Vasoactive Medications and the Microcirculation in Septic Shock: A Scoping Review.

Abstract

To summarize knowledge and identify gaps in evidence regarding the effects of vasoactive medications on microvascular perfusion in septic shock. We conducted a comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials. Studies included adult patients with septic shock who received vasoactive therapy with corresponding microcirculatory measurements between 1946 and May 7, 2025. Data extraction was performed in Covidence by two independent reviewers. Data items included study design, patient population, vasoactive medication, macrohemodynamics, and microcirculation measurements and techniques. Thirty-three studies were included evaluating several vasoactive medications and microvascular measurement techniques. Despite heterogeneous study design, studies that recruited patients within 24 hours tended to report more significant microcirculatory changes. Microcirculatory changes and cardiac index only aligned in 39% of cases, highlighting a disconnect between global hemodynamics and microvascular perfusion. Several vasoactives, including norepinephrine, vasopressin, terlipressin, and levosimendan demonstrated context-dependent improvements in peripheral/sublingual microcirculation. Despite limitations in directly monitoring gastric microcirculation, dobutamine may enhance perfusion; however, further studies are needed to support dobutamine and other vasoactive agents' impacts on clinical outcomes. Despite growing interest in perfusion-guided care, significant challenges remain in understanding how vasoactive agents affect the microcirculation. Clarifying these effects through standardized research and point-of-care perfusion monitoring remains a challenge in advancing outcome-driven resuscitation strategies.