Javier Ripollés-Melchor, Ángel V Espinosa, Ignacio Monge-García, César Aldecoa, Manu L N G Malbrain, Juan V Lorente, Begoña Quintana-Villamandos, Rosalía Navarro-Pérez, Ane Abad-Motos, María J Colomina, Alicia Ruiz-Escobar, Rachel Budithi, Diana Fernández-García, Paula Fernández-Valdes-Bango, Alfredo Abad-Gurumeta
Protocolized intraoperative arterial pressure-targeting strategies did not demonstrate a consistent incremental benefit over contemporary usual care in major noncardiac surgery. Mortality and MINS remained compatible with no treatment effect. Although AKI showed the most favorable estimates, the evidence remained uncertain, was sensitive to individual-trial exclusion, and should be interpreted cautiously.
BACKGROUND: Whether protocolized intraoperative arterial pressure-targeting strategies provide incremental benefit beyond contemporary usual care remains uncertain. We performed a Bayesian meta-analysis of randomized trials in major noncardiac surgery.
METHODS: MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to January 5, 2026, with additional literature surveillance through June 29, 2026. Randomized trials comparing protocolized intraoperative arterial pressure-targeting strategies with usual care or lower-pressure approaches were included. The primary outcome was all-cause mortality; secondary outcomes were acute kidney injury (AKI) and myocardial injury after noncardiac surgery (MINS). Bayesian random-effects meta-analysis was prespecified as the primary analytical framework, with confirmatory frequentist analyses.
RESULTS: Fifteen randomized trials met the inclusion criteria. Mortality (13 trials) remained centered around an OR of 1.00 (frequentist OR 1.00, 95% CI 0.83-1.21; Bayesian median OR 1.00, 95% CrI 0.73-1.38), with wide Bayesian prediction intervals (OR 0.56-1.78). AKI (14 trials) showed the most favorable estimates (frequentist OR 0.87, 95% CI 0.73-1.03; Bayesian median OR 0.88, 95% CrI 0.70-1.05), but estimates remained compatible with no clinically important benefit, heterogeneity was moderate, and leave-one-out analyses, excluding each trial in turn, showed sensitivity to individual-trial exclusion. MINS (8 trials) likewise remained compatible with no treatment effect (frequentist OR 1.04, 95% CI 0.93-1.15; Bayesian median OR 1.05, 95% CrI 0.90-1.26). Exploratory analyses suggested that any potential renal benefit may depend on the broader hemodynamic context in which arterial pressure targets are implemented.
CONCLUSIONS: Protocolized intraoperative arterial pressure-targeting strategies did not demonstrate a consistent incremental benefit over contemporary usual care in major noncardiac surgery. Mortality and MINS remained compatible with no treatment effect. Although AKI showed the most favorable estimates, the evidence remained uncertain, was sensitive to individual-trial exclusion, and should be interpreted cautiously.