Introduction

Cardiac output (CO) is a key determinant of oxygen delivery. Low cardiac output syndrome (LCOS) causes organ dysfunction, prolonged hospital stay, and reduces survival in perioperative settings and in critical illness (Algarni et al. 2011; Maganti et al. 2010; Maganti et al. 2005; Lomivorotov et al. 2017; Zangrillo et al. 2020). Ultimately, the inability of the circulatory system to match oxygen demand is considered the main pathophysiological cause underlying the development of multi-organ failure and death (Schoemaker et al. 1988; Vincent et al. 2012). When heart function is incapable of providing enough CO to support tissues metabolic demands, inotropes can be administered with the goal of improving cardiac contractility and, therefore, restore and maintain an adequate oxygen delivery (Fellahi et al. 2013; Francis et al. 2014).

Similarly, maintenance of an adequate mean arterial pressure (MAP) is widely accepted as fundamental to ensure end-organ perfusion, and most professional guidelines recommend starting vasopressor administration when fluid resuscitation alone is unable to restore MAP (Evans et al. 2021; Van Diepen et al. 2017; Chioncel et al. 2020; Møller et al. 2018; Møller et al. 2016).

As a consequence, every clinician caring for patients with cardiovascular dysfunction is familiar with inotropes and vasopressors. Vasoactive medications are typically used in cardiogenic shock, septic shock, acute heart failure, and patients undergoing cardiac or high-risk non-cardiac surgery. In general, every critically ill patient may require some degree of haemodynamic support.

Inotropes and vasopressors have been administered for decades to patients with cardiovascular failure, and, as many other interventions (e.g. blood products transfusion, intra-aortic balloon pump), entered in routine clinical practice well before development of the evidence-based medicine concept. Accordingly, their safety and efficacy have never been formally tested. We will summarise recent evidence regarding use of inotropes and vasopressors in critically ill patients.