Dear Editor
A recent trial showed that cardiac output (CO)-guided low dose inotrope infusion did not reduce postoperative infection rates during major gastrointestinal surgery; rather, it increased the incidence of postoperative acute cardiac events, particularly tachycardia.[1] However, based on our experience, it is important to emphasize the significance of combined pharmacotherapy and individualized precision treatment.
The study did not explore the potential of combining inotropes with other medications. In clinical practice, low dose inotrope infusion combined with vasopressors (such as norepinephrine) can effectively stabilize the intraoperative mean arterial pressure, improve organ perfusion, and promote postoperative recovery, especially in cases of intraoperative blood loss, significant blood pressure fluctuations, or poor response to fluid resuscitation in hypotension.[2] Postoperatively, Beta-blockers (such as metoprolol or bisoprolol) can slow the heart rate and alleviate the cardiac burden.[3]
The study relied on a single CO parameter, deviating from current guidelines.[4] In practice, combining CO with dynamic preload responsiveness (such as pulse pressure variation and stroke volume variation) and adjusting fluid supplementation in a timely manner can significantly reduce postoperative complications.[5] The dose of inotropes is closely related to the risks and efficacy, requiring precise dosage management.[2,6] Accurate haemodynamic guidance (cardiac index 2.5–4.0 L/min/m², central venous pressure 5–12 mmHg) can reduce mortality and complications. [7]
The study lacked preoperative health assessments to determine whether haemodynamic-guided low dose inotrope infusion therapy and its intensity were needed. Haemodynamic-guided therapy may benefit patients with haemodynamic instability due to cardiovascular disease, malnutrition, or poor physiological function.[2] In particular, for patients with a history of heart disease, preoperative evaluation should be conducted using echocardiography, B-type natriuretic peptide, and cardiac stress testing.[8]
It is important to note that inotrope is not directly anti-infective and that broad-spectrum antibiotics prevent postoperative infections.[6]
References
1. Group OIT. Cardiac output-guided haemodynamic therapy for patients undergoing major gastrointestinal surgery: OPTIMISE II randomised clinical trial. BMJ 2024;387. doi: https://doi.org/10.1136/bmj-2024-080439
2. Jentzer JC, Hollenberg SM. Vasopressor and inotrope therapy in cardiac critical care. Journal of Intensive Care Medicine 2021;36(8):843-56. https://doi.org/10.1177/0885066620917630
3. Heliste M, Pettilä V, Berger D, et al. Beta-blocker treatment in the critically ill: a systematic review and meta-analysis. Annals of medicine 2022;54(1):1994-2010. https://doi.org/10.1080/07853890.2022.2098376
4. Members WC, Thompson A, Fleischmann KE, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology 2024;84(19):1869-969.
5. Perel A, Habicher M, Sander M. Bench-to-bedside review: Functional hemodynamics during surgery-should it be used for all high-risk cases? Critical care 2013;17:1-8. https://doi.org/10.1186/cc11448
6. Motwani SK, Saunders H. Inotropes. Anaesthesia & Intensive Care Medicine 2021;22(4):243-48. https://doi.org/10.1016/j.mpaic.2021.02.011
7. Platt AT, Conolly S, Round J. Monitoring of the cardiovascular system: insertion and assessment. Critical care manual of clinical procedures and competencies Chichester: John Wiley 2013
8. Aspromonte N, Feola M, Scardovi AB, et al. Early diagnosis of congestive heart failure: clinical utility of B-type natriuretic peptide testing associated with Doppler echocardiography. Journal of Cardiovascular Medicine 2006;7(6):406-13. doi: 10.2459/01.JCM.0000228690.40452.d3
Haemodynamic-guided combined pharmacotherapy and precision treatment in major gastrointestinal surgery