Design: Two-centre, randomised, single-blind trial
Population: 504 adults aged ≥45 with cardiovascular risk factors, major non-cardiac surgery
Primary outcome: Time-weighted average MAP <65 mmHg in first 20 min after induction
Effect: Median 0.0 vs 0.0 mmHg (IQR 0–0.56 vs 0–0.84); P = 0.37

This two-centre Austrian trial, published 25 September in Anesthesiology, randomised 504 adults aged 45 and over with cardiovascular risk factors undergoing major non-cardiac surgery to a crystalloid bolus within 60 minutes before induction, or standard care. The trial was single-blind.

The primary outcome was the time-weighted average of mean arterial pressure below 65 mmHg in the first 20 minutes after induction or until incision. There was no difference: the median was 0.0 mmHg in both groups (interquartile ranges 0.0 to 0.56 and 0.0 to 0.84; P = 0.37).

Pre-loading is still widely used to head off hypotension after induction. This trial, in exactly the patients at risk, shows it does not work, and it adds fluid that some patients do not need. Attention belongs on induction technique, dosing and vasopressor readiness.

Stop giving a routine crystalloid bolus before induction to prevent hypotension.
Give fluid before induction only for a clear deficit, such as dehydration or bowel preparation.
Have a vasopressor ready and titrate induction agents in patients at risk of hypotension.
Avoid unnecessary fluid in patients with heart failure or renal impairment.

Why it matters

Retires a routine that adds fluid and time without protecting blood pressure.

The statistics, in plain English

A median of 0.0 mmHg in both groups means most patients spent little or no time below 65 mmHg either way. The interquartile ranges overlapped almost completely, so there is no hint of a hidden benefit.