Published October 27, 2026 · Important negative randomized trial · Pediatric critical care
Primary source: PRESSURE trial, JAMA, PMID 42806496
The pragmatic PRESSURE trial randomized 1,900 critically ill children at 23 pediatric intensive care units in three countries. All required mechanical ventilation and vasoactive therapy for hypotension. The experimental strategy targeted a mean arterial pressure above the fifth percentile for age, while controls received attending-physician-selected targets.
Children receiving the permissive strategy were exposed to a 37.5% lower median norepinephrine-equivalent total dose. Median mean arterial pressure while on vasoactives was 58 versus 61 mm Hg. Yet the prespecified combined outcome of 30-day mortality and duration of invasive ventilation did not significantly improve (probabilistic index 0.52; 95% CI 0.49–0.54; P=.23). Most secondary outcomes were also similar; survivor PICU stay was modestly shorter, and kidney replacement therapy and adverse events did not differ detectably.
Strength and limitations. Large pragmatic randomized comparison with patient-important outcomes. It was unblinded; the composite endpoint needs clinical interpretation, and children receiving different forms of circulatory support may not behave alike. Reduced drug exposure is a process outcome, not proof of improved survival.
Clinical practice: Supports careful reassessment of automatically escalating vasopressors to higher targets, under local critical-care protocols—not generalized hypotension tolerance.
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