Individualized versus conventional intraoperative blood pressure management among major non-cardiac surgery patients: a systematic review and meta-analysis of randomized controlled trials

Introduction Intraoperative hypotension is common during non-cardiac surgery and is associated with high rates of morbidity and mortality. Individualized blood pressure management aims to minimize postoperative complications by tailoring patients’ blood pressure targets based on their baseline values rather than relying on conventional management. This meta-analysis aims to evaluate the efficacy of individualized and conventional blood pressure management strategies in patients undergoing non-cardiac surgery. Methods We conducted a search of PubMed, Scopus, Web of Science, and Cochrane CENTRAL from their inception to January 2026 to identify randomized controlled trials (RCTs) that compared individualized blood pressure management with conventional care in adults undergoing major non-cardiac surgery. The primary outcomes were acute kidney injury/renal replacement therapy and all-cause mortality. The secondary outcomes included myocardial infarction, delirium, postoperative cognitive dysfunction, composite complications, mean intraoperative mean arterial pressure (MAP), and length of hospital stay. Results Nine RCTs comprising 4,017 patients (with 2,014 receiving individualized blood pressure management and 2,003 in the control group) were included. Individualized blood pressure management did not significantly reduce the risk of acute kidney injury/the need for renal replacement therapy (RR 0.88, 95% CI: 0.68–1.15, p = 0.36) or all-cause mortality (RR 0.96, 95% CI: 0.63–1.46, p = 0.83) compared to conventional management. Similarly, no significant differences were observed for myocardial infarction, postoperative cognitive dysfunction, composite complications, or length of hospital stay. However, individualized management significantly reduced delirium rates (RR 0.55, 95% CI: 0.35–0.88, p = 0.01) and achieved higher mean intraoperative MAP (MD 5.53 mmHg, 95% CI: 1.66–9.40, p = 0.01). Conclusion Individualized intraoperative blood pressure management did not reduce major postoperative complications, such as acute kidney injury, or mortality rates compared to conventional care. However, it was associated with reduced postoperative delirium and improved intraoperative hemodynamic stability. These findings suggest that while individualized strategies may not significantly affect clinical outcomes, they offer benefits in preventing delirium. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261319820 .