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Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial.
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- Author(s): Lamontagne, François; Richards-Belle, Alvin; Thomas, Karen; Harrison, David A.; Sadique, M. Zia; Grieve, Richard D.; Camsooksai, Julie; Darnell, Robert; Gordon, Anthony C.; Henry, Doreen; Hudson, Nicholas; Mason, Alexina J.; Saull, Michelle; Whitman, Chris; Young, J. Duncan; Rowan, Kathryn M.; Mouncey, Paul R.; 65 trial investigators
- Source:
JAMA: Journal of the American Medical Association; 3/10/2020, Vol. 323 Issue 10, p938-949, 12p- Subject Terms:
VASOCONSTRICTORS; INTENSIVE care patients; MORTALITY; OLDER patients; CRITICALLY ill patient care; HYPOTENSION; ARTERIAL pressure; ATRIAL arrhythmias; COGNITION disorders; INTENSIVE care units; CONFIDENCE intervals; HOSPITAL mortality; RANDOMIZED controlled trials; KAPLAN-Meier estimator; STATISTICAL sampling; ACUTE kidney failure; DISEASE complications - Source:
- Additional Information
- Abstract:
Importance: Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients.Objective: To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm Hg) reduces mortality at 90 days in ICU patients aged 65 years or older with vasodilatory hypotension.Design, Setting, and Participants: A multicenter, pragmatic, randomized clinical trial was conducted in 65 ICUs in the United Kingdom and included 2600 randomized patients aged 65 years or older with vasodilatory hypotension (assessed by treating clinician). The study was conducted from July 2017 to March 2019, and follow-up was completed in August 2019.Interventions: Patients were randomized 1:1 to vasopressors guided either by MAP target (60-65 mm Hg, permissive hypotension) (n = 1291) or according to usual care (at the discretion of treating clinicians) (n = 1307).Main Outcome and Measures: The primary clinical outcome was all-cause mortality at 90 days.Results: Of 2600 randomized patients, after removal of those who declined or had withdrawn consent, 2463 (95%) were included in the analysis of the primary outcome (mean [SD] age 75 years [7 years]; 1387 [57%] men). Patients randomized to the permissive hypotension group had lower exposure to vasopressors compared with those in the usual care group (median duration 33 hours vs 38 hours; difference in medians, -5.0; 95% CI, -7.8 to -2.2 hours; total dose in norepinephrine equivalents median, 17.7 mg vs 26.4 mg; difference in medians, -8.7 mg; 95% CI, -12.8 to -4.6 mg). At 90 days, 500 of 1221 (41.0%) in the permissive hypotension compared with 544 of 1242 (43.8%) in the usual care group had died (absolute risk difference, -2.85%; 95% CI, -6.75 to 1.05; P = .15) (unadjusted relative risk, 0.93; 95% CI, 0.85-1.03). When adjusted for prespecified baseline variables, the odds ratio for 90-day mortality was 0.82 (95% CI, 0.68 to 0.98). Serious adverse events were reported for 79 patients (6.2%) in the permissive care group and 75 patients (5.8%) in the usual care group. The most common serious adverse events were acute renal failure (41 [3.2%] vs 33 [2.5%]) and supraventricular cardiac arrhythmia (12 [0.9%] vs 13 [1.0%]).Conclusions and Relevance: Among patients 65 years or older receiving vasopressors for vasodilatory hypotension, permissive hypotension compared with usual care did not result in a statistically significant reduction in mortality at 90 days. However, the confidence interval around the point estimate for the primary outcome should be considered when interpreting the clinical importance of the study.Trial Registration: isrctn.org Identifier: ISRCTN10580502. [ABSTRACT FROM AUTHOR] - Abstract: Copyright of JAMA: Journal of the American Medical Association is the property of American Medical Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
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