Management Algorithm for Vasoplegic Shock After Cardiac Surgery: An Interdisciplinary Collaboration.

Abstract

Vasoplegic shock is distributive shock that follows cardiopulmonary bypass, characterized by hypotension, low systemic vascular resistance, and catecholamine resistance despite preserved or elevated cardiac output. Reported incidence ranges from 5% to 50%. Associated adverse outcomes include acute kidney injury, prolonged intensive care unit stay, and mortality. A single, universally accepted consensus definition is lacking, and few evidence-based best-practice management strategies exist. A panel of 12 clinicians-cardiac surgeons, anesthesiologists, intensivists, and pharmacists-from 6 institutions conducted a structured expert review. PubMed and Embase were searched for research studies, including clinical trials, retrospective analyses, and mechanistic studies covering epidemiology, risk factors, prevention, and therapeutic strategies. Through iterative discussion and consensus building, the panel developed a pragmatic, algorithmic framework for management. Risk factors include preoperative renin-angiotensin-aldosterone inhibition, prior cardiac surgery, longer bypass duration, and higher transfusion burden. Preventive strategies include adjusting preoperative medications, managing intraoperative anesthetics and perfusion, and judicious transfusion thresholds. First-line therapy remains norepinephrine, with early addition of vasopressin, followed by angiotensin II for escalating support. Adjuncts such as methylene blue, hydroxocobalamin, and corticosteroids are complementary and considered in refractory cases, guided by mechanism and adverse effect profile. Vasoplegic shock is a common, high-mortality complication after cardiac surgery. We present an expert-derived treatment pathway intended as practical guidance for escalation, and we identify future research priorities.