Vasopressors and inotropes: a perioperative reference

This document is a reference guide for anaesthetists, registrars, and junior doctors caring for patients in the perioperative period and post-operative recovery environments. It covers the agents named across three recent clinical investigations supplied by ARRC — Saugel et al. (BJA 2025), Ortega-Hernández et al. (Frontiers in Cardiovascular Medicine 2025), and Jammer et al. (BJA 2025, the SQUEEZE study) — and is anchored to the BJA Education review of vasoactive therapy in shock by Jha, Zilahi, and Rhodes (2021), with supporting pharmacology drawn from peer-reviewed and authoritative sources cited at the end.

The intent is breadth and accuracy rather than algorithmic prescription. Local protocols, drug availability, and individual clinical context should always govern choice.

Why a refresher matters

Three recent observational studies converge on the same uncomfortable signal: vasopressors are increasingly used to defend perioperative blood pressure, but cumulative exposure carries its own price. The SQUEEZE study of 25,675 patients across 42 countries found postoperative vasopressor infusions in 3.9% of noncardiac-surgery patients, with strong associations between any postoperative vasopressor infusion and 30-day mortality (12.5%), AKI, ventilation, and prolonged length of stay. The Saugel cohort of 38,338 noncardiac-surgery patients showed both intraoperative hypotension and cumulative noradrenaline dose were independently associated with postoperative AKI. The Ortega-Hernández AMI-CS cohort demonstrated that mortality scales with the number of vasoactive agents used, even when haemodynamic targets are achieved — with vasopressin and levosimendan showing especially high early-day hazards.

The choice of agent is not innocuous. A working knowledge of receptor pharmacology, kinetics, and characteristic adverse-effect profiles is part of using these drugs safely.

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References

Sources supplied by ARRC are marked with an asterisk (*). All references are open access or freely available.

1. * Saugel B, Sander M, Katzer C, et al. Association of intraoperative hypotension and cumulative norepinephrine dose with postoperative acute kidney injury in patients having noncardiac surgery: a retrospective cohort analysis. Br J Anaesth 2025;134(1):54–62. https://doi.org/10.1016/j.bja.2024.11.005

2. * Ortega-Hernández JA, González-Pacheco H, Araiza-Garaygordobil D, et al. Higher vasoactive usage despite hemodynamic goals is associated with higher mortality in acute myocardial infarction-related cardiogenic shock. Front Cardiovasc Med 2025;12:1461714. https://doi.org/10.3389/fcvm.2025.1461714

3. * Jammer I, Martin P, Wunsch H, et al. Vasopressor use after noncardiac surgery: an international observational study (SQUEEZE). Br J Anaesth 2025;135(6):1609–1617. https://doi.org/10.1016/j.bja.2025.07.034

4. Jha A, Zilahi G, Rhodes A. Vasoactive therapy in shock. BJA Educ 2021;21(7):270–277. https://doi.org/10.1016/j.bjae.2021.03.002

5. Saugel B, Fletcher N, Gan TJ, et al. PeriOperative Quality Initiative (POQI) international consensus statement on perioperative arterial pressure management. Br J Anaesth 2024;133(2):264–276. https://doi.org/10.1016/j.bja.2024.04.046

6. Shankar A, Gurumurthy G, Sridharan L, et al. A clinical update on vasoactive medication in the management of cardiogenic shock. Clin Med Insights Cardiol 2022;16:11795468221075064. https://doi.org/10.1177/11795468221075064

7. Khanna A, English SW, Wang XS, et al. Angiotensin II for the treatment of vasodilatory shock (ATHOS-3). N Engl J Med 2017;377:419–430. https://doi.org/10.1056/NEJMoa1704154

8. Papathanakos G, Andrianopoulos I, Xenikakis T, et al. Levosimendan, a promising pharmacotherapy in cardiogenic shock: a comprehensive review. Eur Cardiol Rev 2024;19:e13. https://doi.org/10.15420/ecr.2023.41

9. Tilney R, Burg MR, Sammut MA. Milrinone. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated 2023. https://www.ncbi.nlm.nih.gov/books/NBK532943/

10. Glykas E, Stamatiou A. The use of metaraminol as a vasopressor in critically unwell patients: a narrative review and a survey of UK practice. Cureus 2022;14(7):e27123. https://doi.org/10.7759/cureus.27123

11. Safer Care Victoria. Metaraminol clinical guideline. State Government of Victoria; updated 2018. https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/critical/metaraminol

12. Statler AR, Kalot M, Khan M, et al. Terlipressin: a comprehensive review for hepatorenal syndrome. Cureus 2023;15(9):e45305. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10587779/

13. Mathew R, Di Santo P, Jung RG, et al. Milrinone as compared with dobutamine in the treatment of cardiogenic shock (DOREMI). N Engl J Med 2021;385:516–525. https://doi.org/10.1056/NEJMoa2026845

14. Mebazaa A, Nieminen MS, Packer M, et al. Levosimendan vs dobutamine for patients with acute decompensated heart failure (SURVIVE). JAMA 2007;297:1883–1891. https://doi.org/10.1001/jama.297.17.1883

15. Hajjar LA, Vincent JL, Barbosa Gomes Galas FR, et al. Vasopressin versus norepinephrine in patients with vasoplegic shock after cardiac surgery (VANCS). Anesthesiology 2017;126:85–93. https://doi.org/10.1097/ALN.0000000000001434

16. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock (SOAP II). N Engl J Med 2010;362:779–789. https://doi.org/10.1056/NEJMoa0907118

17. Schubert AK, Wiesmann T, Eberhart LH, et al. (HYPOTENS investigators). Treatment of intraoperative hypotension with cafedrine/theodrenaline versus ephedrine. Anaesthesist 2021;70(4):298–307. https://doi.org/10.1007/s00101-020-00867-7

18. Vail E, Gershengorn HB, Hua M, et al. Association between US norepinephrine shortage and mortality among patients with septic shock. JAMA 2017;317:1433–1442. https://doi.org/10.1001/jama.2017.2841