Targeting each patient's own cardiac index in major surgery does not cut complications

Design

Multicentre, single-blind, randomised superiority trial

Population

1,111 high-risk patients having elective major abdominal surgery

Primary outcome

Composite of AKI, myocardial injury, severe infection, cardiac arrest or death at 7 days

Effect

44.3% vs 46.9%; RR 0.94 (95.1% CI 0.83–1.08)

PELICAN, in JAMA, randomised 1,111 high-risk patients having elective major abdominal surgery at 12 European university centres. One group received haemodynamic therapy aimed at keeping cardiac index at the patient's own preoperative resting value; the other received routine care with cardiac index monitored but hidden.

The composite of acute kidney injury, myocardial injury, severe infection, non-fatal cardiac arrest or death within seven days occurred in 44.3% versus 46.9% (RR 0.94). No individual component differed.

Individualised flow targets are an appealing idea and have been widely promoted. This trial suggests that, in high-risk abdominal surgery, steering to a personal cardiac index does not reduce early complications compared with good routine care.

Anaesthetic teams need not add cardiac output-guided targets to routine practice on the basis of this idea; standard haemodynamic management remains appropriate.

• Do not adopt personal cardiac index targets for major abdominal surgery on current evidence
• Expect early complications in nearly half of high-risk major abdominal surgery patients
• Use the high complication rate when consenting high-risk patients

Why it matters

Individualised flow targets have been promoted without trial proof, and this trial did not provide it.

The statistics, in plain English

An RR of 0.94 with an interval from 0.83 to 1.08 means anything from a 17% reduction to an 8% increase fits the data, so a large benefit is unlikely.

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