Intensive MAP Targets, Delirium, and Surgical-Site Infection
Intraoperative blood pressure is one of those variables we watch continuously and still debate at the end of the day. How high is “high enough,” and does pursuing a higher mean arterial pressure (MAP) actually change outcomes that patients feel? A September 2026 systematic review and meta-analysis in Anesthesiology and Perioperative Science (Springer) pooled randomized trials of intensive versus standard blood-pressure management in adults having noncardiac surgery. The results are useful precisely because they are uneven, and that unevenness should shape how we discuss targets in the OR.
Across 18 RCTs and more than 16,000 patients, intensive management (whether a fixed higher MAP goal or an individualized target tied to baseline) was associated with lower risks of postoperative delirium (roughly RR 0.72) and surgical-site infection (roughly RR 0.64). Myocardial injury, acute kidney injury, and mortality did not clearly improve. Trial sequential analysis supported a benefit for delirium and suggested that, with the evidence in hand, a large benefit for myocardial injury or AKI of the size the authors cared about was unlikely. Stroke, pneumonia, heart failure, ICU admission, and length of stay likewise showed no clear between-group differences.
Interpreting the findings
For delirium, the signal is encouraging, especially in the individualized higher-target subgroup in exploratory analyses. Sensitivity work did show some fragility, however: when one influential study is removed, the pooled estimate can lose conventional significance. That does not erase the finding, but it does argue for humility. Avoiding prolonged hypotension remains good practice, whereas promising that a single MAP number will eliminate delirium does not.
The SSI association is intriguing and receives less attention in anesthesia circles than organ injury. Tissue perfusion, vasoconstrictor strategy, and fluid choices may all lie on the causal path, or the finding may partly reflect correlated perioperative care. In either case, it is one more reason not to treat “run them dry and soft” as a default when infection risk is already high.
The null results matter as well. Clinicians who expected tighter MAP control to reliably reduce myocardial injury or AKI in noncardiac surgery will not find that certainty in this meta-analysis. We should continue to treat hypotension promptly, but we should not present intensive targets as proven multi-organ insurance.
Implications for practice
In this pooled RCT evidence base, intensive intraoperative blood-pressure management was linked to lower postoperative delirium and SSI risk than standard management. Myocardial injury, AKI, and mortality were not clearly reduced, so MAP intensification should not be oversold as organ protection for every endpoint. In subgroup exploration, individualized higher targets set relative to baseline looked more promising for delirium than fixed absolute targets, although the interaction tests were not definitive.
I continue to prevent and treat clinically important hypotension, and I consider higher or individualized goals for patients at elevated risk of delirium or infection, within a broader anesthetic plan. The single-study fragility and the moderate-certainty ratings call for careful local protocol design; they are not a reason to ignore the signal.
Source
- Intraoperative blood pressure management strategies and postoperative outcomes in patients undergoing noncardiac surgery: a systematic review and meta-analysis. Anesthesiology and Perioperative Science (Springer). Article · PDF
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.