Individualized Perioperative Blood Pressure Management in Patients Undergoing Major Abdominal Surgery: The IMPROVE-multi Randomized Clinical Trial.

Summary

In 1142 high-risk patients undergoing major abdominal surgery at 15 German centers, individualized MAP targets based on preoperative nighttime MAP did not reduce a 7-day composite of AKI, myocardial injury, nonfatal cardiac arrest, or death versus routine care (RR 1.10; 95% CI 0.93-1.30; P=.31). None of 22 secondary outcomes differed, including infections and a 90-day major adverse event composite.

Key Findings

• Composite primary outcome occurred in 33.5% with individualized MAP vs 30.5% with routine care (RR 1.10; 95% CI 0.93-1.30; P=.31).
• No significant differences across 22 secondary outcomes, including 7-day infections (15.9% vs 17.1%; P=.63) and 90-day KRT/MI/cardiac arrest/death composite (5.7% vs 3.5%; P=.12).
• Intervention set intraoperative MAP targets using preoperative mean nighttime MAP from ambulatory monitoring; control targeted MAP ≥65 mm Hg.

Clinical Implications

Maintain standard MAP targets of ≥65 mm Hg during major abdominal surgery; do not escalate complexity by aligning targets to nighttime MAP, as this did not improve early organ injury or mortality.

Limitations

• Single-blind design may allow performance bias at the provider level
• Generalizability limited to German university hospitals and major abdominal surgery; short primary follow-up (7 days)

Future Directions

Test perfusion-guided strategies (e.g., autoregulation indices, organ-specific perfusion monitoring), evaluate microcirculatory endpoints, and assess different populations and longer-term outcomes.