Effect of individualised versus routine intraoperative blood pressure management on acute kidney injury in noncardiac surgery: a GRADE-assessed meta-analysis of randomised controlled trials.

BACKGROUND: We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) to determine whether individualised intraoperative blood pressure (BP) management improves postoperative outcomes in patients having noncardiac surgery compared with routine BP management. METHODS: A comprehensive literature search was performed across PubMed, Scopus, Web of Science, and Embase for relevant RCTs. The primary outcome was the incidence of postoperative acute kidney injury (AKI). We performed frequentist (random-effects model with Knapp-Hartung adjustment) and Bayesian meta-analyses. RESULTS: Ten RCTs (n=5842 patients) were included. Although individualised, compared with routine, intraoperative BP management resulted in significantly higher intraoperative BP (reflected by a reduction in the area under a mean arterial pressure (MAP) of 65 mm Hg; mean difference -44.5 mm Hg × min, 95% confidence interval [CI] -58.5 to -30.4, P=0.0005), it did not reduce the incidence of AKI (risk ratio [RR] 0.83, 95% CI 0.65-1.07, P=0.13), 30-day mortality (RR 0.78, 95% CI 0.35-1.75, P=0.44), or myocardial injury (RR 1.11, 95% CI 0.92-1.35, P=0.14). A significant reduction in postoperative delirium was observed (RR 0.46, 95% CI 0.25-0.83, P=0.02). Bayesian analysis indicated a 91% probability of any degree of AKI protection (RR<1); however, the probability of this benefit reaching a clinically meaningful threshold (RR<0.8) was low (39%). CONCLUSIONS: Compared with routine intraoperative BP management (typically targeting MAP ≥60-65 mm Hg), individualised intraoperative BP management resulted in higher intraoperative BP but did not significantly reduce postoperative AKI. Individualised intraoperative BP management might decrease the risk of postoperative delirium. SYSTEMATIC REVIEW PROTOCOL: CRD420251186093.