Intraoperative blood pressure management in noncardiac surgery: a narrative review based on current evidence

PURPOSE: Blood pressure is closely monitored during anaesthesia, yet the optimal intraoperative target remains uncertain. This narrative review synthesizes contemporary observational and randomized evidence and explores emerging strategies for individualized haemodynamic management. METHODS: We reviewed major observational cohort studies, randomized controlled trials (RCTs), consensus statements, and recent technological developments addressing intraoperative hypotension, MAP thresholds, and strategies to prevent perioperative organ injury in adult noncardiac surgery. RESULTS: Large observational datasets consistently demonstrate graded, duration-dependent associations between intraoperative MAP 60-70 mmHg and postoperative myocardial injury, acute kidney injury, and mortality . These findings have informed international recommendations to avoid MAP below 60-65 mmHg. However, contemporary multicentre RCTs enrolling more than 13,000 patients show that targeting higher or individualized MAP thresholds does not improve patient-centred outcomes compared with routine care (typically MAP ≥ 65 mmHg) . Only one small trial reported benefit with individualized systolic targets. Emerging evidence suggests that hypotension reflects heterogeneous haemodynamic endotypes (vasodilation, hypovolaemia, myocardial depression, bradycardia), potentially explaining why uniform pressure targets fail to improve outcomes. Continuous blood pressure monitoring, proactive norepinephrine infusion, predictive analytics, and closed-loop vasopressor systems reliably reduce hypotension exposure, although definitive outcome benefits remain unproven. CONCLUSIONS: Observational and randomized data are concordant: MAP ≥ 60-65 mmHg appears sufficient for most noncardiac surgical patients. Future progress will likely depend on mechanistic endotyping, integration of advanced monitoring, and precision-guided haemodynamic strategies rather than escalation of universal MAP targets alone.