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 20 February 2018

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News

Blood pressure management strategies among high-risk patients undergoing abdominal surgery

This week's issue of the Journal of the American Medical Association examines the effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery.

News image

Perioperative hypotension is associated with an increase in postoperative morbidity and mortality, but the appropriate management strategy remains uncertain.

Dr Emmanuel Futier and colleagues evaluated whether an individualized blood pressure management strategy tailored to individual patient physiology could reduce postoperative organ dysfunction.

The Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study was a multicenter, randomized, parallel-group clinical trial conducted in 9 French university and nonuniversity hospitals.

46% in the individualized treatment group had postoperative organ dysfunction by day 30
Journal of the American Medical Association

Adult patients at increased risk of postoperative complications with a preoperative acute kidney injury risk index of class III or higher undergoing major surgery lasting 2 hours or longer under general anesthesia were enrolled from 2012 through 2016.

Individualized management strategy aimed at achieving a systolic blood pressure (SBP) within 10% of the reference value or standard management strategy of treating SBP less than 80 mm Hg or lower than 40% from the reference value during and for 4 hours following surgery.

The team's primary outcome was a composite of systemic inflammatory response syndrome and dysfunction of at least 1 organ system of the renal, respiratory, cardiovascular, coagulation, and neurologic systems by day 7 after surgery.

Secondary outcomes included the individual components of the primary outcome, durations of ICU and hospital stay, adverse events, and all-cause mortality at 30 days after surgery.

Among 298 patients who were randomized, 292 patients completed the trial, and were included in the modified intention-to-treat analysis.

The researchers' primary outcome event occurred in 38% of patients assigned to the individualized treatment strategy vs 52% assigned to the standard treatment strategy.

The team observed that 46% of patients in the individualized treatment group, and 63% in the standard treatment group had postoperative organ dysfunction by day 30.

There were no significant between-group differences in severe adverse events or 30-day mortality.

Dr Futier's team concludes, "Among patients predominantly undergoing abdominal surgery who were at increased postoperative risk, management targeting an individualized systolic blood pressure, compared with standard management, reduced the risk of postoperative organ dysfunction."

JAMA 2017;318(14):1346-1357
13 October 2017

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