Intraoperative Hypotension Management

Target Blood Pressure

The British Journal of Anaesthesia recommends maintaining a mean arterial pressure (MAP) ≥60 mmHg in high-risk patients to prevent acute kidney injury, myocardial injury, myocardial infarction, and death 1, 2, 3, 4
The target systolic blood pressure should be ≥90-100 mmHg to prevent organ complications 2, 3
The target MAP should be increased when venous or compartmental pressure is elevated (e.g., Trendelenburg position, gas peritoneal insufflation, high intra-abdominal pressure) by adding the compartmental pressure value to the target MAP 1, 5
In patients with pre-existing hypertension, consider a higher target MAP based on the patient's baseline blood pressure 1

Correct fluid depletion fully before administering vasopressors 6
Use goal-directed fluid therapy with stroke volume monitoring to guide fluid resuscitation 6
Use balanced crystalloids (Ringer's Lactate or Plasmalyte) at a rate of 1-2 ml/kg/hour 7
Avoid 0.9% saline due to the risk of hyperchloremic acidosis and kidney dysfunction 7

Norepinephrine is the first-line vasopressor after optimizing volume status: 9, 6, 8
Phenylephrine as an alternative: 9

Consider continuous arterial blood pressure monitoring to reduce the severity and duration of hypotension compared to intermittent monitoring 4, 2, 3
Place an arterial line for continuous monitoring in patients requiring vasopressors 8
Use a combination of central venous pressure (CVP) and stroke volume variation (SVV) monitoring to guide hemodynamics 7
Monitor for fluid responsiveness before administering additional fluids, as approximately 50% of hypotensive patients are not responsive to fluids 8

Do not use vasopressors as first-line therapy without ensuring adequate volume status 6, 7
Do not avoid vasopressors entirely when hypotension persists despite adequate volume, as prolonged hypotension can cause organ injury 6
Do not delay initiating vasopressors while waiting for additional fluid resuscitation in patients with severe hypotension, as this can be life-threatening 8
When hypotension occurs during low CVP maintenance (e.g., hepatic surgery), treat with vasopressors rather than fluid boluses to avoid increasing CVP and surgical bleeding 7

In patients with high cardiovascular risk, consider a higher target MAP (75 mmHg) to reduce myocardial injury 1
In elderly patients (≥65 years), a target MAP of 95-100 mmHg may reduce postoperative delirium by up to 50% 5, 9
Postoperative hypotension is often undetected and may be more important than intraoperative hypotension due to its potential to be prolonged and untreated 5, 4, 2, 3