BRAIN-targeted Goal-directed Therapy in High-risk Patients undeRgOing Major electIve SurgEry: the BRAIN-PROMISE Study

Overview

The aim of the study is to further understand whether the use of non-invasive monitoring NIRS (Near Infrared Spectroscopy) is useful in reducing postoperative complications in high-risk patients undergoing elective surgery.

Detailed description

Background:

Perioperative complications lead to impaired quality of life as well as prolonged disability. In high risk patients, early hemodynamic optimization with the goal of achieving and maintaining tissue oxygenation in the perioperative period has resulted in an improvement of outcomes and a reduction in surgery-related complications. Maintenance of adequate oxygen delivery to tissue, is one of the fundamental aspects of anesthesia. Regional Oxygen Saturation of the brain tissue (rSO2) as measured by near-infrared spectroscopy (NIRS) is a promising tool in vascular surgery and cardiac surgery for the monitoring of global cerebral perfusion.

Objectives:

This study has the purpose to assess whether an rSO2-based hemodynamic optimization algorithm is able to reduce overall perioperative complications in high risk patients.

Design:

BRAIN-PROMISE is a monocentric, randomized controlled trial.

Population:

Hypertensive elderly or frail patients undergoing major surgery.

Experimental Intervention:

Cases will be managed using a NIRS-targeted goal directed therapy.

Control Intervention:

Controls will be managed according to standard care.

Outcomes:

The primary outcome are the incidence of perioperative complications at 30 days and the percentage of successful reversal of reduction in NIRS.

Trial size:

A total of 200 patients will be randomized.

Interventions

• Device Near Infrared Spectroscopy (NIRS)
  The anesthesiologist will apply optodes before induction of anesthesia and before preoxygenation, to detect baseline NIRS level, NIRS will be monitored continuously up to post-anaesthesia care unit (PACU) discharge, or up to three the investigator's after ICU admission. When a decrease in NIRS value over 10% is detected, or if NIRS value is below 60%, patients will start hemodynamic optimization, to reverse the reduction in NIRS and return to baseline values, according to a predefined protocol.
• Device Standard Care
  Controls will be treated according to standard of care, maintaining a MAP≥65 and an adequate cardiac output according to the hemodynamic monitoring chosen by the anesthesiologist (invasive blood pressure monitoring or pulse contour monitors). NIRS will be recorded also in controls, but caring anesthesiologists will be blinded to NIRS.

Primary outcome measures

• The overall incidence of perioperative complications (including postoperative cognitive dysfunction and delirium). [Time frame: 30 day after randomization]
• Percentage of successful reversal of reduction in NIRS, according to the hemodynamic optimization protocol. [Time frame: intraoperative]

Secondary outcome measures (7)

• NIRS variations over time, and according to interventions [Time frame: intraoperative]
• Percentage of time with NIRS within safety limits (<10% reduction) [Time frame: intraoperative]
• Bispectral index (BIS) over time [Time frame: intraoperative]
• Mean arterial pressure (MAP) over time [Time frame: intraoperative]
• sevorane concentration over time [Time frame: intraoperative]
• Use of vasopressors and fluids to maintain MAP [Time frame: intraoperative]
• Evaluate fluid administration [Time frame: intraoperative]

Eligibility criteria

Inclusion criteria

• hypertensive patients with American Society of Anesthesiologists (ASA) score≥ 2 with either Age ≥ 65 years or frailty score ≥5
• presence of an arterial catheter during anesthesia
• planned high-risk surgery (abdominal, vascular, urologic, thoracic one-lung ventilation (OLV) procedures), longer than 60 minutes, in general anesthesia
• ability to give informed consent according to International Conference on Harmonization ICH/ Good Clinical Practice (GCP), and national/local regulations

Exclusion criteria

• Unable to consent to study inclusion
• Language barrier
• Severe neurological or psychiatric disease
• End-stage dementia
• Total Intravenous anesthesia
• No use of hypertensive medication at home.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Open label

Primary purpose

Diagnostic

Study locations

Italy · 1 center

• Humanitas Research Hospital — Rozzano

Publications

• Greco M, Calgaro G, Cavallo M, Pugliese S, Mascari M, Piccirillo F, Pradella A, Piccioni F, Cecconi M. Brain-targeted goal-directed therapy in high-risk patients undergoing major elective surgery: Study protocol for the BRAIN-PROMISE randomized trial. Contemp Clin Trials. 2025 Jul;154:107940. doi: 10.1016/j.cct.2025.107940. Epub 2025 May 4. PMID 40328360

Identifiers

NCT: NCT04266574 · 1211

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗