Beyond hypotension management: clinical mechanisms, risks, and efficacy of vasopressors in noncardiac surgery patients

Q: Why is postoperative hypotension a major clinical concern in noncardiac surgery?

Postoperative hypotension is described as frequent and clinically significant, with strong associations to adverse outcomes such as acute renal disease, myocardial infarction, and stroke. Even brief episodes of mean arterial pressure below 65 mmHg are independently linked to poorer surgical outcomes.

Q: How can the need for vasopressors after noncardiac surgery be interpreted?

The letter states that vasopressor requirement may indicate a patient's susceptibility rather than only the intensity of intraoperative complications. It may reflect occult hypovolemia, elevated surgical stress, or higher baseline comorbidity.

Q: What are the key differences in the proposed effects of norepinephrine, phenylephrine, and ephedrine?

Norepinephrine is presented as balanced for α1-vasoconstriction with mild β1 inotropy, helping maintain cardiac output and vascular tone. Phenylephrine is described as a pure α1-agonist that may reduce organ perfusion and stroke volume while increasing afterload. Ephedrine is described as causing brief rises in heart rate and blood pressure with less consistency due to combined direct and indirect adrenergic stimulation.

Sep 29, 2026

Uploaded by dhado

Letter to the editor analyzing postoperative hypotension in noncardiac surgery and the clinical role of vasopressors. It links hypotension to adverse outcomes including acute renal disease, myocardial infarction, and stroke, and notes that brief mean arterial pressure episodes below 65 mmHg correlate with worse results. It contrasts norepinephrine, phenylephrine, and ephedrine mechanisms and tradeoffs, explaining how vasopressor need may reflect susceptibility, occult hypovolemia, surgical stress, and baseline comorbidity. It argues for proactive monitoring and evidence-based guidelines while addressing ethics, consent, funding, and conflicts of interest.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Letter to the Editor

Background and clinical significance of postoperative hypotension

Vasopressor mechanisms, risks, and efficacy

Clinical implications for monitoring and guidelines

Declarations and administrative sections

Letter to the Editor Beyond hypotension management: clinical mechanisms, risks, and efficacy of vasopressors in noncardiac surgery patients Qasim Abbas, MBBSa , Ahmad Mubashir, MBBSa , Maria Qadri, MBBSb , Hammad Javaid, MBBSc , Kritick Bhandari, MBBSd ,* Dear Editor, Postoperative hypotension remains a frequent and clinically significant challenge in the perioperative management of patients undergoing noncardiac surgery. Vasopressor administration has significant effects on patient outcomes, especially in terms of morbidity, mortality, and long-term consequences, while being frequently seen as a routine measure[1] . Acute renal disease, myocardial infarction, and stroke are among the adverse outcomes that are strongly linked to postoperative hypotension, but their prevalence varies greatly. Poorer outcomes in surgical patients have been independently associated with even brief bouts of mean arterial pressure < 65 mmHg[2,3] . This has caused a change in emphasis from reactive treatment to personalized hemodynamic support and proactive monitoring[1,4] . To maintain appropriate perfusion pressures, vasopressors like norepinephrine and phenylephrine are being mostly used more and more in perioperative bundles. Their application is not without controversy though, especially when it comes to finding a balance between restoring perfusion and possibly compromising local blood flow[1,4] According to a new study, the need for vasopressors following non-cardiac surgery may indicate a patient’s susceptibility rather than just the intensity of intraoperative complications. For instance, patients who need postoperative vasopressor support frequently have occult hypovolemia, elevated surgical stress, or higher baseline comorbidity[1,5] . Vasopressors are used for physiological reasons because of their capacity to modify adrenergic receptors and restore vascular tone. Systemic vascular resistance is raised, and cardiac output is supported by agents like aDepartment of Internal Medicine, Sharif Medical and Dental College, University of Health Sciences, Lahore, Pakistan, bDepartment of Internal Medicine, Jinnah Sindh Medical University, Karachi, Pakistan, cDepartment of Internal Medicine, King Edward Medical University, Lahore, Pakistan and dDepartment of Internal Medicine, KIST Medical College and Teaching Hospital, Lalitpur, Nepal Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. *Corresponding author. Address: Department of Internal Medicine, KIST Medical College and Teaching Hospital, Gwarko, Imadol, Lalitpur 44600, Nepal. Tel.: +[977 9818091534. E-mail: bhandarikritick@gmail.com](977 9818091534. E-mail: bhandarikritick@gmail.com) (K. Bhandari). Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Annals of Medicine & Surgery (2026) 88:1154–1155 Received 31 October 2025; Accepted 4 December 2025 Published online 15 December 2025 [http://dx.doi.org/10.1097/MS9.0000000000004595](http://dx.doi.org/10.1097/MS9.0000000000004595) norepinephrine that provide balanced α1-adrenergic vasoconstriction with mild β1-mediated inotropy[3] . In contrast, phenylephrine is a pure α1-agonist, which may result in decreased organ perfusion and stroke volume but also increased afterload. Combining direct and indirect adrenergic stimulation, ephedrine causes a brief rise in heart rate and blood pressure with less consistency[3]. Vasopressors may therefore be used as a stand-in for identifying high-risk groups that require more frequent monitoring, heightened surveillance, or customized perioperative optimization techniques[5] .

FAQs

Why is postoperative hypotension a major clinical concern in noncardiac surgery?

Postoperative hypotension is described as frequent and clinically significant, with strong associations to adverse outcomes such as acute renal disease, myocardial infarction, and stroke. Even brief episodes of mean arterial pressure below 65 mmHg are independently linked to poorer surgical outcomes.

How can the need for vasopressors after noncardiac surgery be interpreted?

The letter states that vasopressor requirement may indicate a patient's susceptibility rather than only the intensity of intraoperative complications. It may reflect occult hypovolemia, elevated surgical stress, or higher baseline comorbidity.

What are the key differences in the proposed effects of norepinephrine, phenylephrine, and ephedrine?

Norepinephrine is presented as balanced for α1-vasoconstriction with mild β1 inotropy, helping maintain cardiac output and vascular tone. Phenylephrine is described as a pure α1-agonist that may reduce organ perfusion and stroke volume while increasing afterload. Ephedrine is described as causing brief rises in heart rate and blood pressure with less consistency due to combined direct and indirect adrenergic stimulation.

Sep 29, 2026

Uploaded by dhado