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Postoperative morbidity and mortality after cardiac surgery with cardiopulmonary bypass (CPB) remain high despite recent advances in both anesthesia and perioperative management. Among modifiable risk factors for postoperative complications, optimal arterial pressure during and after surgery has been under debate for years. Recent data suggest that optimizing arterial pressure to the baseline of the patient may improve outcomes. We hypothesize that optimizing the mean arterial pressure (MAP) to the baseline MAP of the patient during cardiac surgery with CPB and during the first 24 hours postoperatively may improve outcomes. The OPTIPAM trial (NCT05403697) will be a multicenter, randomized, open-label controlled trial testing the superiority of optimized MAP management as compared with a MAP of 65 mm Hg or more during both the intraoperative and postoperative periods in 1,100 patients scheduled for cardiac surgery with CPB. The primary composite end point is the occurrence of acute kidney injury, neurological complications including stroke or postoperative delirium, and death. The secondary end points are hospital and intensive care unit lengths of stay, Day 7 and Day 90 mortality, postoperative cognitive dysfunction on Day 7 and Day 90, and quality of life at Day 7 and Day 90. Two interim analyses will assess the safety of the intervention. The OPTIPAM trial will assess the effectiveness of an individualized target of mean arterial pressure in cardiac surgery with CPB in reducing postoperative morbidity. NCT05403697 [ABSTRACT FROM AUTHOR]

This post-hoc analysis of a randomized controlled trial was undertaken to establish the determinants of postoperative complications and acute kidney injury in high-risk noncardiac surgery patients supported with hemodynamic treatment strategies. We conducted a post-hoc analysis of patients enrolled in the OPtimization Hemodynamic Individualized by the respiratory QUotiEnt (OPHIQUE) trial. Operating rooms in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. We enrolled 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia. All patients were treated according to hemodynamic treatment strategies which included cardiac output optimization by titration of fluid challenge and targeted systolic blood pressure to remain within ±10% of the reference value. We assessed the association between pre-operative and intra-operative exposure of interest with a composite primary outcome of major complications or death within seven days following surgery using a multivariable logistic regression model. We also assessed the association between these exposures of interest and acute kidney injury. The data of 341 patients were analyzed. In multivariate analysis, the factors independently associated with the primary outcome were age (OR = 1.04 (1.01–1.06), P = 0.002), preoperative hemoglobin concentration (OR = 0.85 (0.75–0.96), P = 0.012), non-vascular surgery (OR = 0.30 (0.17–0.53), P < 0.0001), and intraoperative surgical complications (OR = 2.08 (1.02–4.24), P = 0.046). The factors independently associated with postoperative acute kidney injury were age (OR = 1.04 (1.01–1.08), P = 0.008), preoperative creatinine concentration (OR = 1.01 (1.00–1.01), P = 0.049), non-vascular surgery (OR = 0.36 (0.20–0.66), P = 0.001), and intraoperative surgical complications (OR = 3.36 (1.50–7.55), P = 0.031). Surgical complications, a lower preoperative hemoglobin concentration, age, and vascular surgery were associated with postoperative complications in a high-risk noncardiac surgery population supported with hemodynamic treatment strategies. • The prevalence of complications was high for patients treated according to hemodynamic treatment strategy. • factors associated with complications in this population were age, the preoperative hemoglobin and surgical complications. • These factors were associated with outcome in this population treated according to hemodynamic treatment strategy. • Neither blood pressure, cardiac output, intraoperative volume, nor norepinephrine dose were associated with complications. [ABSTRACT FROM AUTHOR]

• There is a need to develop non-invasive markers to identify tissue hypoperfusion. • The Respiratory Exchange Ratio is a non-invasive marker of tissue perfusion. • Does algorithm based on the Respiratory Exchange Ratio reduce complications? • The Respiratory Exchange Ratio did not reduce postoperative complications. There is a need to develop non-invasive markers to identify the occurrence of anaerobic metabolism in high-risk surgery. Our objective was to demonstrate that a goal-directed therapy algorithm incorporating the respiratory exchange ratio (ratio between CO 2 production and O 2 consumption) can reduce postoperative complications. We conducted a randomized, multicenter, controlled clinical trial in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia were enrolled. The control group was treated according to current hemodynamic guidelines. The interventional group was treated according to an algorithm based on the measurement of the respiratory exchange ratio. The primary outcome was a composite of major complications or death within seven days of surgery. The secondary outcomes were the length of hospital stay, 30-day mortality, and the total intraoperative volume of fluids administered. The primary outcome occurred for 78 patients (45.6%) in the interventional group and 83 patients (48.8%) in the control group (relative risk: 0.93, 95% confidence interval [CI]: 0.75–1.17; p = 0.55). There were no clinically relevant differences between the two groups for secondary outcomes. In high-risk surgery, a goal-directed therapy algorithm integrating the measurement of the respiratory-exchange ratio did not reduce a composite outcome of major postoperative complications or death within seven days after surgery compared to routine care. ClinicalTrials.gov, NCT03852147. [ABSTRACT FROM AUTHOR]