Higher Intraoperative Blood Pressure Targets in Noncardiac Surgery

Key Takeaways

• Higher targets were not associated with less acute kidney injury or acute myocardial injury, and trial sequential analysis supported those null findings.
• No significant effect was observed for in-hospital or 30-day mortality, while evidence for 30-day major cardiovascular events, stroke, and length of stay remained insufficient.
• Postoperative delirium was lower in pooled analysis but remained inconclusive by trial sequential analysis, and major postoperative outcomes were not improved versus routine management.

In a systematic review and meta-analysis of 15 randomized trials involving 15,603 adults undergoing elective noncardiac surgery with general anesthesia, higher intraoperative blood pressure targets did not improve the main postoperative outcomes assessed versus routine management. Across studies, the comparison was between maintaining higher intraoperative pressures and usual routine targets during anesthesia care. Pooled analysis suggested less postoperative delirium with higher targets, but trial sequential analysis indicated that finding remained uncertain. Overall, the cumulative evidence did not show broad postoperative benefit from targeting higher intraoperative blood pressure values.

This PRISMA-guided review used meta-analysis and trial sequential analysis to assess randomized evidence in adults undergoing elective noncardiac surgery with general anesthesia. Investigators compared higher intraoperative blood pressure targets with routine blood pressure management across studies using either fixed absolute thresholds or personalization to preoperative baseline. Both standardized and individualized higher-target strategies were included in the randomized evidence base. The search spanned PubMed, Cochrane CENTRAL, Scopus, and Embase from inception through April 2026. Pooled outcomes were in-hospital or 30-day mortality, postoperative delirium, acute kidney injury, 30-day major cardiovascular events, acute myocardial injury, stroke, length of stay, and intraoperative hypotension.

For acute kidney injury, higher targets were not associated with benefit, with a relative risk of 0.95, a 95% confidence interval of 0.85 to 1.06, p=0.36, and I²=16%. Acute myocardial injury also showed no difference, with a relative risk of 1.02, a 95% confidence interval of 0.94 to 1.12, p=0.59, and I²=0%. In-hospital or 30-day mortality was likewise unchanged, with a relative risk of 1.00, a 95% confidence interval of 0.75 to 1.34, p=1.00, and I²=0%. Trial sequential analysis supported firm null evidence for the kidney and myocardial injury outcomes. Those outcomes most clearly showed no postoperative benefit in the cumulative randomized evidence.

Evidence for 30-day major cardiovascular events, stroke, and length of stay remained insufficient for firm conclusions. Postoperative delirium was the only pooled outcome favoring higher targets, with a relative risk of 0.73, a 95% confidence interval of 0.54 to 0.98, p=0.04, and I²=26%. Trial sequential analysis indicated that the cumulative delirium evidence was still insufficient to be conclusive. Higher intraoperative blood pressure targets did not improve major postoperative outcomes versus routine management, and any reduction in delirium remained unconfirmed.