Vasopressors to treat or prevent hypotension during and after major surgery: a scoping review

This is the authors' abstract. We don't add key points for this paper.

Perioperative hypotension is common and associated with adverse postoperative outcomes. Vasopressors are central to management, yet the optimal agent and their subsequent impacts on end organ outcomes remain unclear. We undertook a scoping review to characterise the current evidence base and address the need for a full systematic review or meta-analysis. A protocol was formulated a priori as per PRISMA-ScR. Subsequently, MEDLINE, Embase and Scopus were searched from 1 January 2000 to 18 July 2025 for studies comparing parenteral vasopressors in adults undergoing major surgery. Randomised control trials and observational studies were included. Data on study design, vasopressor strategies, initiation criteria, and postoperative outcomes were extracted and synthesised descriptively. Sixteen studies (n = 6,927) were included. Most were small, single-centre and observational, predominantly in cardiothoracic surgery. Vasopressor initiation criteria were highly variable with studies divided broadly between hypotension-based triggers and vasoplegic syndrome, the latter inconsistently defined. A variety of vasopressors were evaluated yet no two studies compared identical regimens. Postoperative outcome reporting was heterogenous, and outcome definitions varied and showed minimal alignment with StEP-COMPAC consensus standards. Eight studies reported significant differences in postoperative clinical outcomes between vasopressor strategies; however, effects were inconsistent, and no vasopressor strategy demonstrated a consistent benefit across studies. Overall, the evidence base for vasopressor therapy in perioperative hypotension is fragmented. Variability in initiation criteria, interventions and outcome definitions limits comparability and precludes meaningful synthesis. Standardised definitions and adequately powered multicentre trials are required to determine optimal vasopressor strategies and their effects on postoperative organ dysfunction.