Protocolized Intraoperative BP Targeting: A Bayesian Look at the Evidence
How hard should we push blood pressure targets in the OR? A Bayesian random-effects meta-analysis published ahead of print September 28, 2026 in Anesthesiology pooled randomized trials of protocolized intraoperative arterial pressure targeting in major noncardiac surgery and asked whether those protocols beat contemporary usual care on mortality, acute kidney injury, and myocardial injury.
The study
The authors searched MEDLINE, Embase, and Cochrane CENTRAL through early 2026, with surveillance into late June, and included 15 randomized trials comparing protocolized pressure-targeting strategies with usual care or lower-pressure approaches. The primary outcome was all-cause mortality. Secondary outcomes were AKI and myocardial injury after noncardiac surgery (MINS). Bayesian random-effects methods were the main analysis, with frequentist checks alongside.
Mortality across 13 trials sat at an odds ratio of about 1.00 (frequentist OR 1.00, 95% CI 0.83 to 1.21; Bayesian median OR 1.00, 95% CrI 0.73 to 1.38), with wide prediction intervals. AKI across 14 trials looked a bit more favorable (frequentist OR 0.87, 95% CI 0.73 to 1.03; Bayesian median OR 0.88, 95% CrI 0.70 to 1.05), but the estimate was still compatible with little or no important benefit, heterogeneity was moderate, and leave-one-out checks showed sensitivity to individual trials. MINS across 8 trials also looked null (frequentist OR 1.04; Bayesian median OR 1.05).
Why it matters
Protocolized higher or individualized targets have been a big conversation in our specialty for years. This analysis does not say blood pressure is irrelevant. It says that once you look across the randomized evidence with a Bayesian lens, protocolized targeting has not shown a clear, consistent win over modern usual care for death or myocardial injury, and the kidney signal is soft and fragile. The authors also note that any renal benefit may depend on the broader hemodynamic context, not just the number on the cuff.
What it means for practice here
In day-to-day noncardiac cases, I still treat sustained hypotension as a problem worth fixing. Vasopressors, fluids when they make sense, depth of anesthesia, and bleeding all matter. What this paper pushes back against is the idea that a rigid high-target protocol by itself will reliably cut mortality or MINS. Avoiding avoidable hypotension remains good medicine. Expecting a protocolized MAP program to deliver large outcome gains may be asking more than the current trial base can support.
I will keep watching for larger trials and clearer definitions of what "usual care" means in each setting. For now, this Bayesian summary is a useful brake on overselling protocolized pressure targets as a mortality or MINS intervention.
Source
- Intraoperative blood pressure targeting in noncardiac surgery: a Bayesian random-effects meta-analysis of randomized trials. Anesthesiology. Publish Ahead of Print, September 28, 2026. doi:10.1097/ALN.0000000000006395. Article (Anesthesiology / LWW)
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.