Outpatient surgery is generally performed in patients with lower baseline cardiovascular risk, but the hemodynamic effects of general or regional anesthesia—induction-related vasodilation, sympathetic blockade, and impaired baroreflex function—do not depend on a procedure’s invasiveness or duration (Lonjaret et al., 2014). The same physiologic vulnerabilities that drive blood pressure instability in major surgery are therefore present, in attenuated form, in the ambulatory setting, and anesthesia providers must maintain patient vitals in order to support adequate tissue perfusion. General guidelines shape blood pressure targets during surgery, though specific tolerances must consider each patient’s unique condition.
Preoperative management of antihypertensive medication is the first practical decision point. Beta-blockers, calcium channel blockers, and diuretics are generally continued through the morning of surgery, whereas renin-angiotensin system antagonists are more often withheld because of their association with refractory hypotension at induction (Lonjaret et al., 2014). Some authors have specifically argued that continuing antihypertensive therapy up to the morning of surgery is reasonable, and perhaps preferable, in ambulatory patients, given the brief anesthetic exposure and the practical difficulty of adjusting long-term regimens around a same-day visit (Lonjaret et al., 2014).
During surgery, the evidence increasingly favors individualized rather than fixed blood pressure targets. Meng and colleagues (2018) proposed classifying patients by baseline blood pressure and maintaining intraoperative values within roughly 10% of baseline for normotensive patients, with wider but still baseline-referenced allowances for those with low or high baseline pressures. This framework suits outpatient surgery well, since most patients are relatively healthy and a brief, low-risk procedure offers little justification for permissive deviation from baseline hemodynamics.
Notably, two large randomized trials have shown that deliberately targeting higher intraoperative mean arterial pressures does not translate into fewer adverse events. Wanner and colleagues (2021) found no reduction in myocardial injury or 30-day major adverse cardiovascular events when targeting a mean arterial pressure of 75 mmHg or higher compared with 60 mmHg in cardiovascular-risk patients, and the international POISE-3 trial similarly found equivalent vascular outcomes between a hypotension-avoidance strategy (mean arterial pressure ≥80 mmHg) and a hypertension-avoidance strategy (≥60 mmHg, with continued antihypertensives) (Marcucci et al., 2023). These findings argue against routinely raising intraoperative blood pressure targets in lower-acuity ambulatory patients on the assumption that higher pressures are protective.
At the same time, sustained or profound hypotension should still be avoided. Schnetz and colleagues (2023) demonstrated that the risk of subsequent hypotension rises exponentially as mean arterial pressure approaches 65 mmHg, though this risk curve has relatively more room for tolerance in younger patients with lower American Society of Anesthesiologists physical status, a profile common among ambulatory surgical candidates. This suggests that while a mean arterial pressure threshold near 65 mmHg remains a reasonable floor, healthier outpatients may tolerate brief excursions with less attendant risk than higher-acuity inpatient populations.
Finally, the outpatient setting introduces a postoperative consideration distinct from inpatient care: same-day discharge. Orthostatic hypotension is common in the first hour after general anesthesia, even following minor procedures, and represents a discharge-readiness issue rather than a purely intraoperative one (Meng et al., 2018). Confirming hemodynamic and orthostatic stability before discharge, rather than focusing exclusively on intraoperative numbers, is therefore an important component of blood pressure management in ambulatory surgery.
Research supports individualized, baseline-referenced intraoperative blood pressure targets, continuation of most chronic antihypertensive medications, avoidance of sustained mean arterial pressure below 65 mmHg, and explicit attention to orthostatic stability before discharge, rather than adoption of a single universal pressure target for outpatient surgery.
References
- Lonjaret, L., Lairez, O., Minville, V., & Geeraerts, T. (2014). Optimal perioperative management of arterial blood pressure. Integrated Blood Pressure Control, 7, 49–59. https://doi.org/10.2147/IBPC.S45292
- Meng, L., Yu, W., Wang, T., Zhang, L., Heerdt, P. M., & Gelb, A. W. (2018). Blood pressure targets in perioperative care: Provisional considerations based on a comprehensive literature review. Hypertension, 72(4), 806–817. https://doi.org/10.1161/HYPERTENSIONAHA.118.11688
- Schnetz, M. P., Danks, D. J., & Mahajan, A. (2023). Preoperative identification of patient-dependent blood pressure targets associated with low risk of intraoperative hypotension during noncardiac surgery. Anesthesia & Analgesia, 136(2), 194–203. https://doi.org/10.1213/ANE.0000000000006238
- Wanner, P. M., Wulff, D. U., Djurdjevic, M., Korte, W., Schnider, T. W., & Filipovic, M. (2021). Targeting higher intraoperative blood pressures does not reduce adverse cardiovascular events following noncardiac surgery. Journal of the American College of Cardiology, 78(18), 1753–1764. https://doi.org/10.1016/j.jacc.2021.08.048
- Marcucci, M., Painter, T. W., Conen, D., Lomivorotov, V., Sessler, D. I., Chan, M. T. V., Borges, F. K., et al. (2023). Hypotension-avoidance versus hypertension-avoidance strategies in noncardiac surgery: An international randomized controlled trial. Annals of Internal Medicine, 176(5), 605–614. https://doi.org/10.7326/M22-3157