Fluid responsiveness-guided preinduction volume optimization and postinduction hypotension in older adults at increased frailty risk: A randomized clinical trial

STUDY OBJECTIVE: To determine whether preinduction volume optimization guided by fluid responsiveness reduces postinduction hypotension in older adults at increased frailty risk. DESIGN: Single-center randomized controlled trial. SETTING: Shanghai Sixth People's Hospital, Shanghai, China. PATIENTS: One hundred adults aged 65 years or older with Risk Analysis Index-C scores greater than 15 undergoing elective gastrointestinal surgery. INTERVENTIONS: Participants were assigned 1:1 to preinduction volume optimization guided by passive leg raising and echocardiographic left ventricular outflow tract velocity-time integral, or usual care. Fluid-responsive participants received 8 mL/kg succinylated gelatin boluses until optimization. MEASUREMENTS: The primary outcome was the occurrence of any mean arterial pressure (MAP) below 65 mmHg during postinduction minutes 1 through 15. MAIN RESULTS: Forty-six of 50 optimization participants were fluid responsive and received colloid. At least 1 MAP value below 65 mmHg occurred in 19 of 50 participants (38%) with optimization and 36 of 50 (72%) with usual care (risk difference, -34.0 percentage points [95% CI, -50.1 to -14.5]; relative risk, 0.53 [95% CI, 0.36 to 0.78]; P = .001). The number needed to treat was 3 (95% CI, 2 to 7), and the fragility index was 7. The mean minimum MAP differed by 4.3 mmHg; the median number of scheduled observations below 65 mmHg was 0 vs 2. CONCLUSIONS: In selected older adults at increased frailty risk, preinduction volume optimization reduced early postinduction hypotension. Differences in hypotension depth and burden were modest, and clinical benefit remains uncertain. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2500095294; registered 6 January 2025; https://www.chictr.org.cn/showproj.html?proj=255888).