B25-15 Optimization of Hemodynamic Control in Surgical and Critically Ill Patients: A Systematic Review and Meta-analysis Comparing Closed-loop and Manual Vasopressor Titration

Rationale Maintaining mean arterial pressure (MAP) within a defined therapeutic range is crucial to prevent hypotension- and hypertension-related organ injury in perioperative and critical care. Manual vasopressor titration is often delayed, whereas closed-loop vasopressor (CLV) systems automatically adjust dosing in real time to maintain target MAP. However, the magnitude, consistency, and clinical significance of CLV performance across care settings remain uncertain. This meta-analysis synthesized randomized evidence to determine whether CLV improves MAP control, reduces blood pressure excursions, and influences clinical outcomes or safety. Methods A PRISMA-2020-compliant systematic review and meta-analysis included randomized controlled trials (January 2000-June 2025) enrolling adults in the operating room or ICU who required vasopressors. Eligible studies compared automated CLV norepinephrine titration versus manual titration and reported MAP-based outcomes. Primary endpoints were time within target MAP and time in hypotension; secondary endpoints included time in hypertension, ICU length of stay, total vasopressor dose, and adverse events. Pooled analyses used random-effects models with prespecified subgroup (clinical setting, baseline risk) and sensitivity analyses. Results Five parallel-group RCTs (N = 176) met inclusion criteria: two intraoperative and three ICU studies. All evaluated CLV norepinephrine titration to predefined MAP targets versus manual control. CLV significantly increased time within target MAP by + 33.9 percentage points (95% CI, 0.204-0.475; I²=75%), reduced time in hypotension by − 10.8 percentage points (95% CI, −0.204 to − 0.012; I²=94%), and reduced time in hypertension by − 11.1 percentage points (95% CI, −0.214 to − 0.009; I²=58%). No consistent differences were found in ICU length of stay or total vasopressor dose, and adverse event rates were similar. Directionality and robustness of benefit were preserved across sensitivity analyses. Conclusions Across perioperative and critical care settings, CLV systems substantially enhance MAP control—markedly increasing time in range and reducing hypotension and hypertension—without added adverse events or drug use. These short-term improvements are clinically relevant given the strong association between brief hypotensive episodes and organ injury. While heterogeneity suggests context-dependent performance, the findings support CLV as a promising strategy to standardize hemodynamic quality, especially in resource-limited or high-workload environments. Future research should include adequately powered, multicenter trials with harmonized MAP targets and longer follow-up to evaluate patient-centered outcomes (e.g., AKI, myocardial injury, delirium, mortality), workflow efficiency, and cost-effectiveness. This abstract is funded by: None