Inotropes and Vasopressors in Special Populations with Septic Shock: A Narrative Review

Septic shock is a major cause of morbidity and mortality in critically ill patients. It requires the rapid initiation of vasopressors, combined with inotropes in some cases, to restore hemodynamic stability. The Surviving Sepsis Campaign provides general recommendations for vasoactive therapy. However, the pharmacokinetic (PK) and pharmacodynamic (PD) behavior of vasopressors can vary significantly in certain patient populations. Older adults, pediatric, obese, underweight and pregnant patients, those with pulmonary hypertension or right ventricular failure, chronic beta-blocker users, those receiving extracorporeal membrane oxygenation support, and renally impaired and hepatically compromised patients are all subject to unique physiological and pathophysiological changes. These affect the PK properties of certain drugs, including their absorption, distribution, metabolism and elimination. PD properties are also affected, influencing receptor responsiveness to the drug. Such variations alter drug efficacy and patient responses. They can also increase the patient’s vulnerability to a drug’s adverse effects. In this narrative review, we comprehensively evaluate the effects of vasoactive agents for septic shock on the hemodynamics of these special populations. We aim to bridge the gaps in existing data to optimize patient care. Our findings emphasize the importance of individualized therapy and offer guidance on the selection and dosing of vasoactive agents to enhance clinical outcomes in special populations with septic shock.