Hypotension Prediction Index-Guided Hemodynamic Management on Postoperative Organ Outcome: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Intraoperative hypotension (IOH) is a frequent occurrence during noncardiac surgery. Hypotensive episodes can compromise tissue perfusion, and cumulative exposure has been associated with adverse outcomes such as acute kidney injury (AKI), myocardial injury, and increased mortality. The Hypotension Prediction Index (HPI) is an artificial intelligence tool designed to predict hypotensive events before they occur, allowing clinicians to intervene proactively to prevent or mitigate hypotension. Although randomized trials and pooled analyses have shown its effectiveness in reducing both the incidence and duration of IOH, its impact on patient-centered outcomes remains unclear. From 1946 to August 8, 2025, we prospectively queried MEDLINE (PubMed), Embase, Cochrane Library, and Web of Science. We included randomized controlled trials in adult surgical patients with invasive arterial monitoring, comparing HPI-guided perioperative hemodynamic management to standard care. Primary outcome was postoperative AKI, and secondary outcomes were postoperative myocardial injury, pneumonia, arrhythmia, stroke, postoperative cognitive dysfunction, including delirium, surgical site infection, length of hospital stay, and mortality. Two authors independently evaluated the risk of bias according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis was performed using RevMan 5.4.1 software. Dichotomous data were presented as risk ratio, 95% confidence interval CI; continuous data were presented as mean difference, 95% CI. All results were pooled using random-effects models. Of 883 imported references, 14 studies (N = 2030) were included for final analysis. No significant difference in incidence of postoperative AKI was observed between HPI-guided management and standard care, RR = 0.87, 95% CI (0.71–1.07). Postoperative myocardial injury was significantly reduced in HPI-guided management group, RR = 0.61, 95% CI (0.39–0.96), although exclusion-based sensitivity analysis suggests that this finding may not be robust. No other significant differences were observed for hospital length of stay, arrhythmia, stroke, cognitive dysfunction (including delirium), surgical site infection, pneumonia, or mortality. Although HPI-guided management is associated with a reduction in postoperative myocardial injury, its significance does not withstand sensitivity analysis. All other postoperative complications, including AKI incidence, are not reduced in the intervention groups. This study has limitations inherent to the heterogeneity of included patient populations, surgical interventions performed, standard of care practices, and reporting of postoperative outcomes.