Inotropes and Vasopressors Use in Critical Care and Perioperative Medicine: Evidence-Based Approach (Review)

Abstract

Inotropes and vasopressors are frequently required in critically ill patients and in patients undergoing major surgery. Several molecules are currently available, including catecholamines, phosphodiesterase-3 inhibitors, vasopressin and its analogues, and calcium sensitizers.We will review current evidence on inotropes use in perioperative and critically ill patients, with focus on most recent randomized controlled trials (RCTs).Despite being widely used in anesthesia and intensive care, evidences on safety and efficacy of inotropes are scarce. Data from observational studies suggest that inotropes administration may increase mortality in cardiac surgery, acute heart failure, and cardiogenic shock patients. However, randomized controlled trials did not confirm these findings in acute care settings.Epinephrine has been associated with increased mortality especially in cardiogenic shock, but randomized trials failed to show evidence of increased mortality associated with epinephrine use. Norepinephrine has been traditionally considered contraindicated in patients with ventricular dysfunction, but recent trials suggested hemodynamic effects similar to epinephrine in patients with cardiogenic shock. Dopamine has no additional advantages over norepinephrine and increases the risk of tachyarrhythmias and may increase mortality in cardiogenic shock. Phosphodiesterase-3 (PDE-3) inhibitors are equivalent to catecholamines in terms of major outcomes. Levosimendan is the most investigated inotrope of the last 30 years, but despite promising early studies, high-quality multicenter RCTs repeatedly failed to show any superiority over available agents. There is no highquality RCT clearly demonstrating superiority of one agent over another. In summary, current evidence suggest that the choice of inotrope is unlikely to affect outcome, as long as the target hemodynamic goals are achieved.Finally, in recent years, mechanical circulatory support (MCS) has become increasingly popular. Thanks to improvement in technology, the safety and biocompatibility of devices are constantly growing. MCS devices have theoretical advantages over inotropes, but their use is limited by costs, availability, and invasiveness.Conclusion. Future studies should investigate safety, efficacy, and cost-effectiveness of primary MCS versus primary inotropes in patients with acute cardiovascular failure.