Design: Systematic review and meta-analysis of 15 RCTs with trial sequential analysis
Population: 15,603 adults having elective non-cardiac surgery under general anaesthesia
Primary outcome: Acute kidney injury, myocardial injury, mortality and delirium
Effect: AKI RR 0.95 (95% CI 0.85–1.06); myocardial injury RR 1.02 (0.94–1.12)

Guidelines recommend keeping mean arterial pressure at 60–65 mmHg or above during non-cardiac surgery, and some clinicians aim higher on the basis of observational links between hypotension and harm. This meta-analysis, published in June, pooled 15 randomised trials (15,603 adults having elective non-cardiac surgery under general anaesthesia) comparing higher targets — fixed or personalised to baseline — with routine management.

Higher targets did not reduce acute kidney injury (RR 0.95, 95% CI 0.85 to 1.06) or myocardial injury (RR 1.02, 0.94 to 1.12), and trial sequential analysis judged both conclusions firm. Mortality was unchanged (RR 1.00). Delirium was lower with higher targets (RR 0.73, 0.54 to 0.98), but the cumulative evidence was not yet sufficient to be sure. Evidence on major cardiovascular events, stroke and length of stay was inconclusive.

This largely settles the kidney and heart question for elective surgery: avoiding hypotension matters, but pushing pressure higher than the usual floor does not add protection, and it brings more vasopressor use. The delirium signal is worth a dedicated trial. The finding applies to elective non-cardiac surgery; it does not address emergency or cardiac surgery.

Keep mean arterial pressure at 65 mmHg or above during elective non-cardiac surgery, in line with guidance.
Do not routinely aim for higher targets to protect the kidneys or heart; trials show no benefit.
Treat hypotension promptly; avoiding it remains the goal.
Watch for further trials on whether higher targets reduce delirium in older patients.
Note the evidence covers elective non-cardiac surgery, not emergency or cardiac cases.

Why it matters

It removes the rationale for chasing higher pressures with vasopressors during routine surgery.

The statistics, in plain English

Risk ratios close to 1 with narrow intervals mean higher targets made no measurable difference to kidney or myocardial injury. Trial sequential analysis confirmed enough patients have been studied for that to be a firm conclusion. For delirium, the benefit was borderline and not yet firm.