Personalized Cardiac Index Targets Did Not Cut Complications After Major Abdominal Surgery. A 90-Day Death Signal Calls for Caution.
In the PELICAN trial of 1,095 high-risk surgical patients, published Oct. 19 in JAMA, the 7-day composite outcome was 44.3 percent with individualized hemodynamic therapy and 46.9 percent with routine care. Deaths by 90 days were higher with the protocol.
Keeping cardiac index at or above each patient's own preoperative resting value during elective major abdominal surgery did not reduce complications or death at 7 days, according to the PELICAN randomized trial published online Oct. 19 in JAMA.
Cardiac index is cardiac output adjusted for body surface area. The PELICAN trial, led by anesthesiologist Bernd Saugel of University Medical Center Hamburg-Eppendorf, tested whether an individualized target beats routine anesthetic care. The investigator-initiated trial was funded by Baxter, which makes the monitoring system used; the paper says the company had no role in the design, conduct or analysis. Registration is NCT05648279.
What did the trial test?
It compared a personalized cardiac index target with usual hemodynamic management in adults at high risk of complications. The trial ran at 12 university medical centers in Austria, the Czech Republic, Denmark, Germany and Spain from October 2023 to October 2025. Patients were 45 or older, scheduled for elective major abdominal surgery lasting at least 90 minutes, and had at least one risk factor such as age 65 or older, an expected operation of three hours or more, diabetes on medication, coronary disease or heart failure.
Resting cardiac index was measured noninvasively by bioreactance, which estimates cardiac output from changes in a small electrical current passed across the chest, usually at least a day before surgery. In the intervention group, an algorithm used balanced crystalloids, extra 500 mL fluid boluses and dobutamine to keep the intraoperative cardiac index at or above that resting value from incision to the end of surgery. In the control group, anesthesiologists managed hemodynamics at their discretion and were blinded to cardiac index. Both groups targeted a mean arterial pressure above 65 mm Hg.
What did it find?
The primary outcome did not differ. Acute kidney injury, acute myocardial injury, severe infection, nonfatal cardiac arrest or death within 7 days occurred in 44.3 percent of the intervention group (243 of 549) and 46.9 percent of the routine-care group (256 of 546), a relative risk of 0.94 (95.1% CI, 0.83 to 1.08; P = .38). No single component differed significantly. Acute kidney injury was 9.6 percent versus 13.0 percent, a difference whose confidence interval crossed 1.
The protocol did change care. Patients in the intervention group received a median of 3,500 mL of fluid versus 2,838 mL, 64.1 percent received dobutamine versus 0.5 percent, and mean intraoperative cardiac index was 3.1 versus 2.7 L/min/m². Median hospital stay was 8 versus 9 days.
More fluid and more dobutamine moved the number on the monitor. They did not move the outcomes that matter to patients.
What about the 90-day deaths?
Mortality at 90 days was 5.7 percent with the intervention (31 of 541) and 2.8 percent with routine care (15 of 540), a relative risk of 2.06 (95% CI, 1.13 to 3.78). This was one of many secondary outcomes and was not adjusted for multiple comparisons. The authors write that it "may represent a chance finding or a potential adverse effect of the intervention" and should be interpreted cautiously. Seven-day deaths were 3 in each group.
The authors also note limits: university centers experienced with this monitoring, no measurement of oxygen delivery, bioreactance not being a reference method for cardiac output, and a primary outcome that could miss later complications. The results do not apply to emergency or non-abdominal surgery.
What does it mean in the operating room?
For high-risk elective abdominal surgery, the trial gives no support for adding a personalized cardiac index protocol to routine care, and the 90-day signal argues against adopting one outside a study. Surgeons and internists who see these patients before surgery can expect anesthesia teams to keep pressure-based targets. In septic shock, a separate trial found that adding dobutamine during source-control surgery cut kidney injury, a different population and question. For another recent hemodynamic trial, see our report on earlier vasopressin in septic shock.
Reported, fact-checked and edited by The Script Pad's editorial staff.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
