Initial Management of Postoperative Vasoplegia

First-Line Treatment: α1-Adrenergic Agonists

The American College of Critical Care recommends starting norepinephrine immediately as the first-line vasopressor to restore mean arterial pressure (MAP) ≥65 mmHg, with a Class I recommendation for norepinephrine in vasoplegia-induced hypotension to maintain adequate perfusion pressure 1, 2
Ensure the patient is not hypovolemic before initiating or escalating vasopressors through repeated volume assessments using dynamic hemodynamic parameters, as recommended by the Critical Care society 1, 2

The Critical Care society recommends vasopressin as a second-line agent (Class IIa recommendation) when refractory to α1-agonists 2
Terlipressin may be considered as an alternative when vasopressin is unavailable or as part of refractory vasoplegia management, according to the Critical Care society 2

The British Journal of Anaesthesia recommends assessing volume status using dynamic hemodynamic parameters (pulse pressure variation, stroke volume variation) rather than static measurements 1
Monitor mixed venous oxygen saturation (SvO2), oxygen extraction ratio, and lactate levels to ensure adequate tissue perfusion, as recommended by the British Journal of Anaesthesia 3
Use echocardiography to differentiate vasoplegia from myocardial dysfunction—vasoplegia presents with normal or high cardiac index despite hypotension, according to the Critical Care society 1, 2

The British Journal of Anaesthesia recommends targeting MAP 65-80 mmHg during the postoperative period 4, 5
Avoid forcing MAP >80 mmHg with excessive vasopressors (Class III recommendation), as this may increase stroke and mortality risk, according to the British Journal of Anaesthesia 5, 3

The British Journal of Anaesthesia identifies preoperative ACE inhibitor or calcium channel blocker use as a risk factor requiring heightened vigilance 4, 5
Active endocarditis, prolonged cardiopulmonary bypass time are also risk factors, according to the British Journal of Anaesthesia 4, 5

The British Journal of Anaesthesia recommends correcting hypocalcemia promptly, as it impairs cardiac contractility, vascular tone, and coagulation 5

Angiotensin II may be considered (Class IIb recommendation) for refractory vasoplegia during cardiopulmonary bypass, according to the Intensive Care Medicine society 6

The European Association for Cardio-Thoracic Surgery, European Association of Cardiothoracic Anesthesiologists, and European Board of Cardiothoracic Surgery recommends hydroxocobalamin for vasoplegic syndrome during cardiopulmonary bypass as a Class IIb recommendation (may be used) 7, 8
The 2025 updated guidelines elevate this to a Class IIb recommendation stating that hydroxocobalamin or angiotensin II may be considered to treat vasoplegic syndrome during CPB 9

The European Association for Cardio-Thoracic Surgery recommends α1-adrenergic agonist vasopressors as initial treatment (Class I recommendation) for vasoplegia 7, 8, 9
Vasopressin, terlipressin, or methylene blue should be considered when refractory to α1-agonists (Class IIa recommendation) for vasoplegia 7, 8, 9
Hydroxocobalamin (5 grams IV) may be considered for refractory vasoplegic syndrome (Class IIb recommendation) 9

Cobalamin is used exclusively for treating vitamin B12 deficiency, not vasoplegic syndrome 10, 11, 12
Standard treatment involves hydroxocobalamin 1 mg intramuscularly for B12 deficiency 10, 11, 12

Hydroxocobalamin for vasoplegia works by scavenging and binding nitric oxide (NO), thereby reversing the pathological vasodilation that characterizes vasoplegic syndrome 13, 14
Cobalamin for B12 deficiency works as a cofactor in metabolic pathways (methionine synthesis, methylmalonic acid metabolism) over days to weeks 13, 14