Intraoperative hypotension is known to contribute to organ injury, including kidney and heart damage. However, the potential benefit of customizing blood pressure management to each patient’s baseline physiology had not been clearly established. The IMPROVE-multi trial sought to address this question in adults at high risk of postoperative complications undergoing major abdominal surgery.
The study enrolled 1,272 patients aged 45 years or older undergoing elective major abdominal surgery expected to last at least 90 minutes, with at least one additional high-risk criterion. Participants were randomized to individualized blood pressure management, where MAP targets were based on preoperative nighttime measurements using automated monitoring, or routine management, which aimed to maintain MAP at 65 mm Hg or higher, as per standard care.
The primary endpoint was a composite of acute kidney injury, acute myocardial injury, nonfatal cardiac arrest, or death within the first seven postoperative days. Secondary outcomes included infectious complications and a composite outcome encompassing kidney replacement therapy, myocardial infarction, cardiac arrest, or death within 90 days after surgery.
Key Findings:
- Of the 1,142 patients randomized, 1,134 were included in the primary analysis.
- The median age of participants was 66 years.
- Women comprised 34.1% of the study population.
- The primary outcome occurred in 33.5% of patients in the individualized blood pressure group.
- The primary outcome occurred in 30.5% of patients in the routine care group.
- The relative risk between the two groups was 1.10, indicating no significant difference.
- None of the 22 secondary outcomes showed significant differences between groups.
- Infectious complications occurred in 15.9% of the individualized group versus 17.1% of the routine care group.
- The 90-day composite outcome occurred in 5.7% of the individualized group versus 3.5% of the routine care group.
The trial’s results suggest that, for high-risk patients undergoing major abdominal surgery, individualized perioperative MAP targets based on preoperative nighttime measurements do not confer added protection against major postoperative complications compared with standard management. Maintaining MAP at or above 65 mm Hg, as routinely practiced, remains an effective approach for reducing the risk of acute kidney injury, myocardial injury, or death in this population.
These findings highlight the need for pragmatic blood pressure management strategies during surgery and indicate that further research is necessary to identify other intraoperative interventions that may meaningfully improve outcomes in high-risk surgical patients.
"The trial highlights the complexity of perioperative care and reinforces that individualized blood pressure strategies may not always translate into measurable clinical benefits," the authors concluded.
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. Published online October 12, 2025. doi:10.1001/jama.2025.17235
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