Reversal of Vasodilatory Shock: Current Perspectives on Conventional, Rescue, and Emerging Vasoactive Agents for the Treatment of Shock

Jonathan H. Chow, MD; Ezeldeen Abuelkasem, MBBCh, MSc; Susan Sankova, MD; Reney A. Henderson, MD; Michael A. Mazzeffi, MD, MPH; Kenichi A. Tanaka, MD, MSc


Anesth Analg. 2019;130(1):15-30. 

In This Article


Anesthesiologists and intensivists have a broad array of vasoconstrictors to utilize when treating patients in vasodilatory shock. These medications target distinct receptors in the RAA system (Ang-2), sympathetic nervous system (NE, Epi, dopamine, dobutamine, and phenylephrine), and vasopressin system (vasopressin, terlipressin, and selepressin). MB targets the NOS and guanylate cyclase pathway, while thiamine and ascorbic acid target potential deficiencies in critically important biochemical pathways.

The vasoconstrictive response can be affected by the underlying vasodilatory stimuli, and combination therapy can be important. Currently, we do not have overwhelming clinical data on either the optimal combination of drugs for vasodilatory shock or the optimal timing for initiation of secondary agents. Ang-2 and ascorbic acid represent the newest additions to our armamentarium for treating vasodilatory shock. They are promising new additions to the lineup of therapies that we have in our toolkit, and more studies are necessary to elucidate exactly which populations may benefit the most from these drugs. While promising, additional high-quality studies are needed to properly evaluate their role in the treatment algorithm for vasodilatory shock.