Hypothesis: “We sought to elucidate whether targeting a higher intraoperative mean arterial pressure in all patients at cardiovascular risk reduces the incidence of postoperative complications following major noncardiac surgery at 30 days and 1 year postoperatively”
Methods
Single-center
Single-blinded
Inclusion criteria
> 45 years of age
Cardiovascular risk
Major noncardiac surgery
Exclusion criteria
Pregnancy
Inclusion in another clinical study with the same endpoints
Previous enrollment in BBB study
Emergent surgery
Active cardiac condition
Transplantation
Anesthetic management
General anesthesia
Target-controlled infusion (TCI) propofol or volatile anesthetics
Analgesia: fentanyl + TCI remifentanil
BIS 45-60
NMBA
+/- Neuraxial analgesia
Controlled ventilation
Groups
MAP target of ≥60 mm Hg (control)
MAP target of ≥75 mm Hg (intervention)
Hemodynamic management
Assess volume status and anesthetic depth
If already optimized, then administering vasopressor
Preference for epinephrine bolus if HR > 80 and ephedrine bolus if HR < 55, otherwise either vasopressor
For non responders recommended norepinephrine infusion vs continued ephedrine boluses (depending on HR)
Outcomes
Primary
hs-cTnI rise on POD 0-3 and/or 30-day MACE/acute AKI
ACS
New/worsening CHF
Coronary revascularization
Stroke
All-cause mortality
Secondary
1 year MACE/CKD
Results
The intervention group had a significantly reduced amount of time with a MAP < 65 mmHg, but there was no difference in acute myocardial injury or 30-day MACE/AKI.
Strengths
Pragmatic
Randomized controlled trial
Low variability in anesthetic management
Low drop-out rate
Inclusion criteria
Endpoints
First of its kind study
Weaknesses
Generalizability
Composite outcome
Potentially underpowered
Key Point: Targeting a MAP ≥75 mm Hg did not reduce postoperative complications as compared to a MAP target of ≥60 mm Hg.