Higher versus Routine Intraoperative Blood Pressure Targets in Noncardiac Surgery: A Systematic Review and Meta-analysis with Trial Sequential Analysis of Randomized Trials

BACKGROUND: Observational studies consistently link intraoperative hypotension to adverse postoperative outcomes, leading guidelines to recommend maintaining mean arterial pressure (MAP) ≥60-65 mmHg during noncardiac surgery. Whether targeting higher intraoperative blood pressure values improves clinical outcomes remains uncertain. METHODS: We conducted a PRISMA-guided search on PubMed, Cochrane CENTRAL, Scopus, and Embase from inception to April 2026. Randomized trials comparing higher intraoperative blood pressure targets, either as fixed absolute thresholds or personalized to preoperative baseline, versus routine blood pressure management in adults undergoing elective noncardiac surgery with general anesthesia were included. Outcomes included in-hospital or 30-day mortality, postoperative delirium, acute kidney injury (AKI), 30-day major cardiovascular events (MACE), acute myocardial injury, stroke, length of stay, and intraoperative hypotension. RESULTS: Fifteen trials (15,603 patients) were included. Higher targets did not reduce AKI (RR = 0.95; 95% CI = 0.85 to 1.06; p = 0.36; I² = 16%) or acute myocardial injury (RR = 1.02; 95% CI = 0.94 to 1.12; p = 0.59; I² = 0%) compared with routine targets, with firm evidence from trial sequential analysis (TSA). Higher targets were associated with a significant reduction in postoperative delirium (RR = 0.73; 95% CI = 0.54 to 0.98; p = 0.04; I² = 26%), although TSA indicated the cumulative evidence remained insufficient to draw firm conclusions. No significant effect was observed on in-hospital or 30-day mortality (RR = 1.00; 95% CI = 0.75 to 1.34; p = 1.00; I² = 0%); evidence on 30-day MACE, stroke, and length of stay was similarly insufficient to draw firm conclusions. CONCLUSION: In adults undergoing elective noncardiac surgery, targeting higher intraoperative blood pressure values does not improve major postoperative outcomes compared with routine management. A potential reduction in postoperative delirium warrants confirmation in adequately powered trials.