📉 Avoid MAP below 60–65: evidence and guidelines align

A narrative review of adult noncardiac surgery evidence found intraoperative MAP 60–70 mmHg is linked to graded, duration-dependent increases in postoperative myocardial injury, acute kidney injury, and mortality, supporting recommendations to avoid MAP below 60–65 mmHg. Across contemporary multicentre RCTs enrolling >13,000 patients, targeting higher or individualized MAP thresholds did not improve patient-centred outcomes versus routine care (typically MAP ≥65 mmHg).

Why It Matters To Your Practice

• MAP <60–65 mmHg is linked to hypotension-associated organ injury signals in large observational cohorts, and those data have shaped international guidance.

• “More pressure” isn’t automatically better: large RCTs suggest routine care targets (often MAP ≥65) perform similarly to higher/individualized targets for most patients.

• Intraoperative hypotension isn’t one problem: endotypes (vasodilation, hypovolaemia, myocardial depression, bradycardia) may require different fixes.

Clinical Benefits

• Using MAP 60–65 as a practical floor helps standardize escalation triggers (fluids, vasopressors, anesthetic adjustment) and reduce hypotension exposure time.

• Continuous BP monitoring, proactive norepinephrine strategies, predictive analytics, and closed-loop vasopressor systems reliably reduce hypotension exposure (even if outcome benefits remain unproven).

• Focusing on duration + depth of hypotension (not just a single nadir) aligns with the graded risk patterns seen in observational datasets.

Managing Risks

• Avoid reflexively driving MAP “high” in all patients; multicentre RCTs (>13,000 patients) did not show improved patient-centred outcomes with higher/individualized targets vs routine care.

• When MAP dips, treat the likely mechanism: vasodilation (vasopressor), hypovolaemia (volume), myocardial depression (inotropy/agent adjustment), bradycardia (rate support).

• Be cautious in extrapolating: only one small trial suggested benefit from individualized systolic targets, so patient selection and context matter.

The Bottom Line

• Evidence and guidelines converge on a pragmatic message for most adult noncardiac surgical patients: avoid MAP below 60–65 mmHg.

• Preventing hypotension exposure is supported; proving outcome gains may require precision approaches (endotyping + advanced monitoring) rather than universally higher MAP targets.