These recommendations were developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort from a network of expert clinicians and methodologists aiming to rapidly produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identification of potentially practice-changing evidence. See www.magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats, available on all devices.

PICO question #1: In adult critically ill patients with hypotension requiring vasopressor support, should we be prescribing a higher blood pressure target (mean arterial pressure (MAP) 75–85 mmHg) compared to a lower blood pressure target (MAP 60–70 mmHg)?

Recommendation: We suggest against the use of higher BP targets (MAP 75–85 mmHg) compared to lower blood pressure targets (MAP 60–70 mmHg) in adult critically ill patients with hypotension requiring vasopressors. (Conditional recommendation).

Summary of evidence: See Table1.

Table 1 Evidence profile outlining outcomes studied, pooled relative and absolute estimates of effect, GRADE certainty rating, and summary statement
Full size table

Justification: Two randomized controlled trials (RCTs; 894 patients) were found to be relevant to our clinical question [1, 2]. Our weak recommendation against higher BP targets takes into consideration the absence of a demonstrated benefit and high resource-demands associated with higher dose or longer duration vasopressor infusions. Additionally, it may be that the prescription of higher thresholds, and a subsequent need for higher doses of vasopressors, leads to increased harm; however, this signal is limited by imprecision and risk of bias.

The guideline panel undertook significant internal debate regarding whether to lower the overall certainty because of lack of blinding given the objective nature of mortality as an outcome and the impracticalities of blinding an intervention such as BP targets. Ultimately, as ICU mortality is often the result of end-of-life decision-making [3], we decided to lower the overall certainty because of risk of bias. The guideline panel also acknowledged the difficulty in making recommendations without quality of life, morbidity indices, or long-term outcome data; and this represents an important consideration for future research in this area.

PICO question #2: In adult trauma patients with hypotension, should we use early vasopressors versus not use early vasopressors?

Recommendation: The panel did not make a recommendation for this question.

Summary of evidence: Please see electronic supplementary material for the evidence profile for this question.

Justification: As a result of the overwhelming concern for residual confounding bias, the panel felt the single RCT [4] addressing this research question provided more informative evidence as to the effect of vasopressor use in trauma as compared with the pooled non-randomized data [5]. Despite starting as high quality, point estimates from the RCT ended with very low certainty secondary to risk of bias and imprecision.

As highlighted by our patient representative, we lack data on long-term morbidity and quality of life indices that severely limits our ability to make a recommendation. Understanding that there is a lack of demonstrated benefit, and given that the use of vasopressors may be associated with increased resources and potentially harm, there was a significant amount of discussion amongst the panel as to whether a conditional recommendation against was most appropriate. Ultimately, given the high degree of uncertainty, it was decided to offer no recommendation at this time.