The PROTECT Trial: PROpofol Titration to Enhance haemodynamiC sTability

University Hospital Basel

Status: Not yet enrolling

Conditions: Anesthesia

Treatments: Procedure: Conventional propofol induction; Procedure: Propofol titration

Study type: Interventional

Funder types: Other

Identifiers

NCT06980688

am24DellKuster

Details and patient eligibility

About

The aim of this multicentre, single-blinded, expertise-based randomised controlled trial is evaluate whether slowly increasing the dose of the anaesthetic drug propofol based on a patient's needs leads to more stable blood pressure compared to giving a standard starting dose in patients aged 55 and older undergoing non-cardiac surgery.

Full description

Propofol is a widely used anaesthetic drug known to lower blood pressure (hypotension) by relaxing blood vessels. The extent of hypotension depends on the dose and speed of propofol administration. A significant drop in blood pressure after anaesthesia is started, known as post-induction hypotension (PIH), can damage organs like the heart and kidneys, especially in older and multimorbid patients.

Target-controlled infusion (TCI) systems are commonly used to deliver anaesthetic drugs like propofol and remifentanil in a controlled way. The standard approach for starting anaesthesia (induction) is to begin with a high dose to quickly make the patient unconscious and suppress the body's response to intubation. Titration is a potentially safer alternative, where the dose is slowly increased until the patient becomes unconscious.

However, current evidence comparing the two methods is limited, especially in older patients. A small retrospective study suggested that titration improves blood pressure stability, and a survey of Swiss anaesthetists showed strong interest in this approach.

This multicentre, single-blinded, expertise-based randomised controlled trial investigates whether titration using TCI systems improves blood pressure stability in patients aged 55 and older undergoing non-cardiac surgery. The results of this trial will help to evaluate the clinical applicability and economic impact of the titration method in routine anaesthesia care and may support its future implementation into standard practice.

Enrollment: 320 estimated patients

Sex: All

Ages: 55+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Adults ≥ 55 years old
• Patients undergoing any of the following planned surgery under general anaesthesia with intubation: Ear, nose and throat, gynaecological, maxillofacial, orthopedic, plastic and reconstructive, spine, urologic, vascular (varicose vein surgery, femoral endarterectomy, peripheral bypass surgery) and visceral surgery
• Standard procedure for anaesthesia with propofol Target-Controlled Infusion (TCI) using the Schnider model and remifentanil TCI using the Minto model
• American Society of Anesthesiologists Physical Status Classification system (ASA PS) I-IV
• Body mass index (BMI) ≥18.5 or <35 kg/m2
• Signed written informed consent

Exclusion criteria

• Special forms of anaesthesia induction, specifically awake tracheal intubation and rapid sequence induction
• Combined anaesthesia procedures (general and regional anaesthesia combined)
• Special forms of general anaesthesia (opioid-free anaesthesia or any opioid-sparring modifications with lidocaine, magnesium, ketamine, clonidine or dexmedetomidine)
• Surgery in the prone position within the first 30 minutes
• Patients with known difficult airway
• Daily consumption of alcohol (> one unit/day) or > seven units/week
• Any regular recreational drug abuse
• Chronic use of benzodiazepines or opioids
• Allergy to propofol
• Patients with known brain pathologies, specifically seizure disorders, stroke within the past 9 months or dementia
• History of awareness
• Inability to follow procedures or insufficient knowledge in German

Trial design

Primary purpose: Other

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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320 participants in 2 patient groups

Titration group

Experimental group

Description:

Patients in the titration group undergo anaesthesia induction using a stepwise approach, where the target effect-site concentration (Cet) of propofol is incrementally increased until loss of consciousness (LOC) is achieved. Once LOC is reached, the remifentanil target concentration is elevated to mitigate the laryngeal stimulus to intubation.

Treatment:

Procedure: Propofol titration

Conventional group

Other group

Description:

Patients in the conventional group receive anaesthesia induction using a predefined high Cet of propofol, set above the typical level required to achieve loss of consciousness (LOC), aiming for rapid induction. After induction, the remifentanil target concentration is adjusted to mitigate the laryngeal stimulus of intubation.

Treatment:

Procedure: Conventional propofol induction