Intraoperative blood pressure management strategies and postoperative outcomes in patients undergoing noncardiac surgery: a systematic review and meta-analysis

Abstract

Abstract Background Current recommendations for intraoperative blood pressure management suggest maintaining mean arterial pressure (MAP) at ≥ 60–65 mmHg to avoid hypotension. However, controversy remains regarding whether higher or individualized MAP targets improve clinically important outcomes in surgical patients. We aimed to determine whether intensive intraoperative blood pressure management, defined as higher fixed or individualized MAP targets, reduces major postoperative morbidity compared with standard management (MAP ≥ 60–65 mmHg). Methods We systematically searched PubMed, Embase, the Cochrane Library, and Web of Science for randomized controlled trials (RCTs) comparing intensive and standard intraoperative blood pressure management in adults undergoing noncardiac surgery. The primary outcomes were postoperative myocardial injury, postoperative delirium (POD), and acute kidney injury (AKI). Secondary outcomes included postoperative mortality, stroke, heart failure, acute respiratory distress syndrome (ARDS), pneumonia, intensive care unit (ICU) admission, surgical site infection (SSI), and hospital length of stay (LOS). Data were pooled using a random-effects model with the Hartung–Knapp adjustment. Risk ratios (RR) were calculated for dichotomous outcomes, and mean differences (MD) were calculated for continuous outcomes. Trial sequential analysis (TSA) was performed to control for random error and assess the conclusiveness of the available evidence. Results Eighteen RCTs involving 16,573 patients were included. Compared with standard management, intensive management was associated with lower risks of POD (10 studies; RR = 0.72, 95% CI [0.55, 0.93]; P = 0.019; moderate-certainty evidence) and SSI (5 studies; RR = 0.64, 95% CI [0.53, 0.76]; P = 0.002; moderate-certainty evidence). However, no significant between-group differences were observed in postoperative myocardial injury (9 studies; RR = 1.02, 95% CI [0.92, 1.13]), AKI (13 studies; RR = 0.92, 95% CI [0.79, 1.06]), or mortality (13 studies; RR = 0.99, 95% CI [0.83, 1.17]). TSA supported a beneficial effect of intensive management on POD, and indicated that a clinically meaningful benefit of the prespecified magnitude was unlikely for myocardial injury and AKI. No significant between-group differences were observed in postoperative stroke, pneumonia, heart failure, ICU admission, or hospital LOS. Conclusions In this systematic review and meta-analysis, intensive intraoperative blood pressure management may reduce the risks of POD and SSI in adults undergoing noncardiac surgery. However, it was not associated with significant differences in postoperative myocardial injury, AKI or mortality. Protocol registration PROSPERO: CRD420261323873.