{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,2]],"date-time":"2026-11-02T11:37:37Z","timestamp":1793619457125,"version":"4.5.0"},"reference-count":53,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2024,12,3]],"date-time":"2024-12-03T00:00:00Z","timestamp":1733184000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Vasopressor therapy represents a key part of intensive care patient management, used to increase and maintain vascular tone and thus adequate tissue perfusion in patients with shock. Norepinephrine is the preferred first-line agent because of its reliable vasoconstrictor effects, with minimal impact on heart rate, and its mild inotropic effects, helping to maintain cardiac output. Whichever vasopressor is used, its effects on blood flow must be considered and excessive vasoconstriction avoided. Other vasoactive agents include vasopressin, which may be considered in vasodilatory states, and angiotensin II, which may be beneficial in patients with high renin levels, although more data are required to confirm this. Dobutamine should be considered, along with continued fluid administration, to help maintain adequate tissue perfusion in patients with reduced oxygen delivery. In this narrative review, we consider the different vasopressor agents, focusing on the importance of tailoring therapy to the individual patient and their hemodynamic response.<\/jats:p>","DOI":"10.3390\/jcm13237372","type":"journal-article","created":{"date-parts":[[2024,12,3]],"date-time":"2024-12-03T11:48:56Z","timestamp":1733226536000},"page":"7372","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":22,"title":["Vasopressor Therapy"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6011-6951","authenticated-orcid":false,"given":"Jean-Louis","family":"Vincent","sequence":"first","affiliation":[{"name":"Department of Intensive Care, Erasme Hospital, Universit\u00e9 libre de Bruxelles, 1070 Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Filippo","family":"Annoni","sequence":"additional","affiliation":[{"name":"Department of Intensive Care, Erasme Hospital, Universit\u00e9 libre de Bruxelles, 1070 Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1726","DOI":"10.1056\/NEJMra1208943","article-title":"Circulatory shock","volume":"369","author":"Vincent","year":"2013","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Xu, Q.Y., Jin, Y.H., Fu, L., and Li, Y.Y. (2024). Application of norepinephrine in the treatment of septic shock: A meta-analysis. Ir. J. Med. Sci., Epub ahead of print.","DOI":"10.1007\/s11845-024-03827-x"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1007\/s00134-018-5391-6","article-title":"Frugal innovation for critical care","volume":"45","year":"2019","journal-title":"Intensive Care Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1389","DOI":"10.1056\/NEJM196612222752501","article-title":"Dopamine in the treatment of hypotension and shock","volume":"275","author":"MacCannell","year":"1966","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"779","DOI":"10.1056\/NEJMoa0907118","article-title":"Comparison of dopamine and norepinephrine in the treatment of shock","volume":"362","author":"Biston","year":"2010","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1097\/CCM.0b013e31823778ee","article-title":"Dopamine versus norepinephrine in the treatment of septic shock: A metaanalysis","volume":"40","author":"Aldecoa","year":"2012","journal-title":"Crit. Care Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"746","DOI":"10.1097\/SHK.0000000000002193","article-title":"The efficacy and safety of vasopressors for septic shock patients: A systemic review and network meta-analysis","volume":"60","author":"Jia","year":"2023","journal-title":"Shock"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1122","DOI":"10.1161\/01.CIR.95.5.1122","article-title":"Vasopressin deficiency contributes to the vasodilation of septic shock","volume":"95","author":"Landry","year":"1997","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1097\/00003246-200203000-00001","article-title":"Depletion of neurohypophyseal content of vasopressin in septic shock","volume":"30","author":"Sharshar","year":"2002","journal-title":"Crit. Care Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s13613-020-0628-2","article-title":"Vasopressin and its analogues in shock states: A review","volume":"10","author":"Demiselle","year":"2020","journal-title":"Ann. Intensive Care"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1164\/rccm.200205-447OC","article-title":"Low-dose vasopressin in the treatment of septic shock in sheep","volume":"168","author":"Sun","year":"2003","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1782","DOI":"10.1007\/s00134-006-0378-0","article-title":"Vasopressin or norepinephrine in early hyperdynamic septic shock: A randomized clinical trial","volume":"32","author":"Lauzier","year":"2006","journal-title":"Intensive Care Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1001\/jama.2016.10485","article-title":"Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock: The VANISH randomized clinical trial","volume":"316","author":"Gordon","year":"2016","journal-title":"JAMA"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"844","DOI":"10.1007\/s00134-019-05620-2","article-title":"Vasopressin in septic shock: An individual patient data meta-analysis of randomised controlled trials","volume":"45","author":"Nagendran","year":"2019","journal-title":"Intensive Care Med."},{"key":"ref_15","first-page":"F274","article-title":"Renal microvascular effects of vasopressin and vasopressin antagonists","volume":"256","author":"Edwards","year":"1989","journal-title":"Am. J. Physiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1097\/ALN.0000000000001434","article-title":"Vasopressin versus norepinephrine in patients with vasoplegic shock after cardiac surgery: The VANCS randomized controlled trial","volume":"126","author":"Hajjar","year":"2017","journal-title":"Anesthesiology"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Xu, J., Cai, H., and Zheng, X. (2023). Timing of vasopressin initiation and mortality in patients with septic shock: Analysis of the MIMIC-III and MIMIC-IV databases. BMC Infect. Dis., 23.","DOI":"10.1186\/s12879-023-08147-6"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1056\/NEJMoa067373","article-title":"Vasopressin versus norepinephrine infusion in patients with septic shock","volume":"358","author":"Russell","year":"2008","journal-title":"N. Engl. J. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1097\/SHK.0b013e318254d41a","article-title":"Normal-range blood lactate concentration in septic shock is prognostic and predictive","volume":"38","author":"Wacharasint","year":"2012","journal-title":"Shock"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1097\/CCM.0000000000005317","article-title":"Association of catecholamine dose, lactate, and shock duration at vasopressin initiation with mortality in patients with septic shock","volume":"50","author":"Sacha","year":"2022","journal-title":"Crit. Care Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1186\/s13054-023-04583-7","article-title":"The vasopressin loading for refractory septic shock (VALOR) study: A prospective observational study","volume":"27","author":"Nakamura","year":"2023","journal-title":"Crit. Care"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1097\/CLD.0000000000000086","article-title":"Terlipressin for hepatorenal syndrome: The practical choice for clinicians","volume":"22","author":"Wahid","year":"2023","journal-title":"Clin. Liver Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1056\/NEJMoa1704154","article-title":"Angiotensin II for the treatment of vasodilatory shock","volume":"377","author":"Khanna","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1186\/s13054-022-04161-3","article-title":"Myocardial effects of angiotensin II compared to norepinephrine in an animal model of septic shock","volume":"26","author":"Garcia","year":"2022","journal-title":"Crit. Care"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1186\/s13054-022-03911-7","article-title":"Vasopressor choice and timing in vasodilatory shock","volume":"26","author":"Wieruszewski","year":"2022","journal-title":"Crit. Care"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1186\/s13054-019-2420-y","article-title":"Broad spectrum vasopressors: A new approach to the initial management of septic shock?","volume":"23","author":"Chawla","year":"2019","journal-title":"Crit. Care"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"949","DOI":"10.1097\/CCM.0000000000003092","article-title":"Outcomes in patients with vasodilatory shock and renal replacement therapy treated with intravenous angiotensin II","volume":"46","author":"Tumlin","year":"2018","journal-title":"Crit. Care Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1097\/SHK.0000000000002109","article-title":"A pilot study of angiotensin II as primary vasopressor in critically ill adults with vasodilatory hypotension: The Aramis study","volume":"59","author":"See","year":"2023","journal-title":"Shock"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1186\/s13054-023-04446-1","article-title":"Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: An exploratory post-hoc analysis of the ATHOS-3 clinical trial","volume":"27","author":"Wieruszewski","year":"2023","journal-title":"Crit. Care"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1186\/s13613-023-01227-5","article-title":"Angiotensin II treatment is associated with improved oxygenation in ARDS patients with refractory vasodilatory shock","volume":"13","author":"Leisman","year":"2023","journal-title":"Ann. Intensive Care"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"939","DOI":"10.1177\/08850666231174870","article-title":"Trajectory of PaO(2)\/FiO(2) ratio in shock after angiotensin II","volume":"38","author":"Wieruszewski","year":"2023","journal-title":"J. Intensive Care Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2006","DOI":"10.1007\/s00018-007-6228-6","article-title":"Angiotensin-converting enzyme 2 in acute respiratory distress syndrome","volume":"64","author":"Imai","year":"2007","journal-title":"Cell Mol. Life Sci."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1360","DOI":"10.1378\/chest.105.5.1360","article-title":"Vasoconstrictor effects of angiotensin II on the pulmonary vascular bed","volume":"105","author":"Lipworth","year":"1994","journal-title":"Chest"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1253","DOI":"10.1164\/rccm.201911-2172OC","article-title":"Renin and survival in patients given angiotensin II for catecholamine-resistant vasodilatory shock. A clinical trial","volume":"202","author":"Bellomo","year":"2020","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1164\/rccm.202005-2050OC","article-title":"Kinetic changes of plasma renin concentrations predict acute kidney injury in cardiac surgery patients","volume":"203","author":"Weiss","year":"2021","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1016\/j.bja.2023.06.056","article-title":"Renin-angiotensin-aldosterone system dynamics after targeted blood pressure control using angiotensin II or norepinephrine in cardiac surgery: Mechanistic randomised controlled trial","volume":"131","author":"Coulson","year":"2023","journal-title":"Br. J. Anaesth."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1097\/01.CCM.0000105581.01815.C6","article-title":"Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: Effect on survival in patients with septic shock","volume":"32","author":"Lorente","year":"2004","journal-title":"Crit. Care Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1097\/00003246-199502000-00010","article-title":"Methylene blue administration in septic shock: A clinical trial","volume":"23","author":"Preiser","year":"1995","journal-title":"Crit. Care Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1186\/s13054-023-04397-7","article-title":"Early adjunctive methylene blue in patients with septic shock: A randomized controlled trial","volume":"27","author":"Kattan","year":"2023","journal-title":"Crit. Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1186\/s13054-024-04839-w","article-title":"Administration of methylene blue in septic shock: Pros and cons","volume":"28","author":"Vincent","year":"2024","journal-title":"Crit. Care"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1016\/j.niox.2010.01.006","article-title":"A dose-finding study of methylene blue to inhibit nitric oxide actions in the hemodynamics of human septic shock","volume":"22","author":"Juffermans","year":"2010","journal-title":"Nitric Oxide"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"102430","DOI":"10.1016\/j.eclinm.2024.102430","article-title":"Efficacy and safety of phospholipid nanoparticles (VBI-S) in reversing intractable hypotension in patients with septic shock: A multicentre, open-label, repeated measures, phase 2a clinical pilot trial","volume":"68","author":"Simpkins","year":"2024","journal-title":"eClinicalMedicine"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1757","DOI":"10.1053\/j.jvca.2023.04.006","article-title":"Hydroxocobalamin for vasodilatory hypotension in shock: A systematic review with meta-analysis for comparison to methylene blue","volume":"37","author":"Brokmeier","year":"2023","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1583","DOI":"10.1056\/NEJMoa1312173","article-title":"High versus low blood-pressure target in patients with septic shock","volume":"370","author":"Asfar","year":"2014","journal-title":"N. Engl. J. Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1001\/jama.2020.0930","article-title":"Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension: A randomized clinical trial","volume":"323","author":"Lamontagne","year":"2020","journal-title":"JAMA"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Angriman, F., Momenzade, N., Adhikari, N.K.J., Mouncey, P.R., Asfar, P., Yarnell, C.J., Ong, S.W.X., Pinto, R., Doidge, J.C., and Shankar-Hari, M. (2024). Blood pressure targets for adults with vasodilatory shock\u2014An individual patient data meta-analysis. NEJM Evid., Epub ahead of print.","DOI":"10.1056\/EVIDoa2400359"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Hamzaoui, O., Goury, A., and Teboul, J.L. (2023). The eight unanswered and answered questions about the use of vasopressors in septic shock. J. Clin. Med., 12.","DOI":"10.3390\/jcm12144589"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"486","DOI":"10.1097\/CCM.0000000000002255","article-title":"Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016","volume":"45","author":"Rhodes","year":"2017","journal-title":"Crit. Care Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1186\/s13054-021-03813-0","article-title":"Equilibrating SSC guidelines with individualized care","volume":"25","author":"Vincent","year":"2021","journal-title":"Crit. Care"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1476","DOI":"10.1001\/jama.2019.14607","article-title":"Effect of selepressin vs placebo on ventilator- and vasopressor-free days in patients with septic shock: The SEPSIS-ACT randomized clinical trial","volume":"322","author":"Laterre","year":"2019","journal-title":"JAMA"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1186\/s13054-017-1798-7","article-title":"Selepressin, a novel selective vasopressin V1A agonist, is an effective substitute for norepinephrine in a phase IIa randomized, placebo-controlled trial in septic shock patients","volume":"21","author":"Russell","year":"2017","journal-title":"Crit. Care"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1186\/s13054-020-03443-y","article-title":"The fluid challenge","volume":"24","author":"Vincent","year":"2020","journal-title":"Crit. Care"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1267","DOI":"10.1016\/j.chest.2018.07.020","article-title":"From early goal-directed therapy to late(r) ScvO2 checks","volume":"154","author":"Vincent","year":"2018","journal-title":"Chest"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/23\/7372\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:46:06Z","timestamp":1760114766000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/23\/7372"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,3]]},"references-count":53,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["jcm13237372"],"URL":"https:\/\/doi.org\/10.3390\/jcm13237372","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,3]]}}}