Continuous versus intermittent non-invasive blood pressure monitoring and intraoperative hypotension: a systematic review and meta-analysis

BACKGROUND: Intraoperative hypotension is associated with postoperative morbidity and mortality. Standard intermittent oscillometric blood pressure monitoring may fail to detect short-lived hypotensive episodes occurring between measurement cycles. Continuous non-invasive finger-cuff monitoring provides beat-to-beat arterial pressure assessment and may reduce cumulative hypotension exposure. This systematic review and meta-analysis evaluated the effect of continuous versus intermittent non-invasive blood pressure monitoring on intraoperative hypotension and related perioperative outcomes. METHODS: A systematic search of PubMed/MEDLINE, Scopus, and Web of Science was conducted in June 2026. Randomized controlled trials comparing continuous non-invasive finger-cuff blood pressure monitoring with intermittent oscillometric upper-arm cuff monitoring in adults undergoing procedures under anesthesia or procedural sedation were included. Random-effects meta-analyses were performed for outcomes with sufficiently comparable data. Effect estimates were reported as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. Risk of bias was assessed using the Cochrane RoB 2 tool, and certainty of evidence was evaluated using GRADE. RESULTS: Twelve randomized controlled trials were included, enrolling 1,466 randomized patients, of whom 1,340 contributed to the eligible comparison arms. Ten studies including 1,126 patients contributed to the meta-analysis of intraoperative hypotension incidence. Continuous monitoring was not associated with a statistically significant reduction in the incidence of intraoperative hypotension compared with intermittent oscillometric monitoring (RR 0.90, 95% CI 0.77-1.04; p = 0.141; I² = 58.2%). However, it was associated with a lower time-weighted average of hypotension (SMD -0.42, 95% CI -0.64 to -0.20; p = 0.0002; I² = 56.5%) and lower AUT/AUC-derived hypotension burden (SMD -0.40, 95% CI -0.58 to -0.23; p < 0.0001; I² = 29.9%). Postoperative nausea was not significantly reduced (RR 0.81, 95% CI 0.51-1.28; p = 0.288), whereas postoperative vomiting was less frequent with continuous monitoring (RR 0.62, 95% CI 0.42-0.92; p = 0.027), although event numbers were low. Treatment-related and safety outcomes were summarized narratively because of heterogeneous reporting. The certainty of evidence ranged from very low to low. CONCLUSIONS: Continuous non-invasive finger-cuff blood pressure monitoring did not significantly reduce the binary incidence of intraoperative hypotension compared with intermittent oscillometric monitoring. However, it was associated with lower cumulative hypotension exposure, as reflected by TWA and AUT/AUC-based metrics. These findings suggest that continuous monitoring may improve the recognition and management of intraoperative hypotension, although the certainty of evidence remains limited. Further high-quality randomized trials using standardized hypotension definitions are warranted.