EJRC Article Review
Effect of Individualised vs. Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery
Adequate perioperative blood pressure (BP) control is a cornerstone in preventing postoperative organ dysfunction. However, there are no evidence-based data on the effective BP target. The aim of the Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study  was to determine whether perioperative individualised BP control could be protective for postoperative organ dysfunction compared to a standard treatment in high risk patients.
This multicentre, randomised, parallel-group clinical trial enrolled patients undergoing major surgery with an expected duration ≥ 2 hours if older than 50 years, with an ASA ≥2 and a preoperative acute kidney injury risk index ≥ III . Patients were randomised to receive a perioperative (from anaesthesia induction to 4 hours post-surgery) standard (SG) control of BP consisting of IV bolus of ephedrine if systolic BP (SBP) was < 80 mmHg or < 40% of the reference value, or an individualised (IG) control of BP through norepinephrine continuous IV infusion in order to keep SBP ± 10% of the reference value. The main outcome was a composite of systemic inflammatory response syndrome (SIRS) and at least 1 organ system dysfunction. Secondary outcomes included individual components of the primary outcome, postoperative complications, LOS and 30 days mortality.
292 patients were included in the intention-to-treat analysis (IG: 147; SG: 145). The majority of patients in both groups underwent elective abdominal surgery. The preinduction BP was not statistically different, but at the end of the intervention period, IG patients had significantly higher values of SBP, DBP and MBP (IG: 120, 60 and 81 mmHg; SG: 110, 56 and 75 mmHg, respectively, p<0.001 in all cases). No differences in terms of fluid management emerged, even though the volume of crystalloids infused during surgery was significantly higher in the SG (p<0.001). In the IG there was significantly lower rate of SIRS and organ dysfunction (p<0.02). As for secondary outcomes, a higher rate of AKI according to RIFLE criteria was registered. Regarding postoperative complications, no statistically significant differences were detected with the exception of pneumonia, sepsis and surgical site infection at 30 days, which were lower in the IG (p<0.03, p<0.009 and p 0.04 respectively). No differences in LOS and 30 days mortality were showed.
The use of a therapeutic algorithm was really a good point of this study. Actually, the event rate in the control group (51.7%) was higher than previewed (>40%), perhaps due to the inclusion of very high risk patients. However, the absolute difference in the primary outcome (14%) was lower than expected (> 20%). It should be noted that BP was measured every 10 minutes and no data are available for the time outside of these points.
In conclusion, despite the fact that it does not have an impact on LOS and 30-day mortality, perioperative patient-targeted BP control was shown to reduce the rate of postoperative organ dysfunction in high risk patients.
Article review prepared and submitted by Simone Carelli (Department of Anaesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy) on behalf of the EJRC.
- Futier E, Lefrant JY, Guinot PG, et al. Effect of Individualised vs. Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery. JAMA, 2017; E1-E12.
- Kheterpal S, Tremper KK, Heung M, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national dataset. Anesthesiology, 2009;110(3):505-515.