The trial—known as the IMPROVE-multi randomized clinical trial—was led by Bernd Saugel and colleagues from the Department of Anesthesiology at the University Medical Center Hamburg-Eppendorf, Germany. The researchers aimed to determine whether customizing blood pressure goals based on a patient’s preoperative nighttime MAP could better prevent organ injury, which is often linked to intraoperative hypotension.
The single-blind trial enrolled adults aged 45 years and older undergoing elective major abdominal procedures expected to last at least 90 minutes. All participants had at least one additional high-risk criterion for postoperative complications. Conducted across 15 German university hospitals, the study ran from February 2023 to April 2024, with final follow-up in July 2024.
Participants were randomly assigned to one of two groups: individualized blood pressure management—where perioperative MAP targets were adjusted according to each patient’s mean nighttime MAP—or routine care, which aimed to maintain MAP at or above 65 mm Hg, a widely accepted standard threshold.
A total of 1,142 patients were randomized, and 1,134 were included in the primary analysis. The median patient age was 66 years, and women accounted for 34.1% of the cohort. The primary composite endpoint included acute kidney injury, myocardial injury, nonfatal cardiac arrest, or death within the first postoperative week.
The study led to the following findings:
- The study found no significant advantage of individualized blood pressure management compared with routine MAP targeting.
- The composite primary outcome occurred in 33.5% of patients in the individualized MAP group and 30.5% in the routine care group.
- The relative risk was 1.10, and the difference between the two groups was not statistically significant.
- Secondary outcomes also showed no meaningful differences between the two approaches.
- Infectious complications were reported in 15.9% of patients receiving individualized management and 17.1% in the routine management group.
- The 90-day composite outcome—including kidney replacement therapy, myocardial infarction, nonfatal cardiac arrest, or death—occurred in 5.7% of the individualized group and 3.5% of the routine care group.
- None of these differences in secondary outcomes reached statistical significance.
The authors concluded that individualized blood pressure targets based on preoperative nighttime MAP do not provide measurable improvements in perioperative outcomes for high-risk patients undergoing abdominal surgery. Despite the theoretical advantage of personalized hemodynamic management, maintaining a MAP of at least 65 mm Hg remains an effective and reliable standard of care.
"These findings contribute important evidence to the ongoing debate about precision blood pressure management in perioperative medicine, suggesting that more complex individualized strategies may not outperform conventional thresholds in this surgical population," the authors wrote.
Reference:
Saugel B, Meidert AS, Brunkhorst FM, et al. Individualized Perioperative Blood Pressure Management in Patients Undergoing Major Abdominal Surgery: The IMPROVE-multi Randomized Clinical Trial. JAMA. 2025;334(21):1893–1904. doi:10.1001/jama.2025.17235
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