Fifth Centile Versus 50th Centile Mean Blood Pressure Targets in Pediatric Septic Shock: A Randomized Controlled Trial.

Summary

In a single-center randomized noninferiority trial (n=144) of pediatric septic shock, targeting the 5th centile MBP was non-inferior to the 50th centile for 28-day mortality. The lower MBP target reduced norepinephrine exposure, vasoactive duration and score, and was associated with lower ARDS prevalence, without differences in length of stay, ventilation, CRRT, or adverse events.

Key Findings

• 28-day mortality did not differ between MBP targets (16.9% vs 23.2%; p=0.41).
• Norepinephrine use was higher with the 50th centile target (85% vs 67%; p=0.04).
• Vasoactive duration and Vasoactive-Inotropic Score were higher with the 50th centile target (30.4 ± 13.3 vs 18.8 ± 10.8 hours; p=0.001; VIS 64.0 ± 35.7 vs 45.2 ± 29.6; p=0.001).
• ARDS prevalence was higher with the 50th centile target (32.8% vs 16.9%; p=0.02); other secondary outcomes showed no significant differences.

Clinical Implications

Lower MBP targets (5th centile) may be safely adopted to minimize vasopressor burden and potentially reduce ARDS in pediatric septic shock, pending confirmation in multicenter trials.

Limitations

• Single-center, open-label design may limit generalizability and introduce performance bias
• Sample size modest; not powered for rare adverse events or long-term outcomes

Future Directions

Multicenter, blinded RCTs comparing personalized hemodynamic targets and evaluating long-term neurodevelopmental and organ failure outcomes.