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

François Lamontagne^{1

2

3}, Maureen O Meade^{4

5}, Paul C Hébert⁶, Pierre Asfar⁷, François Lauzier^{8

9

10}, Andrew J E Seely^{11

12}, Andrew G Day¹³, Sangeeta Mehta¹⁴, John Muscedere¹⁵, Sean M Bagshaw¹⁶, Niall D Ferguson¹⁴, Deborah J Cook^{4

5}, Salmaan Kanji¹², Alexis F Turgeon^{9

10}, Margaret S Herridge¹⁴, Sanjay Subramanian¹⁷, Jacques Lacroix¹⁸, Neill K J Adhikari^{14

19}, Damon C Scales^{14

19}, Alison Fox-Robichaud⁴, Yoanna Skrobik²⁰, Richard P Whitlock^{21

22}, Robert S Green²³, Karen K Y Koo²⁴, Teddie Tanguay²⁵, Sheldon Magder²⁰, Daren K Heyland¹³; Canadian Critical Care Trials Group.

Affiliations

¹ Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca.
² Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca.
³ Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada. francois.lamontagne@usherbrooke.ca.
⁴ Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁵ Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
⁶ Department of Medicine and Research Centre, Université de Montréal, Montreal, QC, Canada.
⁷ Department of Medical Intensive Care Medicine, University Hospital Angers, Angers, France.
⁸ Department of Medicine, Université Laval, Quebec, QC, Canada.
⁹ Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, 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.
¹¹ Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ottawa, ON, Canada.
¹² Ottawa Hospital Research Institute, Ottawa, ON, Canada.
¹³ Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
¹⁴ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁵ Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
¹⁶ Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
¹⁷ Department of Critical Care Medicine, Mercy St John's Medical Center, St Louis, MO, USA.
¹⁸ Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada.
¹⁹ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
²⁰ McGill University, Montreal, QC, Canada.
²¹ Department of Surgery, McMaster University, Hamilton, ON, Canada.
²² Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
²³ Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
²⁴ Department of Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA.
²⁵ Canadian Association of Critical Care Nurses, London, ON, Canada.

PMID: 26891677
DOI: 10.1007/s00134-016-4237-3

Randomized Controlled Trial

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

François Lamontagne et al. Intensive Care Med. 2016 Apr.

. 2016 Apr;42(4):542-550.

doi: 10.1007/s00134-016-4237-3. Epub 2016 Feb 18.

Authors

Affiliations

¹ Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca.
² Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca.
³ Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada. francois.lamontagne@usherbrooke.ca.
⁴ Department of Medicine, McMaster University, Hamilton, ON, Canada.
⁵ Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
⁶ Department of Medicine and Research Centre, Université de Montréal, Montreal, QC, Canada.
⁷ Department of Medical Intensive Care Medicine, University Hospital Angers, Angers, France.
⁸ Department of Medicine, Université Laval, Quebec, QC, Canada.
⁹ Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, 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.
¹¹ Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ottawa, ON, Canada.
¹² Ottawa Hospital Research Institute, Ottawa, ON, Canada.
¹³ Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
¹⁴ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁵ Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
¹⁶ Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
¹⁷ Department of Critical Care Medicine, Mercy St John's Medical Center, St Louis, MO, USA.
¹⁸ Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada.
¹⁹ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
²⁰ McGill University, Montreal, QC, Canada.
²¹ Department of Surgery, McMaster University, Hamilton, ON, Canada.
²² Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
²³ Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
²⁴ Department of Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA.
²⁵ Canadian Association of Critical Care Nurses, London, ON, Canada.

PMID: 26891677
DOI: 10.1007/s00134-016-4237-3

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.

Keywords: Blood pressure targets; Resuscitation; Shock; Vasopressors.

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Comment in

The quest for the optimal blood pressure in septic shock.
Dhooria S, Sehgal IS, Agarwal R. Dhooria S, et al. J Thorac Dis. 2016 Sep;8(9):E1019-E1022. doi: 10.21037/jtd.2016.08.27. J Thorac Dis. 2016. PMID: 27747051 Free PMC article. No abstract available.

References

1. N Engl J Med. 2010 Mar 4;362(9):779-89 - PubMed
1. Shock. 2015 Jun;43(6):530-9 - PubMed
1. Crit Care Med. 2012 Mar;40(3):725-30 - PubMed
1. N Engl J Med. 2014 Apr 24;370(17):1583-93 - PubMed
1. Crit Care. 2011;15(2):R98 - PubMed

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

Affiliations

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

Authors

Affiliations

Abstract

Comment in

References

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LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical