Protocolised intraoperative blood pressure targets showed no consistent benefit over usual care

Design

Bayesian random-effects meta-analysis of randomised trials

Population

15 trials of adults having major noncardiac surgery

Primary outcome

All-cause mortality; acute kidney injury and myocardial injury secondary

Effect

Mortality OR 1.00 (95% CI 0.83–1.21); AKI OR 0.87 (0.73–1.03); MINS OR 1.04 (0.93–1.15)

This Bayesian meta-analysis pooled 15 randomised trials in major noncardiac surgery that compared protocolised arterial pressure-targeting strategies against usual care or lower-pressure approaches. The primary outcome was all-cause mortality, with acute kidney injury and myocardial injury after noncardiac surgery as secondary outcomes.

Mortality was centred squarely on no effect (OR 1.00, 95% CI 0.83–1.21), and myocardial injury likewise (OR 1.04). Acute kidney injury gave the most favourable estimate (OR 0.87, 95% CI 0.73–1.03), but it remained compatible with no clinically important benefit, heterogeneity was moderate, and removing single trials changed the result.

This does not mean hypotension is harmless; the comparator was contemporary usual care, which may itself avoid much hypotension. What it shows is that adding a formal target protocol on top of attentive care has not yet shown a consistent return. Any renal benefit may depend on the wider haemodynamic strategy, such as fluids and cardiac output, not the pressure number alone. It was published on 28 September 2026.

• Keep avoiding sustained intraoperative hypotension as part of usual care.
• Do not expect a protocolised blood pressure target alone to reduce mortality or myocardial injury.
• Any kidney benefit was uncertain and may depend on the wider haemodynamic plan.
• Individualise targets for patients with chronic hypertension or renal risk, as now.
• Watch for larger trials before adopting a formal target protocol for all major surgery.

Why it matters

It questions whether target-driven protocols add anything to careful routine management.

Don't overread it

It does not show that intraoperative hypotension is safe; usual care already avoided it.

The statistics, in plain English

An odds ratio of 1.00 means no difference. For kidney injury, the interval 0.73–1.03 includes 1, so no benefit is still possible. A Bayesian credible interval gives the range where the true effect probably lies, given the data. When removing one trial changes the result, the finding is fragile.

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