Phenotype-driven use of vasopressin in distributive shock: results of a national consensus
Year: 2026
Type: article
Abstract: Distributive shock is a major cause of haemodynamic instability in critically ill and perioperative patients. Despite norepinephrine being the recommended primary treatment, its adverse effects, which are dose-dependent and include arrhythmias and myocardial ischaemia, along with catecholamine resistance, support the consideration of additional non-adrenergic approaches. Growing evidence suggests that vasopressin can restore vascular tone through non-adrenergic pathways, reduce catecholamine exposure, and potentially enhance organ function, although uncertainties remain regarding optimal timing, patient selection, and practical implementation. This Italian national consensus aimed to provide phenotype-driven, bedside-applicable guidance on the practical use of vasopressin in vasodilatory shock, with an emphasis on haemodynamic stabilisation, catecholamine sparing, and organ protection. Using a modified RAND/UCLA appropriateness method, a multidisciplinary panel of intensivists and anaesthesiologists evaluated six clinical phenotypes: overwhelming septic shock, septic shock with tachycardia/tachyarrhythmia, septic shock with acute kidney injury, post-cardiac surgery refractory vasoplegia, persistent post-reperfusion shock during liver transplantation, and shock in severe ARDS with right ventricular dysfunction. Each scenario was explored using real-world composite vignettes to enhance bedside applicability. Across phenotypes, early adjunctive low-dose vasopressin was rated as appropriate, often at norepinephrine base doses of approximately 0.2 μg/kg/min, and as early as 0.1–0.2 μg/kg/min when tachyarrhythmia risk is prominent. In post-cardiac surgery refractory vasoplegia, vasopressin was rated as appropriate to restore vascular tone and reduce catecholamine toxicity, whereas the strategy of tapering vasopressin before norepinephrine was uncertain due to disagreement. Vasopressin was also rated as first-line support in severe ARDS to maintain vascular tone without increasing pulmonary vascular resistance. The consensus integrates evidence suggesting catecholamine-sparing effects, lower atrial fibrillation risk, and possible reductions in renal replacement therapy, while highlighting safety considerations and key evidence gaps regarding the optimal triggers, phenotype-specific effects, and long-term outcomes. This study offers practical guidance for integrating vasopressin into a customised vasopressor strategy and outlines the priorities for future research in precision haemodynamic management.
Authors: Federica Morselli, Irene Coloretti, Giacomo Monti, Ettore Panascia, Gianluca Paternoster, Luigi Tritapepe, Valentina Ajello, Elena Bignami, Sergio Cattaneo, Maurizio Cecconi, Alberto Corona, Gennaro De Pascale, Katia Donadello, Abele Donati, Francesco Forfori, Giacomo Grasselli, Salvatore Grasso, Fabio Guarracino, Giovanna Panarello, Daniela Pasero, Sabino Scolletta, Massimo Girardis
Institutions: Azienda Ospedaliero-Universitaria di Modena, IRCCS Ospedale San Raffaele, IRCCS San Raffaele Roma, Policlinico Universitario di Catania, Azienda Ospedaliero Universitaria Policlinico "G.Rodolico - San Marco", University of Basilicata, Ospedale San Carlo, Azienda Ospedaliera San Camillo-Forlanini, Policlinico Tor Vergata, University of Parma, Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia, IRCCS Humanitas Research Hospital, Aziende Socio Sanitarie Territoriale della Valcamonica, Agostino Gemelli University Polyclinic, Istituti di Ricovero e Cura a Carattere Scientifico, University of Verona, University of Pisa, Azienda Ospedaliera Universitaria Pisana, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Bari Aldo Moro, University of Chieti-Pescara, University of Pittsburgh Medical Center, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Sassari, Azienda Ospedaliera Universitaria Senese
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,079
OpenAlex ID: W7225796400
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