Beyond hypotension management: clinical mechanisms, risks, and efficacy of vasopressors in noncardiac surgery patients

Dear Editor,

Postoperative hypotension remains a frequent and clinically significant challenge in the perioperative management of patients undergoing noncardiac surgery. Vasopressor administration has significant effects on patient outcomes, especially in terms of morbidity, mortality, and long-term consequences, while being frequently seen as a routine measure^[1]. Acute renal disease, myocardial infarction, and stroke are among the adverse outcomes that are strongly linked to postoperative hypotension, but their prevalence varies greatly. Poorer outcomes in surgical patients have been independently associated with even brief bouts of mean arterial pressure < 65 mmHg^[2,3]. This has caused a change in emphasis from reactive treatment to personalized hemodynamic support and proactive monitoring^[1,4]. To maintain appropriate perfusion pressures, vasopressors like norepinephrine and phenylephrine are being mostly used more and more in perioperative bundles. Their application is not without controversy though, especially when it comes to finding a balance between restoring perfusion and possibly compromising local blood flow^[1,4]

According to a new study, the need for vasopressors following non-cardiac surgery may indicate a patient’s susceptibility rather than just the intensity of intraoperative complications. For instance, patients who need postoperative vasopressor support frequently have occult hypovolemia, elevated surgical stress, or higher baseline comorbidity^[1,5]. Vasopressors are used for physiological reasons because of their capacity to modify adrenergic receptors and restore vascular tone. Systemic vascular resistance is raised, and cardiac output is supported by agents like norepinephrine that provide balanced α1-adrenergic vasoconstriction with mild β1-mediated inotropy^[3]. In contrast, phenylephrine is a pure α1-agonist, which may result in decreased organ perfusion and stroke volume but also increased afterload. Combining direct and indirect adrenergic stimulation, ephedrine causes a brief rise in heart rate and blood pressure with less consistency^[3].

Vasopressors may therefore be used as a stand-in for identifying high-risk groups that require more frequent monitoring, heightened surveillance, or customized perioperative optimization techniques^[5]. Furthermore the hemodynamic profile and choice of vasopressor are also significant clinical factors. Because of its mild β-adrenergic activity and balanced α-adrenergic activity, norepinephrine is often preferred because it maintains cardiac output and vascular tone. On the other hand, although being widely used, phenylephrine may impair splanchnic perfusion and lower cardiac output^[2,6].

Hence, vasopressor use after noncardiac surgery should not be viewed solely as a reactive measure to hypotension but as a clinical signal with prognostic significance. Future guidelines must include evidence-based recommendations on postoperative vasopressor use to improve outcomes, decrease complications, and enhance the quality of perioperative care. This work has been prepared in compliance with the TITAN Guidelines 2025 governing declaration and use of AI (TITAN 2025)^[7].

Ethical approval

IRB approval was not required because no data were collected for this article.

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Sources of funding

The authors received no funding for this paper.

Author contributions

Q.A. and A.M. contributed to the conception, literature search, and drafting of the manuscript; M.Q., H.J., and K.B. contributed to data interpretation, critical revision, and manuscript editing.

Conflicts of interest disclosure

The authors have no financial or non-financial interests to disclose.

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Not applicable.

Guarantor

Kritick Bhandari.

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Not commissioned, externally peer-reviewed.

Data availability statement

Not applicable.