Cardiac Index Targets in High-Risk Abdominal Surgery: The PELICAN Trial
Goal-directed hemodynamic therapy has been chasing a clear win for a long time. The PELICAN trial, published October 19, 2026 in JAMA, tested a smarter version of the idea: instead of pushing cardiac output as high as it will go, keep each patient at their own awake resting cardiac index during major abdominal surgery.
The study
Investigators at 12 university centers in five European countries randomized high-risk adults having elective major abdominal surgery. Before surgery, each patient had a resting cardiac index measured noninvasively with bioreactance. In the intervention group, clinicians used fluids and dobutamine on a protocol to keep the intraoperative cardiac index at or above that resting value. In the control group, cardiac index was measured but hidden, and care was left to the anesthesiologist. Both groups aimed for a MAP above 65 mm Hg.
The intervention clearly worked on the monitor. Average intraoperative cardiac index was higher, patients got more fluid, and about two thirds got dobutamine compared with almost none in the control group. But in the 1,095 patients analyzed, the composite of AKI, myocardial injury, severe infection, nonfatal cardiac arrest, or death within 7 days was 44.3% with the protocol and 46.9% with routine care, a difference that was not significant. AKI trended lower without reaching significance. In a secondary outcome, 90-day mortality was higher in the protocol group, 5.7% versus 2.8%. The authors are appropriately careful that this could be chance, since it was one of many unadjusted secondary outcomes, but it is not something I would wave away.
Why it matters
This trial joins OPTIMISE II and iPEGASUS in a pattern that is hard to ignore. Moving a flow number with fluids and inotropes does not reliably move patient outcomes. Higher cardiac index does not guarantee better oxygen delivery if we are diluting hemoglobin to get there, and under general anesthesia oxygen demand is already lower than when the patient is awake. More dobutamine and more volume also carry their own costs, including tachycardia and fluid overload.
What it means for practice here
For my higher risk abdominal cases, the basics still carry most of the weight: keep the MAP where it belongs, give fluid when there is a reason to think the patient is volume responsive, and avoid both the dry and the drowned extremes. Cardiac output monitoring still has a role when I need to understand why a patient is unstable. What PELICAN tells me is that a protocol built to hold a number, even a personalized one, is not the same as better care, and that routine inotrope use to hit a target in otherwise stable patients deserves real caution.
The trial ran in academic centers with a lot of hemodynamic monitoring experience and only in elective abdominal surgery, so it does not settle every question. It does make me more comfortable that thoughtful routine care is a reasonable standard.
Source
- Saugel B, et al; PELICAN Trial Group. 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. Article (JAMA)
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.