 9 Université Laval, Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Quebec, QC, Canada , Quebec (Canada)
  • 10 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 , Quebec (Canada)
  • 11 University of Ottawa, Thoracic Surgery and Critical Care Medicine, Ottawa, ON, Canada , Ottawa (Canada)
  • 12 Ottawa Hospital Research Institute, Ottawa, ON, Canada , Ottawa (Canada)
  • 13 Kingston General Hospital, Clinical Evaluation Research Unit, Kingston, ON, Canada , Kingston (Canada)
  • 14 University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada , Toronto (Canada)
  • 15 Queen’s University, Department of Medicine, Kingston General Hospital, Kingston, ON, Canada , Kingston (Canada)
  • 16 Faculty of Medicine and Dentistry, University of Alberta, Division of Critical Care Medicine, Edmonton, AB, Canada , Edmonton (Canada)
  • 17 Mercy St John’s Medical Center, Department of Critical Care Medicine, St Louis, MO, USA , St Louis (United States)
  • 18 Université de Montréal, Department of Pediatrics, CHU Sainte-Justine, Quebec, Canada , Quebec (Canada)
  • 19 Sunnybrook Health Sciences Centre, Department of Critical Care Medicine, Toronto, ON, Canada , Toronto (Canada)
  • 20 McGill University, Montreal, QC, Canada , Montreal (Canada)
  • 21 McMaster University, Department of Surgery, Hamilton, ON, Canada , Hamilton (Canada)
  • 22 McMaster University, Population Health Research Institute, Hamilton, ON, Canada , Hamilton (Canada)
  • 23 Dalhousie University, Department of Critical Care, Halifax, NS, Canada , Halifax (Canada)
  • 24 Swedish Medical Center, Department of Critical Care Medicine, Seattle, WA, USA , Seattle (United States)
  • 25 Canadian Association of Critical Care Nurses, London, ON, Canada , London (Canada)
Type
Published Article
Journal
Intensive Care Medicine
Publisher
Springer Berlin Heidelberg
Publication Date
Feb 18, 2016
Volume
42
Issue
4
Pages
542–550
Identifiers
DOI: 10.1007/s00134-016-4237-3
Source
Springer Nature
Keywords
License
Yellow

Abstract

PurposeIn 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.MethodsWe 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.ResultsA 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.ConclusionsThis 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.

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