Takeaway

Personalized perioperative blood pressure management based on individual nighttime MAP is feasible and could improve patient outcomes.

Key findings:

• 93% success rate in preoperative nighttime blood pressure monitoring
• 85% of patients had mean nighttime MAP significantly different from standard 65 mmHg
• Median time-weighted average MAP below personalized target: 3.29 mmHg

Study details:

• 105 patients enrolled, 98 randomized
• Ages 45+ years
• Major non-cardiac surgery patients
• Conducted at two university hospitals in Germany

Excerpts

nighttime MAP is a surrogate for the individual intraoperative hypotension harm threshold.

While individual patients may require higher intraoperative blood pressure to ensure adequate organ perfusion, other patients – presumably those who have lower “normal” blood pressure – may well tolerate lower blood pressure during surgery (and may even be harmed by aggressively targeting higher blood pressure)

Individual nighttime mean arterial pressure (MAP) may be a reasonable blood pressure target.

assumed “that nighttime MAP is a surrogate for the individual intraoperative hypotension harm threshold”

Nighttime MAP meaningfully differs from a MAP of 65 mmHg in most patients.

preoperative mean nighttime MAP was at least 10 mmHg higher than a MAP of 65 mmHg in more than 8 out of 10 patients.

Abstract

Study objective

We hypothesize that personalized perioperative blood pressure management maintaining intraoperative mean arterial pressure (MAP) above the preoperative mean nighttime MAP reduces perfusion-related organ injury compared to maintaining intraoperative MAP above 65 mmHg in patients having major non-cardiac surgery. Before testing this hypothesis in a large-scale trial, we performed this bicentric pilot trial to determine a) if performing preoperative automated nighttime blood pressure monitoring to calculate personalized intraoperative MAP targets is feasible; b) in what proportion of patients the preoperative mean nighttime MAP clinically meaningfully differs from a MAP of 65 mmHg; and c) if maintaining intraoperative MAP above the preoperative mean nighttime MAP is feasible in patients having major non-cardiac surgery.

Design

Bicentric pilot randomized trial.

Setting

University Medical Center Hamburg-Eppendorf, Hamburg, Germany, and RWTH Aachen University Hospital, Aachen, Germany.

Patients

Patients ≥ 45 years old having major non-cardiac surgery.

Interventions

Personalized blood pressure management.

Measurements

Proportion of patients in whom preoperative automated nighttime blood pressure monitoring was possible; proportion of patients in whom the preoperative mean nighttime MAP clinically meaningfully differed from a MAP of 65 mmHg (difference > ±10 mmHg); intraoperative time-weighted average MAP below the preoperative mean nighttime MAP.

Main results

We enrolled 105 patients and randomized 98 patients. In 98 patients (93 %), preoperative automated nighttime blood pressure monitoring was possible. In 83 patients (85 %), the preoperative mean nighttime MAP clinically meaningfully differed from a MAP of 65 mmHg. The median time-weighted average MAP below the preoperative mean nighttime MAP was 3.29 (1.64, 6.82) mmHg in patients assigned to personalized blood pressure management.

Conclusions

It seems feasible to determine the effect of personalized perioperative blood pressure management maintaining intraoperative MAP above the preoperative mean nighttime MAP on postoperative complications in a large multicenter trial.

Citation

Bergholz A, Grüßer L, Khader WTAK, Sierzputowski P, Krause L, Hein M, Wallqvist J, Ziemann S, Thomsen KK, Flick M, Breitfeld P, Waldmann M, Kowark A, Coburn M, Kouz K, Saugel B. Personalized perioperative blood pressure management in patients having major non-cardiac surgery: A bicentric pilot randomized trial. J Clin Anesth. 2024 Nov 27;100:111687. doi: 10.1016/j.jclinane.2024.111687. Epub ahead of print. PMID: 39608100.

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