Does continuous arterial blood pressure monitoring during anaesthesia in older frail patients reduce harm and improve quality of life following major surgery?

Research question Does continuous arterial blood pressure monitoring during surgery benefit patients who are high risk, particularly those who are older and living with frailty? Background Intra-operative hypotension (low blood pressure during surgery) occurs in two-thirds of operations and is associated with renal, cerebral and myocardial injury and mortality. Patients over 65 years old who are living with frailty are at elevated risk, including many patients requiring anaesthesia and surgery for a hip fracture. Emerging evidence suggests that continuous arterial blood pressure monitoring during surgery, established before anaesthesia, may reduce exposure to intra-operative hypotension compared to intermittent blood pressure measurements. However, this has not been shown in older patients living with frailty nor demonstrated that prevention of hypotension reduces harm or improves quality of life. Aims To combine complementary work packages (WP) to synthesise evidence to ask: 'Does continuous arterial blood pressure monitoring during surgery benefit patients who are high risk, particularly those who are older and living with frailty?' Methods WP1: A systematic review and meta-analysis will evaluate whether continuous blood pressure monitoring reduces exposure to intra-operative hypotension, perioperative morbidity, and mortality. The review will be prospectively registered with PROSPERO and reported according to PRISMA guidelines. WP2: Clinician attitudes towards continuous arterial monitoring in older patients living with frailty presenting for trauma surgery will be assessed through surveys and focus groups within a research framework. Key stakeholders will be purposively sampled to ensure a full range of opinions are captured. These will ascertain facilitators and barriers to continuous blood pressure monitoring in high-risk patients. WP3: We will undertake a feasibility study of continuous invasive arterial blood pressure monitoring vs standard care (intermittent blood pressure monitoring) in patients over 65 years old and living with frailty requiring hip fracture surgery. Up to 100 patients will be randomised (1:1) across four sites during 15 months of recruitment to continuous arterial blood pressure monitoring or standard care. We will collect feasibility data (including recruitment rate, treatment crossover, retention rate), baseline patient characteristics, intra-operative anaesthetic and surgical data, perioperative complications, adverse events, clinical outcomes and patient-reported quality of life at 120 days. The flow of participants will be reported in a CONSORT diagram, and outcomes will be summarised by group. A nested qualitative study will examine the experiences of patients, carers, and clinicians of the intervention and trial processes. Timelines for delivery The study will last 30 months, with WP1 and 2 completed within 24 months. WP3 will have a 6-month setup period, 15 months of recruitment, and 120 days of follow-up, allowing 5-6 months for analysis, report writing, and stakeholder events. Anticipated Impact and Dissemination The key impact will be determining whether a full trial is feasible- if so, we will progress to a researcher-led application. Data from all WPs will be presented at conferences and published in peer-reviewed journals with open access. We will communicate directly with the Royal Colleges of Anaesthesia and Surgery and other relevant groups. At the end of the study, we will report back to our stakeholders.