Management of post-resuscitation vasoplegic shock: targets, strategies and outcomes

Despite advancements in management of cardiac arrest, mortality remains high due to extended brain injury, severe myocardial dysfunction and systemic inflammatory response leading to refractory shock. Accordingly, in addition to fluid therapy, vasopressors are often required after return of spontaneous circulation (ROSC) to counteract vasoplegia and to preserve end-organ perfusion. In this narrative review, we discuss the current evidence on the use of adrenergic and non-adrenergic vasopressors after cardiac arrest. Currently, the recommended target is a mean arterial pressure (MAP) of at least 60-65 mmHg and there is little evidence to support aiming for a MAP above 70 mmHg. Norepinephrine remains the most commonly used vasopressor to manage arterial hypotension after ROSC. Outside of clinical research, there is insufficient data to support the routine use of vasopressin, angiotensin II or non-selective nitric oxide inhibitors. Multimodal, real-time hemodynamic monitoring may help clinicians identify the predominant circulatory phenotype and guide vasopressor choice, dosing and timing to reduce the risk of adverse events. More research is needed to establish the role of a balanced vasopressor approach in the management of post-resuscitation vasoplegic shock.