Key result
Targeting an 80 mmHg MAP during general anaesthesia increases AKI nearly fivefold compared to 60 mmHg.
Why the study?
High-quality evidence to guide haemodynamic management during general anaesthesia is limited, and previous trials on blood pressure targets have suffered from poor adherence and limited between-group separation.
Does targeting a higher minimum mean arterial blood pressure (70 mmHg, 80 mmHg, or 90% of baseline systolic) compared to 60 mmHg improve postoperative outcomes in high-risk patients undergoing major surgery under general anaesthesia?
RCT (n=483)
Single-blinded
Centralised and conducted online in real-time immediately before surgery through REDCap, 3x3x2x4 factorial design
Yes
Does targeting a higher minimum mean arterial blood pressure (70 mmHg, 80 mmHg, or 90% of baseline systolic) compared to 60 mmHg improve postoperative outcomes in high-risk patients undergoing major surgery under general anaesthesia?
In high-risk patients undergoing general anaesthesia, targeting a higher minimum mean arterial pressure of 80 mmHg is feasible but may increase the risk of acute kidney injury and cardiac arrhythmias compared to a 60 mmHg target.
Higher MAP targets warrant caution in high-risk surgery; challenges assumptions favoring elevated intraoperative pressures.
BACKGROUND: There is limited high-quality evidence to guide haemodynamic and respiratory management during general anaesthesia. The goal of this trial was to test the feasibility of testing different ventilatory settings and blood pressure targets. Previous trials on blood pressure targets have suffered from poor adherence and limited between-group separation. This manuscript focuses on the overall feasibility, as well as blood pressure targets. METHODS: This was a multicentre, randomised, factorial, clinical trial conducted at eight hospitals in Denmark. 483 patients ASA 3-5, scheduled for major surgery under general anaesthesia, were included. Patients were randomised to a minimum mean arterial blood pressure (MAP) target of 60, 70 or 80 mmHg, or 90% of baseline systolic blood pressure. The primary outcomes focused on feasibility, while secondary outcomes included intra- and postoperative complications, hospital length of stay, quality of life and recovery and mortality. RESULTS: Out of 1690 eligible patients, 483 (29%) were randomised, below the goal of 50%. Separation in blood pressure was achieved and blood pressure during vasoactive treatment was within predefined target ranges. There was no difference in most of the postoperative outcomes. Some complications, including acute kidney injury (OR 4.74, 95% CI 1.17; 31.8) and cardiac arrhythmias (OR 8.13, 95% CI 1.35; 156), were more common in the MAP-80-mmHg group compared to the MAP-60-mmHg group. The MAP-80-mmHg group had fewer days alive and out of hospital within 30 days (median difference -1.88 days, 95% CI -3.50; -0.26). CONCLUSIONS: While not all feasibility goals were achieved, separation in blood pressure and adherence to targets were adequate. Larger trials are needed to determine the optimal blood pressure target during general anaesthesia. TRIAL REGISTRATION: Clinicaltrials.gov: NCT06047119.
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Pælestik et al. (2026) conducted an RCT in High-risk patients (ASA 3-5) undergoing major surgery under general anaesthesia (n=483). Minimum mean arterial blood pressure (MAP) targets vs. MAP 60 mmHg (reference group) was evaluated on Proportion of eligible patients randomised (feasibility). In this feasibility trial, targeting a mean arterial pressure of 80 mmHg during general anaesthesia increased the risk of acute kidney injury (OR 4.74) and cardiac arrhythmias (OR 8.13) compared to a 60 mmHg target.
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