Effect of intraoperative personalized goal-directed hemodynamic management on acute myocardial injury in high-risk patients having major abdominal surgery: a post-hoc secondary analysis of a randomized clinical trial

Abstract

Acute myocardial injury is common after noncardiac surgery and associated with mortality. Impaired intraoperative cardiovascular dynamics are a risk factor for acute myocardial injury. Optimizing intraoperative cardiovascular dynamics may thus reduce acute myocardial injury. We aimed to investigate the effect of intraoperative personalized goal-directed hemodynamic management on the incidence of acute myocardial injury. We hypothesized that personalized goal-directed hemodynamic management reduces the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. We performed a post-hoc secondary analysis of a randomized clinical trial including 180 high-risk major abdominal surgery patients that were randomized to personalized goal-directed hemodynamic management or routine hemodynamic management. We compared the incidences of acute myocardial injury—defined according to the Fourth Universal Definition of Myocardial Infarction (2018)—between patients randomized to personalized goal-directed hemodynamic management or routine hemodynamic management by calculating the relative and absolute risk reduction together with 95% Wald confidence intervals and P values. Acute myocardial injury occurred in 4 of 90 patients (4%) in the personalized goal-directed hemodynamic management group and in 12 of 90 patients (13%) in the routine hemodynamic management group (relative risk: 0.33, 95% confidence interval: 0.11 to 0.99, P = 0.036; absolute risk reduction: − 9%, 95% confidence interval: − 17% to − 0.68%, P = 0.034). In this post-hoc secondary analysis, intraoperative personalized goal-directed hemodynamic management reduced the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. This needs to be confirmed in larger prospective trials.

Hypotension Prediction Index guided Goal Directed therapy and the amount of Hypotension during Major Gynaecologic Oncologic Surgery: a Randomized Controlled clinical Trial

“…As excellently pointed out in a recent paper by Saugel et al, the most common haemodynamic target variables are blood flow variables (CO), dynamic cardiac preload variables (PPV or SVV), and arterial pressure, but targeted arterial pressure management, surprisingly, is not properly considered GDT [ 35 ]. Haemodynamic treatment strategies need specific haemodynamic target variables and values that trigger specific interventions (vasopressor, fluids, inotrope or a combination of these): all of these haemodynamic treatment strategies can be counted as “GDT”, but they are used in very different ways with different effects on outcome [ 10 , 19 , 32 – 35 ]. In this study we tried to define a specifically “modified” GDT protocol that took into account blood pressure as well as flow.…”

“…Despite careful hemodynamic monitoring and protocols for vasopressor and fluid administration, accurate control of MAP remains a challenge [ 10 , 18 , 19 ]. According to several authors fluid optimization before induction of GA and during elective surgery has a minor impact on hypotensive events occurring immediately after induction and during surgery [ 13 , 15 , 20 ].…”