Intraoperative hypotension and adverse postoperative outcomes: a systematic review and meta-analysis of randomised controlled trials
In brief
Targeting higher intraoperative blood pressure shows no mortality or kidney-injury benefit
A meta-analysis of nine randomized trials (14 658 adults) found that aiming for a higher mean arterial pressure during surgery did not lower 30-day death rates, acute kidney injury, or myocardial injury compared with lower-pressure targets. The lack of effect may reflect the modest blood-pressure differences actually achieved, leaving the optimal intraoperative pressure range uncertain.
- Journal
- British journal of anaesthesia (Q1)
- Published
- 10 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Marc Sicova, Jamal Alkadri, Daniel Sibley, Jimmy Schenk, Matthijs Kant, Teus Kappen, et al.
- PMID
- 42575833
- DOI
- 10.1016/j.bja.2026.05.061
Why clinicians should know about it
- Picked for Anesthesiology and Pain Medicine (top studies of the week, 16 August 2026): Intraoperative hypotension RCT meta-analysis
- Picked for Surgery (paper of the day, 12 August 2026).
Abstract
BACKGROUND: Intraoperative arterial hypotension commonly occurs and is associated with adverse outcomes. Evidence on causality from RCTs is sparse. This meta-analysis aimed to summarise evidence from RCTs that categorise groups based on MAP thresholds, examining the impact on mortality, acute kidney injury (AKI), and myocardial injury in patients undergoing noncardiac surgery. METHODS: A systematic search of PubMed, Embase, and Web of Science was conducted for RCTs in adults undergoing noncardiac surgery that categorised groups based on MAP thresholds. The primary objective was to examine the effect of differences in achieved MAP on the primary outcome of all-cause mortality within 30 days of surgery. AKI, myocardial injury, and MAP achieved in the intervention and control arms were analysed as secondary outcomes. For each study, two groups were identified: an intervention ('higher-pressure' target) group, and a control ('lower-pressure' target) group. Exploratory analysis examined whether the difference in achieved MAP between groups modified the study outcomes. RESULTS: Nine RCTs comprising 14 658 patients did not demonstrate a difference in the primary outcome of all-cause mortality between intervention and control groups (RR: 1.06, 95% CI: 0.77-1.45, I2=0%). No differences were observed for secondary outcomes in 13 RCTs. Differences in intraoperative MAP between study groups were not associated with study outcomes. CONCLUSIONS: Higher vs lower intraoperative MAP did not affect all-cause 30-day mortality, AKI, or myocardial injury; however, only limited differences in blood pressure were achieved between study groups. Stratification by differences in achieved pressure did not alter the results. Systematic review protocol. PROSPERO (CRD420251230069).
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.