Vasoactive support in asphyxiated neonates: Evidence, uncertainty, and clinical practice

Perinatal asphyxia is a critical condition frequently associated with hemodynamic instability, often necessitating vasoactive support. Despite the established benefits of therapeutic hypothermia, significant mortality and long-term morbidity persist, particularly in severe cases. The objective of this narrative review is to critically evaluate the available evidence on vasoactive therapies in asphyxiated neonates, compare the hemodynamic effects of commonly used agents, and propose a physiology-based, phenotype-driven approach to cardiovascular management during therapeutic hypothermia. Available evidence remains limited and heterogeneous, with few high-quality studies specifically addressing this population. While commonly used vasoactive agents exert distinct physiologic effects, no single agent has demonstrated clear superiority in improving clinical outcomes. Current evidence supports an individualized, physiology-based approach to vasoactive therapy guided by the underlying hemodynamic phenotype and informed by multimodal monitoring. Further prospective studies are needed to define optimal therapeutic strategies and improve outcomes in this high-risk population.