Intraoperative Hypotension in Non-cardiac Surgery: a Comprehensive Review of Contemporary Evidence and Management Strategies
Keywords:
goal-directed fluid therapy, hypotension prediction index, intraoperative hypotension, mean arterial pressure, noncardiac surgery, protective hemodynamicsAbstract
Background: Intraoperative hypotension (IOH) is a frequent and critical modifiable risk factor in patients undergoing non-cardiac surgery, exhibiting strong correlations with postoperative organ dysfunction and increased mortality. This comprehensive review synthesizes contemporary evidence regarding the definitions, pathophysio-logical mechanisms, risk factors, and proactive management strategies for IOH. Methods: A comprehensive literature review was conducted, analyzing pivotal clinical trials, systematic reviews, and international guidelines published up to 2026 (including ESAIC 2025, ACC/AHA 2024, and AAGBI/BIHS 2026) focusing on hemodynamic management in non-cardiac surgical populations. Results: The definition of IOH remains heterogeneous, although recent 2025 ESAIC guidelines recommend an absolute intraoperative mean arterial pressure (MAP) threshold of 60-65 mmHg to protect organ perfusion. Despite growing interest in individualized blood pressure targets, recent randomized controlled trials (such as PRETREAT and IMPROVE-multi) and meta-analyses demonstrate that strict individualization or higher MAP targets do not significantly improve long-term functional outcomes or reduce postoperative complications compared to standard targets (≥ 60-65 mmHg). In medication management, recent trial data (POISE-3, SPACE, STOP-OR-NOT) support the 2026 AAGBI/BIHS recommendations to continue ACEIs/ARBs on the day of surgery to mitigate postoperative hypertension without increasing severe complications. For intraoperative monitoring and intervention, goal-directed fluid therapy utilizing dynamic indices (SVV/PPV) and the implementation of AI-driven predictive analytics, such as the Hypotension Prediction Index, offer advanced frameworks to proactively detect and manage impending hypotensive episodes before organ injury occurs. Furthermore, the newly emerged concept of “Protective Hemodynamics” via the 5-step C.L.E.A.R. pathway provides a structured approach to multi-organ preservation. Conclusion: Effective management of IOH requires a paradigm shift from reactive treatment to proactive prevention. Maintaining a target MAP ≥ 60-65 mmHg, optimizing anesthetic techniques, implementing dynamic fluid protocols, and integrating AI predictive software constitute the core pillars to minimize adverse perioperative outcomes in non-cardiac surgery.
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