Fluid responsiveness-guided preinduction volume optimization and postinduction hypotension in older adults at increased frailty risk: A randomized clinical trial

Study objective To determine whether preinduction volume optimization guided by fluid responsiveness reduces postinduction hypotension in older adults at increased frailty risk. Design Single-center randomized controlled trial. Setting Shanghai Sixth People's Hospital, Shanghai, China. Patients One hundred adults aged 65 years or older with Risk Analysis Index-C scores greater than 15 undergoing elective gastrointestinal surgery. Interventions Participants were assigned 1:1 to preinduction volume optimization guided by passive leg raising and echocardiographic left ventricular outflow tract velocity-time integral, or usual care. Fluid-responsive participants received 8 mL/kg succinylated gelatin boluses until optimization. Measurements The primary outcome was the occurrence of any mean arterial pressure (MAP) below 65 mmHg during postinduction minutes 1 through 15. Main results Forty-six of 50 optimization participants were fluid responsive and received colloid. At least 1 MAP value below 65 mmHg occurred in 19 of 50 participants (38%) with optimization and 36 of 50 (72%) with usual care (risk difference, −34.0 percentage points [95% CI, −50.1 to −14.5]; relative risk, 0.53 [95% CI, 0.36 to 0.78]; P = .001). The number needed to treat was 3 (95% CI, 2 to 7), and the fragility index was 7. The mean minimum MAP differed by 4.3 mmHg; the median number of scheduled observations below 65 mmHg was 0 vs 2. Conclusions In selected older adults at increased frailty risk, preinduction volume optimization reduced early postinduction hypotension. Differences in hypotension depth and burden were modest, and clinical benefit remains uncertain. Clinical trial registration Chinese Clinical Trial Registry (ChiCTR2500095294; registered 6 January 2025; https://www.chictr.org.cn/showproj.html?proj=255888 ).