Inotropes, Vasopressors and Vasodilators

  • Nandor MarczinEmail author
  • Paola Carmona
  • Steffen Rex
  • Eric E. C. de Waal


Indications, selection and duration of inotropic support during and following cardiac surgery remain variable and controversial. Nevertheless, it is employed frequently for anticipated or manifest hemodynamic instability ranging from low cardiac output to established shock stages. This chapter provides a background, justification and overview of inotropic and vasopressor therapy with a strong clinical rather than molecular and pharmacological focus. Current treatment strategies and principles of crucial aspects of medical management are discussed. The main clinical classification of inotropes and to a lesser degree vasoactive agents is included as well as clinical utilities of the most frequently used agents are described. Due to the significance of right ventricular dysfunction a section is dedicated to the right ventricle and pulmonary circulation. Finally, a summary of treatment strategies for the most common clinical scenarios is provided.


Hypotension Low cardiac output Inotropes Inopressors Inodilators Inhaled nitric oxide 


  1. 1.
    Ball L, Costantino F, Pelosi P. Postoperative complications of patients undergoing cardiac surgery. Curr Opin Crit Care. 2016;22:386–92.CrossRefGoogle Scholar
  2. 2.
    Hauffe T, Kruger B, Bettex D, Rudiger A. Shock management for cardio-surgical intensive care unit patient: the silver days. Card Fail Rev. 2016;2:56–62.CrossRefGoogle Scholar
  3. 3.
    Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM. Low cardiac output syndrome after cardiac surgery. J Cardiothorac Vasc Anesth. 2017;31:291–308.CrossRefGoogle Scholar
  4. 4.
    Tariq S, Aronow WS. Use of inotropic agents in treatment of systolic heart failure. Int J Mol Sci. 2015;16:29060–8.CrossRefGoogle Scholar
  5. 5.
    Wanderer JP, Rathmell JP. Complex information for anesthesiologists presented quickly and clearly: vasopressor variation: intra- and international variation in perioperative utilization of vasopressors and inotropes in cardiac surgery. Anesthesiology. 2014;120:A29.CrossRefGoogle Scholar
  6. 6.
    Baehner T, Boehm O, Probst C, Poetzsch B, Hoeft A, Baumgarten G, Knuefermann P. Cardiopulmonary bypass in cardiac surgery. Anaesthetists. 2012;61:846–56.CrossRefGoogle Scholar
  7. 7.
    Day JR, Taylor KM. The systemic inflammatory response syndrome and cardiopulmonary bypass. Int J Surg. 2005;3:129–40.CrossRefGoogle Scholar
  8. 8.
    Landis RC. 20 years on: is it time to redefine the systemic inflammatory response to cardiothoracic surgery? J Extra Corpor Technol. 2015;47:5–9.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Osawa EA, Rhodes A, Landoni G, Galas FR, Fukushima JT, Park CH, et al. Effect of perioperative goal-directed hemodynamic resuscitation therapy on outcomes following cardiac surgery: a randomized clinical trial and systematic review. Crit Care Med. 2016;44:724–33.CrossRefGoogle Scholar
  10. 10.
    Belletti A, Castro ML, Silvetti S, Greco T, Biondi-Zoccai G, Pasin L, et al. The Effect of inotropes and vasopressors on mortality: a meta-analysis of randomized clinical trials. Br J Anaesth. 2015;115:656–675, 2015.CrossRefGoogle Scholar
  11. 11.
    Nielsen DV, Algotsson L. Outcome of inotropic therapy: is less always more? Curr Opin Anaesthesiol. 2015;28:159–64.CrossRefGoogle Scholar
  12. 12.
    McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Bohm M, Dickstein K, et al. ESC committee for practice guidelines. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European society of cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33:1787–847.CrossRefGoogle Scholar
  13. 13.
    Mebazaa A, Parissis J, Porcher R, Gayat E, Nikolaou M, Boas FV, et al. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods. Intensive Care Med. 2011;37:290–301.CrossRefGoogle Scholar
  14. 14.
    Mebazaa A, Pitsis AA, Rudiger A, Toller W, Longrois D, Ricksten SE, et al. Clinical review: practical recommendations on the management of perioperative heart failure in cardiac surgery. Crit Care. 2010;14:201.CrossRefGoogle Scholar
  15. 15.
    Ghignone M, Girling L, Prewitt RM. Volume expansion versus norepinephrine in treatment of a low cardiac output complicating an acute increase in right ventricular afterload in dogs. Anesthesiology. 1984;60:132–5.CrossRefGoogle Scholar
  16. 16.
    Levy B, Perez P, Perny J, Thivilier C, Gerard A. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2011;39:450–5.CrossRefGoogle Scholar
  17. 17.
    Annane D, Vignon P, Renault A, Bollaert PE, Charpentier C, Martin C, CATS Study Group, et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet. 2007;370:676–84.CrossRefGoogle Scholar
  18. 18.
    Greco T, Calabro MG, Covello RD, Greco M, Pasin L, Morelli A, Landoni G, Zangrillo A. A Bayesian network meta-analysis on the effect of inodilatory agents on mortality. Br J Anaesth. 2015;114:746–56.CrossRefGoogle Scholar
  19. 19.
    Bozhinovska M, Taleska G, Fabian A, Sostaric M. The role of levosimendan in patients with decreased left ventricular function undergoing cardiac surgery. Open Access Maced J Med Sci. 2016;4:510–6.CrossRefGoogle Scholar
  20. 20.
    Farmakis D, Alvarez J, Gal TB, Brito D, Fedele F, Fonseca C, et al. Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper. Int J Cardiol. 2016;222:303–12.CrossRefGoogle Scholar
  21. 21.
    Cholley B, Caruba T, Grosjean S, Amour J, Ouattara A, Villacorta J, et al. Effect of Levosimendan on low cardiac output syndrome in patients with low ejection fraction undergoing coronary artery bypass grafting with cardiopulmonary bypass: The LICORN randomized clinical trial. JAMA. 2017;318:548–56.CrossRefGoogle Scholar
  22. 22.
    Guarracino F, Heringlake M, Cholley B, Bettex D, Bouchez S, Lomivorotov VV, et al. Use of Levosimendan in cardiac surgery: an update after the LEVO-CTS, CHEETAH, and LICORN trials in the light of clinical practice. J Cardiovasc Pharmacol. 2018;71:1–9.CrossRefGoogle Scholar
  23. 23.
    Argenziano M, Chen JM, Cullinane S, Choudhri AF, Rose EA, Smith CR, et al. Arginine vasopressin in the management of vasodilatory hypotension after cardiac transplantation. J Heart Lung Transplant. 1999;18:814–7.CrossRefGoogle Scholar
  24. 24.
    Dunser MW, Bouvet O, Knotzer H, Arulkumaran N, Hajjar LA, Ulmer H, et al. Vasopressin in cardiac surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2018;32:2225–32.CrossRefGoogle Scholar
  25. 25.
    Harjola VP, Mebazaa A, Celutkiene J, Bettex D, Bueno H, Chioncel O, et al. Contemporary management of acute right ventricular failure: a statement from the heart failure association and the working group on pulmonary circulation and right ventricular function of the European society of cardiology. Eur J Heart Fail. 2016;18:226–41.CrossRefGoogle Scholar
  26. 26.
    Benedetto M, Romano R, Baca G, Sarridou D, Fischer A, Simon A, Marczin N. Inhaled nitric oxide in cardiac surgery: evidence or tradition? Nitric Oxide. 2015;49:67–79.CrossRefGoogle Scholar
  27. 27.
    Germann P, Braschi A, Della Rocca G, Dinh-Xuan AT, Falke K, Frostell C, et al. Inhaled nitric oxide therapy in adults: European expert recommendations. Intensive Care Med. 2005;31:1029–41.CrossRefGoogle Scholar
  28. 28.
    Potapov E, Meyer D, Swaminathan M, Ramsay M, El Banayosy A, Diehl C, et al. Inhaled nitric oxide after left ventricular assist device implantation: a prospective, randomized, double-blind, multicenter, placebo-controlled trial. J Heart Lung Transplant. 2011;30:870–8.PubMedGoogle Scholar
  29. 29.
    Vachiery JL, Huez S, Gillies H, Layton G, Hayashi N, Gao X, Naeije R. Safety, tolerability and pharmacokinetics of an intravenous bolus of sildenafil in patients with pulmonary arterial hypertension. Br J Clin Pharmacol. 2011;71:289–92.CrossRefGoogle Scholar
  30. 30.
    Humbert M, Lau EM, Montani D, Jais X, Sitbon O, Simonneau G. Advances in therapeutic interventions for patients with pulmonary arterial hypertension. Circulation. 2014;130:2189–208.CrossRefGoogle Scholar
  31. 31.
    Zwissler B, Kemming G, Habler O, Kleen M, Merkel M, Haller M, et al. Inhaled prostacyclin (PGI2) versus inhaled nitric oxide in adult respiratory distress syndrome. Am J Respir Crit Care Med. 1996;154(6 Pt 1):1671–7.CrossRefGoogle Scholar
  32. 32.
    Olschewski H, Rohde B, Behr J, Ewert R, Gessler T, Ghofrani HA, Schmehl T. Pharmacodynamics and pharmacokinetics of inhaled iloprost, aerosolized by three different devices, in severe pulmonary hypertension. Chest. 2003;124:1294–304.CrossRefGoogle Scholar
  33. 33.
    Rex S, Busch T, Vettelschoss M, de Rossi L, Rossaint R, Buhre W. Intraoperative management of severe pulmonary hypertension during cardiac surgery with inhaled iloprost. Anesthesiology. 2003;99:745–7.CrossRefGoogle Scholar
  34. 34.
    Hajiyev V, Erkenov T, Smechowski A, Soeren J, Fritzsche D. Follow-up on ECMO after cardiac surgery: how can we evaluate therapy? Heart Surg Forum. 2019;22:E011–4.CrossRefGoogle Scholar
  35. 35.
    Voeller RK, Kelly R. Postcardiotomy shock: Which patients benefit from extracorporeal membrane oxygenation? J Thorac Cardiovasc Surg. 2018;156(5):1883–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Nandor Marczin
    • 1
    • 2
    • 3
    Email author
  • Paola Carmona
    • 4
  • Steffen Rex
    • 5
    • 6
  • Eric E. C. de Waal
    • 7
  1. 1.Section of Anaesthesia, Pain Medicine and Intensive CareImperial CollegeLondonUK
  2. 2.Department of AnaesthesiaThe Royal Brompton and Harefield NHS Foundation TrustHarefieldUK
  3. 3.Department of Anaesthesia and Intensive CareSemmelweis UniversityBudapestHungary
  4. 4.Anaesthesia, Critical Care and Pain Medicine DepartmentConsorcio Hospital General of ValenciaValenciaSpain
  5. 5.Department of AnesthesiologyUniversity Hospitals LeuvenLeuvenBelgium
  6. 6.Department of Cardiovascular SciencesKU LeuvenLeuvenBelgium
  7. 7.Department of AnesthesiologyUniversity Medical Centre UtrechtUtrechtThe Netherlands

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