Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial

• Published in: British journal of anaesthesia : BJA Vol. 133; no. 2; pp. 277 - 287
• Main Authors: Funcke, Sandra, Schmidt, Götz, Bergholz, Alina, Argente Navarro, Pilar, Azparren Cabezón, Gonzalo, Barbero-Espinosa, Silvia, Diaz-Cambronero, Oscar, Edinger, Fabian, García-Gregorio, Nuria, Habicher, Marit, Klinkmann, Gerd, Koch, Christian, Kröker, Alina, Mencke, Thomas, Moral García, Victoria, Zitzmann, Amelie, Lezius, Susanne, Pepić, Amra, Sessler, Daniel I., Sander, Michael, Haas, Sebastian A., Reuter, Daniel A., Saugel, Bernd
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.08.2024; Elsevier
• Subjects: Abdomen - surgery; Aged; Aged, 80 and over; anaesthesia; Cardiac Output; Cardiotonic Agents - administration & dosage; Cardiotonic Agents - therapeutic use; Cardiovascular; cardiovascular dynamics; Dobutamine - administration & dosage; Elective Surgical Procedures - adverse effects; Female; Fluid Therapy - methods; haemodynamic monitoring; Humans; individualised; Male; Middle Aged; Monitoring, Intraoperative - methods; morbidity; mortality; Postoperative Complications - epidemiology; Postoperative Complications - prevention & control; randomised controlled trial; cardiac output; haemodynamic monitoring; cardiovascular dynamics; individualised; mortality; randomised controlled trial; morbidity; anaesthesia
• ISSN: 0007-0912; 1471-6771; 1471-6771
• DOI: 10.1016/j.bja.2024.03.040

It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery. We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03–3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis. Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications. NCT03021525.