Highlight
- This large international cohort study identified that 3.9% of patients undergoing major noncardiac surgery received postoperative vasopressor infusions.
- There was substantial inter-hospital variability in vasopressor use (0% to 18%), unexplained by patient or procedural factors.
- Postoperative vasopressor administration was consistently associated with increased in-hospital mortality, organ dysfunction, and prolonged hospital stays.
- The findings underscore clinical uncertainty around postoperative hypotension management and the need for standardized evidence-based protocols.
Study Background
Hypotension following major noncardiac surgery is a common clinical challenge, contributing to increased morbidity, mortality, and healthcare costs. Maintaining adequate blood pressure in the postoperative period is critical to ensure sufficient organ perfusion and prevent complications such as acute kidney injury, myocardial injury, and stroke. Vasopressors, pharmacological agents that constrict blood vessels to elevate blood pressure, are often employed postoperatively when fluid resuscitation alone is insufficient. Despite their widespread use, the frequency, patterns of administration, and association with clinical outcomes remain poorly characterized on a global scale. This knowledge gap hinders development of optimal management strategies and guidelines for managing postoperative hypotension in noncardiac surgery patients.
Study Design
This prospective international observational study was conducted from October 2020 to October 2023 across 228 hospitals in 42 countries, enrolling a total of 25,675 adult patients undergoing noncardiac surgery. Two cohorts were defined: Cohort A included all consecutive patients undergoing surgery within a single 1-week period at each site, representing an unselected surgical population. Cohort B consisted of an additional sampled cohort of up to 30 consecutive patients per site who received postoperative vasopressor infusions within one year after surgery.
The primary outcome of interest in Cohort A was the incidence of postoperative vasopressor infusions, defined as any continuous vasopressor administration postoperatively. Secondary outcomes assessed in both cohorts included in-hospital mortality, incidence of organ dysfunction, length of hospital stay, and complications potentially related to vasopressor use. Data analysis adjusted for case-mix and procedural variables to identify patterns and associations.
Key Findings
Among the 19,768 patients in Cohort A, postoperative vasopressor infusions were administered in 770 cases, representing 3.9% of the population. The use of vasopressors varied markedly between hospitals, ranging from 0% to 18%. This inter-hospital variability persisted even after statistical adjustment for patient demographics, surgical complexity, and baseline risk, with a median odds ratio of 2.30 indicating significant institutional practice differences.
Importantly, patients who received postoperative vasopressor infusions exhibited markedly worse outcomes. The in-hospital mortality rate among these patients was 15.5%, substantially higher than those not receiving vasopressors. Additionally, these patients demonstrated increased rates of organ failure—such as acute kidney injury and respiratory failure—and experienced prolonged hospital stays, signaling a more complicated postoperative course.
The findings were consistent across both cohorts, reinforcing the association between postoperative vasopressor use and adverse clinical outcomes. While causality cannot be definitively established in this observational study, the data highlight that postoperative vasopressor administration may serve as a marker of hemodynamic instability and severe illness in the perioperative period.
Expert Commentary
This comprehensive international study elucidates critical aspects of postoperative vasopressor use that have previously been underappreciated. The substantial variability in vasopressor administration between hospitals—unrelated to patient or procedural factors—suggests a lack of consensus or standardized protocols guiding postoperative blood pressure management. These discrepancies may reflect differences in local clinical culture, resource availability, or guidelines adherence.
The association of vasopressor use with increased mortality and organ dysfunction underscores the importance of careful hemodynamic management. However, vasopressors themselves may have deleterious effects, including reduced tissue perfusion in some vascular beds and arrhythmogenic potential. Thus, their use must balance benefits in restoring perfusion pressure against potential harms.
Limitations include the observational design, which precludes causal inference, and potential unmeasured confounding such as differences in vasopressor dosing, timing, and underlying hemodynamic trajectories. Nevertheless, the large, international scope and robust risk adjustment enhance the generalizability of the findings.
Going forward, randomized controlled trials are warranted to delineate which subsets of patients benefit from vasopressors postoperatively and to define optimal initiation thresholds and targets. Additionally, enhancing perioperative monitoring may identify hypotension earlier and guide individualized treatment to improve outcomes.
Conclusion
This landmark study provides the first large-scale international perspective on postoperative vasopressor use following noncardiac surgery. Although vasopressor infusions are relatively infrequent, their use varies widely across hospitals and correlates with significantly worse clinical outcomes, including mortality and organ dysfunction. These findings emphasize the urgent need for standardized clinical guidelines and prospective trials to optimize hemodynamic management in the postoperative setting to improve patient safety and outcomes.
Funding and Clinical Trials Registration
The study was conducted under the auspices of the European Society of Anaesthesiology and Intensive Care (ESAIC) with tracking ID ESAIC_CTN_SQUEEZE and registered at ClinicalTrials.gov (NCT03805230).
References
Jammer I, Martin P, Wunsch H, Debouche S, Harlet P, Moonesinghe R, Forni L, Creagh-Brown B; Writing committee for the Squeeze investigators. Vasopressor use after noncardiac surgery: an international observational study. Br J Anaesth. 2025 Aug 11:S0007-0912(25)00450-7. doi: 10.1016/j.bja.2025.07.034. Epub ahead of print. PMID: 40796492.
