title: Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca.|Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada. francois.lamontagne@usherbrooke.ca.|Centre Hospitalier Universitaire de Sherbrooke, 3001 12e avenue N., Sherbrooke, QC, J1H 5N4, Canada. francois.lamontagne@usherbrooke.ca.
authors.forename: François
authors.initials: F
authors.lastname: Lamontagne
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada.|Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Maureen O
authors.initials: MO
authors.lastname: Meade
authors.affiliation: Department of Medicine and Research Centre, Université de Montréal, Montreal, QC, Canada.
authors.forename: Paul C
authors.initials: PC
authors.lastname: Hébert
authors.affiliation: Department of Medical Intensive Care Medicine, University Hospital Angers, Angers, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Asfar
authors.affiliation: Department of Medicine, Université Laval, Quebec, QC, Canada.|Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada.|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.
authors.forename: François
authors.initials: F
authors.lastname: Lauzier
authors.affiliation: Thoracic Surgery and Critical Care Medicine, University of Ottawa, Ottawa, ON, Canada.|Ottawa Hospital Research Institute, Ottawa, ON, Canada.
authors.forename: Andrew J E
authors.initials: AJE
authors.lastname: Seely
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Day
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mehta
authors.affiliation: Department of Medicine, Kingston General Hospital, Queen's University, Kingston, ON, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Muscedere
authors.affiliation: Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
authors.forename: Sean M
authors.initials: SM
authors.lastname: Bagshaw
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Niall D
authors.initials: ND
authors.lastname: Ferguson
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada.|Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cook
authors.affiliation: Ottawa Hospital Research Institute, Ottawa, ON, Canada.
authors.forename: Salmaan
authors.initials: S
authors.lastname: Kanji
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec, QC, Canada.|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.
authors.forename: Alexis F
authors.initials: AF
authors.lastname: Turgeon
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Margaret S
authors.initials: MS
authors.lastname: Herridge
authors.affiliation: Department of Critical Care Medicine, Mercy St John's Medical Center, St Louis, MO, USA.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Subramanian
authors.affiliation: Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada.
authors.forename: Jacques
authors.initials: J
authors.lastname: Lacroix
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.|Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: Neill K J
authors.initials: NKJ
authors.lastname: Adhikari
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.|Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: Alison
authors.initials: A
authors.lastname: Fox-Robichaud
authors.affiliation: McGill University, Montreal, QC, Canada.
authors.forename: Yoanna
authors.initials: Y
authors.lastname: Skrobik
authors.affiliation: Department of Surgery, McMaster University, Hamilton, ON, Canada.|Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Whitlock
authors.affiliation: Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Green
authors.affiliation: Department of Critical Care Medicine, Swedish Medical Center, Seattle, WA, USA.
authors.forename: Karen K Y
authors.initials: KKY
authors.lastname: Koo
authors.affiliation: Canadian Association of Critical Care Nurses, London, ON, Canada.
authors.forename: Teddie
authors.initials: T
authors.lastname: Tanguay
authors.affiliation: McGill University, Montreal, QC, Canada.
authors.forename: Sheldon
authors.initials: S
authors.lastname: Magder
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
authors.forename: Daren K
authors.initials: DK
authors.lastname: Heyland
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D062186:Arterial Pressure / Q000187:drug effects*; D005260:Female; D006801:Humans; D007022:Hypotension / Q000188:drug therapy* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D012769:Shock / Q000150:complications; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*
chemical_list: D014662:Vasoconstrictor Agents
keywords: Blood pressure targets; Resuscitation; Shock; Vasopressors