Intensive MAP Targets, Delirium, and Surgical-Site Infection
Intraoperative blood pressure is one of those variables we watch continuously and still argue about at the end of the day: how high is “high enough,” and does chasing 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 talk about 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 a large benefit for myocardial injury or AKI of the size the authors cared about was unlikely with the evidence in hand. Stroke, pneumonia, heart failure, ICU admission, and length of stay likewise showed no clear between-group differences.
What this changes—and what it doesn’t
For delirium, the signal is encouraging, especially in the individualized higher-target subgroup in exploratory analyses. Still, sensitivity work showed some fragility: drop one influential study and 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; promising that a single MAP number will eliminate delirium is not.
The SSI association is intriguing and less often discussed in anesthesia circles than organ injury. Tissue perfusion, vasoconstrictor strategy, and fluid choices may all sit in the causal path—or the finding may partly reflect correlated perioperative care. Either way, it is another reason not to treat “run them dry and soft” as a default when infection risk is already high.
The nulls matter too. If your mental model was that tighter MAP control would reliably cut myocardial injury or AKI in noncardiac surgery, this meta-analysis does not deliver that certainty. We still treat hypotension promptly; we simply should not market intensive targets as proven multi-organ insurance.
Clinical takeaways
- Intensive intraoperative BP management was linked to lower postoperative delirium and SSI risk versus standard management in this pooled RCT evidence base.
- Myocardial injury, AKI, and mortality were not clearly reduced—so do not oversell MAP intensification as organ-protection for every endpoint.
- Individualized higher targets (relative to baseline) looked more promising for delirium than fixed absolute targets in subgroup exploration, but interaction tests were not definitive.
- Continue to prevent and treat clinically important hypotension; consider higher or individualized goals in patients at elevated delirium or infection risk, within a broader anesthetic plan.
- Read single-study fragility and moderate-certainty ratings as a call for careful local protocol design, not as 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.