Targeting higher blood pressure in noncardiac surgery did not reduce organ injury

Design

Systematic review and meta-analysis of randomised trials with trial sequential analysis

Population

15,603 adults having elective noncardiac surgery, 15 trials

Primary outcome

Acute kidney injury, myocardial injury, delirium, mortality

Effect

AKI RR 0.95 (95% CI 0.85 to 1.06); myocardial injury RR 1.02 (0.94 to 1.12)

This systematic review and meta-analysis, published in June, pooled 15 randomised trials (15,603 adults) of elective noncardiac surgery under general anaesthesia. Trials compared higher blood pressure targets, either fixed or personalised to baseline, with routine management, which in most guidance means keeping mean arterial pressure at least 60 to 65 mmHg.

Higher targets did not reduce acute kidney injury (RR 0.95, 95% CI 0.85 to 1.06) or acute myocardial injury (RR 1.02, 0.94 to 1.12), and trial sequential analysis judged both findings firm. Mortality did not differ (RR 1.00, 0.75 to 1.34). Delirium was lower with higher targets (RR 0.73, 0.54 to 0.98), but the cumulative evidence was insufficient for a firm conclusion. Data on major cardiovascular events, stroke and length of stay were also inconclusive.

Observational links between intraoperative hypotension and harm have pushed many anaesthetists towards higher pressures, with more vasopressor use. This analysis suggests that, once the routine threshold is met, pushing higher does not protect the kidney or heart. The routine floor in current guidance still stands; what changes is the case for going well above it. The possible delirium benefit is worth watching, particularly in older patients.

• Maintain mean arterial pressure at or above the routine threshold of about 60 to 65 mmHg during noncardiac surgery.
• Do not routinely target higher pressures to protect the kidney or myocardium.
• Consider individual baseline pressure in patients with long-standing poorly controlled hypertension.
• Note the possible but unconfirmed delirium benefit when deciding targets for older patients.
• Avoid vasopressor escalation solely to reach higher numbers without a clinical reason.

Why it matters

It challenges the drift towards higher intraoperative pressure targets driven by observational associations rather than trial benefit.

Don't overread it

This does not show that hypotension below the routine threshold is safe; the guideline floor is unchanged.

The statistics, in plain English

Both kidney and myocardial injury intervals sit around 1 with narrow ranges, and trial sequential analysis suggests more trials are unlikely to change the answer. The delirium result just reaches significance (upper limit 0.98) but has not accumulated enough evidence to be considered settled.

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