Individualized Cardiac Index–Guided Therapy Does Not Reduce Postoperative Complications

Individualized cardiac index–guided hemodynamic therapy targeting each patient's preoperative resting cardiac index did not reduce early postoperative complications compared with routine hemodynamic therapy in high-risk patients undergoing elective major abdominal surgery, according to the PELICAN randomized clinical trial published in JAMA.

The investigators noted that cardiac index is not routinely monitored during surgery and that it remains unclear whether intraoperative hemodynamic therapy should be guided by it. Rather than maximizing cardiac index, as in 2 previous multicenter trials, PELICAN tested maintaining each patient's preoperative resting value.

The multicenter, single-blind trial randomized 1,111 patients aged 45 years or older with at least 1 high-risk criterion at 12 university medical centers in Austria, the Czech Republic, Denmark, Germany, and Spain. Cardiac index was measured with the noninvasive bioreactance Starling Fluid Management System (Baxter). In the intervention group, clinicians used fluids and dobutamine to keep intraoperative cardiac index at least equal to the preoperative resting value, while control-group clinicians were blinded to cardiac index. Among 1,095 patients in the primary analysis, a composite of acute kidney injury, acute myocardial injury, severe infectious complications, nonfatal cardiac arrest, or death within 7 postoperative days occurred in 44.3% of the intervention group and 46.9% of the routine therapy group (relative risk, 0.94; 95.1% CI, 0.83-1.08).

No individual component of the composite differed between groups, and the intervention did not reduce risk in any prespecified subgroup. Mortality within 90 days was higher with the intervention (5.7% vs 2.8%). The authors cautioned that this exploratory secondary outcome was not adjusted for multiple testing and may reflect chance or a potential adverse effect of the intervention.

Limitations included the absence of oxygen delivery measurements, restriction to elective abdominal surgery, conduct at experienced university centers, and use of bioreactance, which the authors noted is not a clinical reference method. The investigators concluded that the findings do not support this individualized approach in this population.

Source: Saugel B, Meidert AS, Meyhoff CS, et al. Individualized cardiac index–guided hemodynamic therapy in high-risk patients undergoing elective major abdominal surgery: the PELICAN randomized clinical trial. JAMA. Published online October 19, 2026. doi:10.1001/jama.2026.18574