Review finds higher blood pressure targets may lower delirium after surgery
An analysis of randomized trials found possible reductions in postoperative delirium and wound infections, but not in kidney injury, heart damage, or death.
High evidenceReviewSome caution advised
Medical disclaimer: This article summarizes research findings and is for informational purposes only. It is not medical advice.
Editorial illustration — not from the study.
The review examined whether keeping blood pressure at higher or individualized levels during surgery provided better postoperative outcomes than standard management, generally defined as maintaining mean arterial pressure at 60–65 mmHg or higher. The studies involved adults having noncardiac operations and compared different blood pressure strategies assigned in randomized trials.
Across the pooled studies, intensive management was linked with fewer cases of postoperative delirium and surgical-site infection. The analysis did not find statistically significant differences in postoperative myocardial injury, acute kidney injury, death, stroke, pneumonia, heart failure, intensive care admission, or hospital length of stay.
The question reviewed
The researchers performed a systematic review and meta-analysis of randomized controlled trials. They searched four medical databases for studies of adults undergoing noncardiac surgery that compared intensive intraoperative blood pressure management—defined as higher fixed targets or individualized mean arterial pressure targets—with standard management using a target of at least 60–65 mmHg. Eighteen trials involving 16,573 patients were included. The main outcomes were postoperative myocardial injury, delirium, and acute kidney injury; other outcomes included mortality and several complications and hospital-care measures.
What the review concluded
Compared with standard management, intensive blood pressure management was associated with a lower risk of postoperative delirium in 10 studies: relative risk 0.72, with a 95% confidence interval of 0.55 to 0.93. It was also associated with a lower risk of surgical-site infection in 5 studies: relative risk 0.64, with a 95% confidence interval of 0.53 to 0.76. The review rated the certainty of evidence for these two outcomes as moderate.
There were no statistically significant differences in postoperative myocardial injury, acute kidney injury, or mortality. The reported relative risks were 1.02 for myocardial injury, 0.92 for acute kidney injury, and 0.99 for mortality. No significant differences were found for stroke, pneumonia, heart failure, intensive care admission, or hospital length of stay. Trial sequential analysis supported a beneficial effect for delirium and suggested that a benefit of the prespecified size was unlikely for myocardial injury and acute kidney injury.
Who this is relevant to
The findings may be relevant to adults undergoing noncardiac surgery in settings and populations similar to those represented in the included randomized trials. The abstract does not establish whether the results apply equally to children, people having cardiac surgery, specific high-risk groups, or every type of operation. It also does not determine the effects of a particular blood pressure target for an individual patient.
The significance
Blood pressure during surgery is a potentially modifiable part of perioperative care, so comparing different management strategies may help clarify which outcomes are affected. In this review of human randomized trials, higher or individualized targets were linked with fewer cases of delirium and surgical-site infection, while several serious outcomes did not differ significantly. These results describe the combined evidence from the included trials and do not establish that one blood pressure strategy will have the same effects in every patient or operation.
Limitations & evidence assessment
The abstract gives limited information about differences among the 18 trials, such as the exact blood pressure targets, how individualized strategies were implemented, types of surgery, patient characteristics, follow-up periods, and risk of bias. The pooled results also depend on the quality and comparability of the included studies, and the number of studies contributing to some outcomes was small. The abstract reports moderate-certainty evidence for delirium and surgical-site infection, rather than high-certainty evidence. A meta-analysis can improve precision by combining studies, but it cannot remove limitations in the underlying trials.
Why this evidence level: Meta-analysis pooling multiple studies sits at the top of common evidence hierarchies.
Evidence levels are editorial estimates derived from study metadata — they are not clinical appraisals.
// Source
Anesthesiology and Perioperative Science · 2026 · DOI: 10.1007/s44254-026-00188-9
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