Written by Joshua Belfer
Spoon Feed
Targeting the 5th percentile mean blood pressure in pediatric septic shock resulted in similar 28-day mortality as targeting the 50th percentile – while reducing vasopressor use, side effects, and complications like ARDS.
By the way, Dr. Belfer has started a new, dedicated PEM blog called HipPEMcrates.com! Check it out! ~Clay Smith
Perfusion not perfection
Despite being the focus of management of septic shock, the optimal blood pressure target in children remains unclear. Current pediatric sepsis guidelines acknowledge the lack of evidence supporting whether to aim for the 5th or 50th percentile mean blood pressure (MBP), leaving clinicians to balance perfusion goals with the risks of excessive vasopressor use. This randomized controlled trial is the first to compare these two mean blood pressure targets in pediatric septic shock. In 144 children admitted to a tertiary care PICU in India, there was no significant difference in 28-day mortality between the groups (16.9% vs. 23.2%). The higher MBP group required more norepinephrine (85% vs. 67%), had longer vasoactive support (30.4 vs. 18.8 hours), more frequent hydrocortisone use, and nearly double the prevalence of ARDS (32.8% vs. 16.9%). No major differences were found in PICU length of stay or ventilation time. Though it’s a single-center study with short-term outcomes, it offers important early data suggesting that lower BP targets may be safe – and potentially safer – in select patients.
How does this change my practice?
Sepsis is the cornerstone of research in the pediatric emergency room – we are always aiming to find the optimal fluid volume, the best vasopressor, and the perfect biomarker. We are typically used to aiming higher with blood pressure targets in septic shock, thinking that more pressure equals better perfusion. But this trial shows that “permissive hypotension” might not just be safe—it might spare kids from excess vasopressors and potential harms. If perfusion looks good and other markers (like lactate and urine output) are improving, I’ll be more comfortable targeting the low end of normal MBP. It’s one more reminder that the goal is perfusion, not perfection.
Another Spoonful
For your convenience, we created this simplified MAP table, adapted from Table 2 in: Age-Based Percentiles of Measured Mean Arterial Pressure in Pediatric Patients in a Hospital Setting.
| Age (years) | MAP (5th percentile) | MAP (50th percentile) | MAP (95th percentile) |
|---|---|---|---|
| 1–3 mo | 41 | 59 | 82 |
| 3–6 mo | 44 | 62 | 86 |
| 6–12 mo | 48 | 67 | 92 |
| 1–2 y | 52 | 72 | 96 |
| 2–3 y | 53 | 71 | 94 |
| 3–4 y | 52 | 69 | 90 |
| 4–5 y | 52 | 69 | 88 |
| 5–6 y | 53 | 69 | 88 |
| 6–7 y | 54 | 71 | 89 |
| 7–8 y | 55 | 72 | 90 |
| 8–9 y | 55 | 72 | 91 |
| 9–10 y | 56 | 73 | 92 |
| 10–11 y | 56 | 73 | 92 |
| 11–12 y | 56 | 73 | 92 |
| 12–13 y | 56 | 73 | 92 |
| 13–14 y | 56 | 74 | 93 |
| 14–15 y | 56 | 74 | 94 |
| 15–16 y | 56 | 75 | 94 |
| 16–17 y | 57 | 75 | 95 |
| 17–18 y | 57 | 76 | 96 |
Source
Fifth Centile Versus 50th Centile Mean Blood Pressure Targets in Pediatric Septic Shock: A Randomized Controlled Trial. Crit Care Med. 2025 Jun 13. doi: 10.1097/CCM.0000000000006718. Epub ahead of print. PMID: 40511998
