Higher versus Routine Intraoperative Blood Pressure Targets in Noncardiac Surgery: A Systematic Review and Meta-analysis with Trial Sequential Analysis of Randomized Trials.

Katie Chiou; Sovann Vikram; Kiana Rowshan; Smeet Shah; Dolly Modha; Edgard Engelman; David Guthrie; Anil Tiwari; Joseph Rinehart; Alexandre Joosten; Bernd Saugel; Sean Coeckelenbergh

doi:10.1097/aln.0000000000006190

PubMed · 42241294

Higher versus Routine Intraoperative Blood Pressure Targets in Noncardiac Surgery: A Systematic Review and Meta-analysis with Trial Sequential Analysis of Randomized Trials.

Katie Chiou·Sovann Vikram·Kiana Rowshan·Smeet Shah·Dolly Modha·Edgard Engelman·David Guthrie·Anil Tiwari·Joseph Rinehart·Alexandre Joosten·Bernd Saugel·Sean Coeckelenbergh

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Abstract

BACKGROUND: Observational studies consistently link intraoperative hypotension to adverse postoperative outcomes, leading guidelines to recommend maintaining mean arterial pressure 60 to 65 mmHg or greater during noncardiac surgery. Whether targeting higher intraoperative blood pressure values improves clinical outcomes remains uncertain. METHODS: The authors conducted a Preferred Reporting Items for Systematic Reviews and Meta-analyses-guided search on PubMed, Cochrane Central Register of Controlled Trials, Scopus, and Embase from inception to April 2026. Randomized trials comparing higher intraoperative blood pressure targets, either as fixed absolute thresholds or personalized to preoperative baseline, versus routine blood pressure management in adults undergoing elective noncardiac surgery with general anesthesia were included. Outcomes included in-hospital or 30-day mortality, postoperative delirium, acute kidney injury (AKI), 30-day major cardiovascular events, acute myocardial injury, stroke, length of stay, and intraoperative hypotension. RESULTS: Fifteen trials (15,603 patients) were included. Higher targets did not reduce AKI (risk ratio [RR], 0.95; 95% CI, 0.85 to 1.06; P = 0.36; I 2 = 16%) or acute myocardial injury (RR, 1.02; 95% CI, 0.94 to 1.12; P = 0.59; I 2 = 0%) compared with routine targets, with firm evidence from trial sequential analysis. Higher targets were associated with a significant reduction in postoperative delirium (RR, 0.73; 95% CI, 0.54 to 0.98; P = 0.04; I 2 = 26%), although trial sequential analysis indicated the cumulative evidence remained insufficient to draw firm conclusions. No significant effect was observed on in-hospital or 30-day mortality (RR, 1.00; 95% CI, 0.75 to 1.34; P = 1.00; I 2 = 0%); evidence on 30-day major cardiovascular events, stroke, and length of stay was similarly insufficient to draw firm conclusions. CONCLUSION: In adults undergoing elective noncardiac surgery, targeting higher intraoperative blood pressure values does not improve major postoperative outcomes compared with routine management. A potential reduction in postoperative delirium warrants confirmation in adequately powered trials.

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Humans Randomized Controlled Trials as Topic Blood Pressure Postoperative Complications Monitoring, Intraoperative Intraoperative Complications Hypotension Surgical Procedures, Operative Intraoperative Care Journal Article Systematic Review Meta-Analysis

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Katie Chiou, Sovann Vikram, Kiana Rowshan, Smeet Shah, Dolly Modha, Edgard Engelman, David Guthrie, Anil Tiwari, Joseph Rinehart, Alexandre Joosten, Bernd Saugel, Sean Coeckelenbergh. 2026-06-04. Higher versus Routine Intraoperative Blood Pressure Targets in Noncardiac Surgery: A Systematic Review and Meta-analysis with Trial Sequential Analysis of Randomized Trials.. https://doi.org/10.1097/aln.0000000000006190

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Blood Pressure subject Humans subject Intraoperative Care subject Journal Article subject Journal Article; Systematic Review; Meta-Analysis resource Meta-Analysis subject Postoperative Complications subject Systematic reviews study

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