Intraoperative Hypotension — From Blood Pressure Thresholds to Individualized Hemodynamic Management: Current State of Knowledge

Abstract

Introduction and Purpose. Intraoperative hypotension (IOH) is common during non-cardiac surgery and has been associated with postoperative organ injury. However, definitions vary between studies, arterial pressure alone does not identify the underlying hemodynamic disturbance, and the optimal blood pressure target remains uncertain. This review examines current evidence on the consequences, monitoring, risk assessment, and management of IOH, with particular attention to individualized hemodynamic management.

Materials and Methods. A structured PubMed/MEDLINE search was performed, with the final search completed on 16 August 2026. Studies published mainly between January 2015 and August 2026 were considered, including randomized and observational studies, systematic reviews, meta-analyses, and current perioperative guidelines and consensus statements.

Results. Deeper and longer IOH is associated with greater postoperative risk, particularly acute kidney injury and myocardial injury, although these associations do not establish causality. Pragmatic MAP thresholds remain clinically useful, but no optimal target has been identified for all patients. Current recommendations favour cause-directed treatment. Continuous and predictive monitoring can reduce hypotension exposure, but improved blood pressure control has not consistently translated into better patient-centred outcomes.

Conclusions. IOH cannot be interpreted from a single blood pressure value alone. Management should consider the severity and duration of hypotension, its likely hemodynamic cause, and patient risk. Further studies are needed to determine which patients benefit from individualized monitoring and treatment.