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Current use of inotropes in circulatory shock



Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock.


From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions.


A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81–90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement).


Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.


Circulatory shock affects about one-third of patients admitted to the intensive care unit (ICU) [1]. Shock is defined as insufficient oxygen and energy supply to organs and is associated with increased mortality [1, 2]. Traditionally, four types of circulatory shock have been distinguished by pathophysiological mechanisms, namely hypovolemic, cardiogenic, distributive and obstructive shock [3]. Critically ill patients present with one or a combination of these four types of circulatory failure [4].

Treatment of circulatory shock relies on timely initiation of adequate fluid resuscitation combined with the use of vasoactive medication to restore tissue perfusion [5, 6]. Despite these therapeutic measures, cardiac output (CO) is often inadequate to deliver enough oxygen to tissues in patients with circulatory shock [7]. Inotropes might improve CO and organ perfusion in patients with circulatory shock [8, 9]. Several guidelines for different types of circulatory shock give different recommendations for the use of inotropes [10,11,12,13]. Despite these different recommendations and the apparent lack of evidence, inotropes are used in daily practice [13, 14]. Data on how inotropes are used in clinical practice are sparse [15]. Individual registries, observational studies, and trials with patients in shock provide insight into the current standard of care. For example, in patients with cardiogenic shock, vasopressors and inotropes were administered in 94%, where dobutamine (49%) and levosimendan (24%) were the most commonly used inotropes [16]. For levosimendan, two systematic reviews with meta-analyses and three large randomized trials have shown neutral effects on various outcomes [17,18,19,20,21], while one trial reported a possibility of harm (lower likelihood of successful weaning from mechanical ventilation and a higher risk of supraventricular tachyarrhythmia)[22]. A recent Cochrane review underlines the low quality of evidence on the use of inotropes in cardiogenic shock with levosimendan showing a short-term survival benefit over dobutamine, while this benefit vanished on long-term follow-up [23]. In other types of shock, use of inotropes is less common. Some patients with septic shock may have improved tissue perfusion with inotropic therapy aimed at increasing oxygen delivery and in this situation, dobutamine is the first-line inotrope [8, 24]. However, a recent network meta-analysis suggests that levosimendan has the highest probability of being the best treatment in septic shock [25]. Yet, no large randomized trials have provided evidence for a mortality benefit of levosimendan over dobutamine in septic shock [26].

Hence, further studies are needed on optimal treatment with inotropes in circulatory shock states. To aid the design and interpretation of future studies on inotropes, it is imperative to evaluate current practice and therapeutic goals of inotropic treatment of shock states to establish what is considered standard of care. The aim of the present study was to establish an overall picture of the standard of care, which was identified from a survey among members of the European Society of Intensive Care Medicine (ESICM). Furthermore, we developed recommendations on the use of inotropes based on a subsequent questionnaire and consensus finding by international experts in the field.


Survey development

Survey questions and response options were developed by the leadership of the Cardiovascular Dynamics Section of ESICM. The survey consisted of 27 questions on the use of vasoactive drugs. The first results on the current use of vasopressors in septic shock were recently published [6]. The present study focused on 14 survey questions related to the use of inotropes in circulatory shock. These questions concerned triggering factors, first-line drug choice, dosing, timing, targets, additional treatment strategies, and effects of inotropes.

The Research Committee of the ESICM endorsed the survey. Data were collected automatically using SurveyMonkey Inc. (

The survey was announced on the ESICM website and was open for participation between November 2016 and April 2017. Members of the Cardiovascular Dynamics section of the ESICM were additionally encouraged to participate via an email linking to the survey sent to email addresses in ESICM’s membership database in November 2016 with two subsequent e-mail reminders in February 2017 and March 2017. No incentives were offered for participation. No personal information was collected, and no log-in was required to participate. Completing the internal consistency of items was enforced by displaying an alert before the questionnaire could be submitted and highlighting mandatory but unanswered questions. It was not possible to review and change the given answers after submission.

Survey reporting

The questionnaire's methodology and results are reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) statement [27]. Ethical approval for this study was not requested, as no identifying data were collected and consent was assumed by participating in the survey.

Experts’ recommendations

Based on the results of the ESICM members’ survey, three authors (TWLS, IVDH and JLT) identified areas of interest and developed 11 questions, including sub-questions and approached a group of 42 experts, who are active members of the Cardiovascular Dynamics (CD) section of the ESICM. These experts have all published research as first or last author in an international peer-reviewed journal in articles identified by the PubMed subject headings “inotrope”, and they were asked to answer the developed experts’ questionnaire in order to summarize overall recommendations for the use of inotropes in circulatory shock based on the ESICM members’ survey and the experts’ questionnaire.

Definitions of the degree of consensus and grades of recommendations were based on the RAND algorithm [28]. Excellent agreement (> 90% agreement) and good agreement (81–90% agreement) were considered as strong grades of recommendation. A weak agreement was defined when 70–80% of the experts agreed. A Delphi-like process was used to achieve these consensus grades.


Data were evaluated as the total distribution of single answers. Answers to the questionnaire items are reported as numbers (percentage). Contingency tables and corresponding Chi-square statistics were reported to describe the pairwise associations between selected demographic variables (European vs. non-European ESICM member, high-income vs. lower-income countries, ICU experience more vs. less than 5 years full time, intensive care as primary specialty vs. other specialties, and university hospital vs. non-university hospital) and the responses regarding inotrope use. The nature of each question’s five answer options and their distribution prospectively defined the answer categories for the subsequent contingency tables analyses (2 × 2). In two cases, only three (question 3) and two (question 7) answer options were used two define the two answer categories for contingency tables. We used the World Bank definition of a “high-income country,” i.e., a per capita gross national income of $12,056 or more [29]. P < 0.05 was considered statistically significant. P-values are reported with their exact value for interpretation and not corrected for multiple testing in this descriptive reporting.


Survey respondents’ characteristics

A total of 839 physicians from 82 countries participated in the survey. A firm estimate of response rate could not be calculated as the invitation to the survey was posted as an open link on the ESICM website. In addition, members of the CD section of the ESICM (n = 10,780 at the time of the survey) received an email invitation to participate. From these addressees, 3111 (29%) opened this e-mail (according to Mail Chimp). This corresponds to a response rate of 27% (839/3111) of those who opened the e-mail. Baseline demographic data of respondents and their ICU and hospitals are presented in Additional file 1: Table S1 [6].

Survey results

All seven questions and answers of the respondents on inotrope use in circulatory shock are summarized in Table 1. Dobutamine was reported to be used as the first-line inotrope in 704 (84%) of questionnaire respondents, followed by PDE-inhibitors (7%), levosimendan (5%), dopamine (4%), and dopexamine (0.1%), while epinephrine was not among the first 5 most used agents. First-line use of dobutamine was more common among non-Europeans than Europeans (88% vs. 82%, p = 0.049).

Table 1 Survey questions on inotropic use

According to respondents, most inotropes are used when there are persistent clinical signs of hypoperfusion (e.g., skin mottling, low urine output) or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors (65%) (Table 1).

Mostly, an adequate CO was the preferred target for inotropic treatment (44%) (Table 1).

The reasons for adding another inotrope when the patient did not respond to the first-line inotropic therapy varied among respondents (Table 1).

Most respondents preferred the combination of norepinephrine plus dobutamine over epinephrine as preferred catecholamine in the treatment of circulatory shock (Table 1).

Concerning the use of phosphodiesterase (PDE)-inhibitors, respondents employed by a university hospital and more experienced respondents were more likely to support PDE-inhibitors in right heart failure than non-university or less experienced respondents (52% vs. 37%, p < 0.001 and 48% vs. 39%, p = 0.01, respectively) (Table 1).

Responses to the use of levosimendan varied among respondents, with experienced clinicians more likely selecting levosimendan than less experienced clinicians (61% vs. 52%, p = 0.01) (Table 1).

Experts’ questionnaire results

Forty-two selected experts gave their recommendations for clinical use of inotropes by responding to the expert-opinion questionnaire (Fig. 1), and 40 of them replied to a follow-up questionnaire (Table 2).

Fig. 1
figure 1

Expert answers to the first questionnaire and level of agreement. Answers are visualized as percentages. Positive answers are presented in green, conditional answers are presented in yellow, negative answers are presented in red. PDE phosphodiesterase, v-a PCO2 veno-arterial PCO2 difference, GoR grade of recommendation

Table 2 Second round questionnaire to 40 experts on inotrope use

Experts achieved excellent agreement (95%) on the statements that inotropes may be indicated in cardiogenic shock, that inotropes are not indicated in hypovolemic shock, that dobutamine but not dopamine can be used for treating circulatory shock in clinical practice, that a low CO can be used as a trigger for starting inotropic treatment, that clinical signs of hypoperfusion can be used as a target for inotropic treatment, and to lower or stop inotropic dosing, if patients experience unacceptable side effects. Other recommendations did not reach excellent agreement and for some the level of agreement was weak.

In general, experts individually stated that a recommended trigger for inotropic treatment should also be a target for the treatment (see Table 3). An exception was LVEF, where 14 of the 24 experts, who did use low LVEF as a trigger for inotropic treatment, did not consider LVEF as a target for the treatment, and three of the 18 experts, who did not choose low LVEF as a trigger did recommend using LVEF as a target for the treatment (Table 4).

Table 3 Summary of consensus among experts and the degree of recommendations
Table 4 Answers from 42 experts on questions Q5 and Q6 from Fig. 1, where the view on triggers and targets for inotropic use are combined. Conditional answers for Q5 in triggers (marked yellow in Fig. 1) are not represented in this table. There was one conditional Q5 answer for MAP, Bradycardia, and ScvO2, and two for v-a CO2


According to the results of this international survey, preferences around the use of inotropes differ among physicians. Most physicians (84%) chose dobutamine as their first-line inotrope, and dopamine, levosimendan, and milrinone (or another PDE-inhibitor) were considered first-line in up to 5% of respondents for patients with circulatory shock. Furthermore, the reasons for using an inotropic agent were diverse. Also, the variation in the primary therapeutic target was diverse, where CO, ScvO2, lactate level and urine output were all well-represented answers among the respondents. Furthermore, the reasons for adding a vasopressor/inotrope if the patient did not respond to the inotropic agent administered to the patient were virtually uniformly distributed among the respondents, underscoring that balancing maximal doses, side effects, possible synergistic drug effects, etc., is challenging for clinicians in late/critical stages of circulatory shock.

The heterogeneous choices of physicians when it comes to inotropes may have various reasons. First, no solid evidence is available to support choosing one agent over another [12]. Recently, meta-analyses showed that for many inotropes evidence to support benefit is absent or weak [17, 18, 30]. Moreover, even a statistically significant effect should still be interpreted with caution since the effects might be small and the clinical relevance uncertain. Second, the evidence is sparse and not robust, not only because of between-trial heterogeneity, but also because of high within-trial patient heterogeneity, combined with little or no individualization in the treatment protocols. In turn, an effect of an inotrope might be present for certain (groups of) patients equalized by harm of the same inotrope in other (groups of) patients in the same trial [31]. As part of patient heterogeneity, the underlying pathophysiology and its impact on hemodynamics may be incompletely understood and therefore, choosing the right agent might be difficult. Third, the optimal therapeutic targets for individual patients or groups of patients are unknown. More data have recently become available supporting different targets in different patients, an example being blood pressure [32]. Furthermore, specific targets for a variable such as CO or cardiac index might be suboptimal. For one patient, a CO of 3.0 L min−1 might be sufficient to maintain organ perfusion, for another patient, this level of CO might be associated with organ hypoperfusion and organ dysfunction. Clearly, bedside titration of inotropes, based on individual patient responses, seems the most rational approach, but defining what those resuscitation targets should be, remains difficult. Finally, despite being available for many years (except for levosimendan in some countries), the optimal use of inotropes is incompletely understood, particularly beyond the choice of the first-line agent. Optimal treatment concepts for timing, dosing, interaction, and preferred combination of agents remain ill-defined.

Standard of care or daily practice is obviously not uniform among the respondents. Solid meta-analyses of all inotropes, performed according to contemporary standards and taking into account bias from funding sources, should become available and updated if new evidence arises [17, 30]. Outcome measures should be uniformly defined and incorporate patient-centred outcomes and not limited to surrogate outcomes such as CO. Therefore, triggers and goals/targets for treatment should be optimized by interpreting evidence of studies on hemodynamic monitoring.

Although primarily being a vasopressor, norepinephrine (in combination with dobutamine) was considered a preferred catecholamine for the treatment of circulatory shock. Even among experts there was disagreement on whether norepinephrine should be considered a pure vasoconstrictor or an agent with combined vasopressor and inotropic effects. Actually, through beta-1 adrenergic receptor stimulation, norepinephrine has been shown to increase systemic and microcirculatory blood flow along with blood pressure and preload in patients with septic shock [33,34,35,36]. Some clinicians might think of norepinephrine and also epinephrine as pure vasopressors because of their most dominant physiological effect, whereas others see it as a vasopressor with clinically relevant inotropic effects that may be enough to support contractility as a single agent. The difficult to target inotropic effect (these agents are titrated primarily based on their vasopressor effect) and their potential arrhythmogenic effects at high doses should be taken into account when these agents are used in this context. Epinephrine was hardly cited, possibly due to studies indicating safety concerns [37, 38].

Another interesting result is that most experts recommended using more than one inotropic agent in the same patient. Reasons for this might be synergistic effects by adding an independent mechanism of action, e.g., in case of adrenoceptor downregulation, or the wish to limit the dose and side effects of each agent [6].

The majority of the respondents of the survey as well as the experts chose dobutamine as preferred inotrope in patients with hypoperfusion to increase CO, which is in accordance with current guidelines [8, 9, 24]. More evidence might come from the ongoing ADAPT multicenter trial ( ID: NCT04166331), which tests the hypothesis that dobutamine will reduce tissue hypoperfusion and associated organ dysfunctions in patients with septic shock and associated septic cardiomyopathy.

Since clinicians prefer having recommendations accompanying evidence summaries in the context of low certainty of evidence [39], we asked international experts in the field to draft and agree on recommendations regarding inotropic treatment. In general, experts agreed that a recommended trigger for starting inotropic treatment should also be a therapeutic target, except for LVEF. Less than half of the experts using LVEF as a trigger for the use of an inotrope, also considered LVEF as the target for this use. This might be due to LVEF not being a continuously available variable, and its value is considered less reliable since it is mostly based on rough estimation of echocardiographic images (eyeballing) rather than exact measurements in clinical practice.

In view of the lack of evidence on the use of inotropes in circulatory shock, we suggest the following research agenda for the coming years:

  1. 1.

    Determine univocal and personalized triggers and targets to start inotrope therapy in circulatory shock states.

    Current evidence and expert opinion differ on the initial triggers to start and then guide inotrope therapy as targets in patients with circulatory shock. Consensus needs to be established on which triggers and target endpoints to use, ideally based on data rather than on expert opinion alone. These could be macro-hemodynamic values (e.g., cardiac output), surrogates of regional (organ) blood flow, or microcirculatory values (tissue perfusion, peripheral circulation) [40].

    As an example, interventional trials have used various triggers to initiate inotropic therapy such as “shock”, “low ejection fraction”, “low cardiac index” or “low SvO2 not responding to fluids”. Also, some trials use a fixed dose while others attempt to reach a given value of cardiac index or SvO2 or an improvement in a given variable (lactate, capillary refill time, microcirculation variables, etc.). It should be determined whether these triggers and targets should be identical for all patients or individualized based on cardiac function, organ perfusion, and underlying patient condition establishing an individualized benefit/risk profile.

  2. 2.

    Determine pharmacokinetics and pharmacodynamics of inotropes in shock.

    Little is known about the pharmacokinetics and pharmacodynamics (e.g., clearance) of available inotropes in the presence of shock. Information on clearance and uptake of inotropes in shock may have implications for specific aspects related to the timing of interventions, the weaning of these drugs, limiting the risk of delayed hemodynamic failure or rebound effects. This might also include research on the concomitant use of other medication (e.g., beta-blockers) and the effects of the various inotropes on the host (inflammatory or immune) response [41]. Finally, the individual variation in responses to inotropic drugs related to genetic related alterations in receptors and/or signaling pathways should be evaluated.

  3. 3.

    Compare and combine available inotropic agents and identify new, safer inotropes.

    Further multicenter randomized controlled trials (with adaptive designs) are needed to compare different inotropic agents (a vs. b) and their combinations (a + b vs. a or b alone) on different outcomes such as organ function, adverse effects and survival. For instance, combining two inotropic agents acting through different mechanisms or receptors (e.g., dobutamine + levosimendan) could permit minimizing the doses of each drug, thus reducing the incidence of adverse effects and increasing safety. The choice of combination should be based on the pharmacologic properties of the different agents (see point 2). New, non-catecholamine inotropic agents that are not associated with side effects such as arrhythmia or hypotension should be identified and tested.

  4. 4.

    Combine inotrope therapy with personalized care bundle.

    While inotrope use needs to be personalized in future research, the other mainstays of circulatory shock treatment must be employed in a similar personalized manner to improve comparability. For instance, optimal MAP targets in circulatory shock and the role of fluid therapy should ideally be established as these will influence inotrope therapy. However, this in itself will be challenging as there is no current consensus on types of fluid, monitoring and other interventions being delivered, nor on how to adopt an optimal personalized approach. For example, a one-size-fits-all approach for MAP targets cannot be optimal.

  5. 5.

    Develop and implement core outcome sets for patients with circulatory shock.

    Core outcome sets (i.e., standardized collection of outcomes measured and reported in all trials for a specific clinical area) should be developed for circulatory shock research due to established inconsistencies in trial outcome selection. Any new trial assessing the benefit/risk of inotropes should include the selection of an adequately targeted study population to improve the “noise/signal ratio” inherent to heterogeneous cohorts (in terms of hemodynamic profile).

  6. 6.

    Evaluate the impact of prolonged (> 72 h) inotropic therapy on myocardial energetics.

    Experimental and clinical data on inotrope use demonstrate direct effects of inotropes on myocardial injury, energetics and modulation of the immune/inflammatory response. The relevance of this to further organ injury and patient outcomes needs to be established. Data from experimental and clinical studies in chronic heart failure suggest that long-term inotropic therapy leads to interstitial calcinosis, myocardial fibrosis and contraction band necrosis [42]. Does this also apply to the context of shock where the duration of inotropic stimulation is expected to be shorter (less than one month)? What is the maximal duration of intravenous inotropic therapy before receptor down regulation, diastolic dysfunction, myocardial injury, and persistent arrhythmias develop in this setting?

  7. 7.

    Establish specific use of inotropes in patients under mechanical circulatory support.

    The use of inotropic agents should be adapted in patients under mechanical circulatory support for cardiogenic shock secondary to acute myocardial infarction. When are these agents indicated in this specific setting, and which hemodynamic targets should be used? The purpose of inotropic stimulation and the choice and doses of the inotropic agent may not be identical at the initiation of mechanical circulatory support, during the maintenance phase, or during the weaning process.

  8. 8.

    Evaluate the best hemodynamic strategy in predominant right ventricular failure.

    In patients with circulatory shock, which is predominantly associated with right ventricular failure, the question should be answered by comparative effectiveness trials if inotropic agents or vasopressors (e.g., norepinephrine to increase coronary perfusion pressure) should be preferred.

  9. 9.

    Better define the interaction between IV fluids and vasoactive agents.

    The physiologic interplay between vasoactive agents and intravenous fluids is evident, but the scientific evidence in terms of comparative effectiveness trials (fluids vs. early vasopressor use, addition of inotropes, etc.) is scarce. For instance, inotropic agents can only increase myocardial contractility, lusitropy, and heart rate. They do not primarily increase cardiac output. For cardiac output to increase there also needs to be sufficient blood volume and vascular tone, as known from the poor impact of inotropic agents in hemorrhagic shock and profound vasoplegia. Therefore, the optimal vasopressor/fluid/inotrope ratio remains to be determined at the individual level.

Ongoing and upcoming studies such as ADAPT (NCT04166331: Effects of dobutamine on tissue hypoperfusion and associated organ dysfunctions in patients with septic shock and associated septic cardiomyopathy) and LevoHeartShock (NCT04020263: Early use of levosimendan versus placebo on top of conventional inotropes in patients with cardiogenic shock) will probably provide important answers to some of these questions.


The number of responses is considered high (corresponding to 27% of ESICM members who opened the e-mail invite), but the methods used to invite individuals to respond did not allow us to report a conclusive response rate. Therefore, response bias might be present, in which case, external validity could be somewhat hampered.

The results presented in this manuscript come from an online survey. Online surveys have limitations like potential multiple responses by a single person. We did not use cookies or log-file/IP address analyses to prevent multiple responses. On the other hand, individual persons are unlikely to spend time answering a survey more than once. Another limitation is the multiple-choice character of our survey, limiting answers to those offered. In addition, studies published after the survey was performed [38, 43,44,45,46] might have altered the answers of the respondents. Nevertheless, after careful analysis of the results of those studies we believe that the experts’ recommendation would not have changed significantly. Furthermore, the recommendations of experts can only reach excellent agreement if the available evidence is solid and clear. The evidence for inotropes in circulatory shock lack this evidence for many questions raised. Furthermore, both patients and studies show high heterogeneity. Therefore, recommendations should be interpreted with caution.


In conclusion, the use of inotropes in critically ill patients is quite heterogeneous as reported by individual caregivers. International experts recommend the use of inotropes in septic and cardiogenic shock (but not in hypovolemia), using an inadequate CO and signs of tissue hypoperfusion as triggers and targets for treatment, and adverse effects and clinical improvement as stopping/weaning criteria. While experts recommend using dobutamine as the first-line agent, they recommend against the use of dopamine. Future studies reporting patient-centred outcomes should focus on specific subpopulations based on prespecified and measurable triggers, targets, and with clear stopping criteria in order to ensure comparability across trials. This would allow a better summary of the evidence and its implementation in future guidelines.

Availability of data and materials

The data of the survey are available from the corresponding author upon reasonable request.



Arterial blood pressure


Checklist for Reporting Results of Internet E-Surveys


Cardiac output


Central venous pressure


European Society of Intensive Care Medicine


Intensive care unit


Intensive care


Left ventricular ejection fraction


Mean arterial pressure






Pulmonary artery occlusion pressure


Surviving Sepsis Campaign

ScvO2 :

Central venous oxygen saturation

v-a PCO2 :

Venous-to-arterial carbon dioxide pressure difference


  1. Sakr Y, Reinhart K, Vincent JL, Sprung CL, Moreno R, Ranieri VM, et al. Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med. 2006;34(3):589–97.

    Article  CAS  PubMed  Google Scholar 

  2. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40(12):1795–815.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Weil MH. Personal commentary on the diagnosis and treatment of circulatory shock states. Curr Opin Crit Care. 2004;10(4):246–9.

    Article  PubMed  Google Scholar 

  4. De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779–89.

    Article  PubMed  Google Scholar 

  5. Vincent JL, De Backer D. Circulatory shock. N Engl J Med. 2013;369(18):1726–34.

    Article  CAS  PubMed  Google Scholar 

  6. Scheeren TWL, Bakker J, De Backer D, Annane D, Asfar P, Boerma EC, et al. Current use of vasopressors in septic shock. Ann Intensive Care. 2019;9(1):20.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Vieillard-Baron A, Caille V, Charron C, Belliard G, Page B, Jardin F. Actual incidence of global left ventricular hypokinesia in adult septic shock. Crit Care Med. 2008;36(6):1701–6.

    Article  PubMed  Google Scholar 

  8. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304–77.

    Article  PubMed  Google Scholar 

  9. Mebazaa A, Tolppanen H, Mueller C, Lassus J, DiSomma S, Baksyte G, et al. Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance. Intensive Care Med. 2016;42(2):147–63.

    Article  CAS  PubMed  Google Scholar 

  10. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–200.

    Article  PubMed  Google Scholar 

  11. Elkayam U, Tasissa G, Binanay C, Stevenson LW, Gheorghiade M, Warnica JW, et al. Use and impact of inotropes and vasodilator therapy in hospitalized patients with severe heart failure. Am Heart J. 2007;153(1):98–104.

    Article  PubMed  Google Scholar 

  12. Belletti A, Castro ML, Silvetti S, Greco T, Biondi-Zoccai G, Pasin L, et al. The Effect of inotropes and vasopressors on mortality: a meta-analysis of randomized clinical trials. Br J Anaesth. 2015;115(5):656–75.

    Article  CAS  PubMed  Google Scholar 

  13. van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017;136(16):e232–68.

    PubMed  Google Scholar 

  14. Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019;40(32):2671–83.

    Article  CAS  PubMed  Google Scholar 

  15. Levy B, Buzon J, Kimmoun A. Inotropes and vasopressors use in cardiogenic shock: when, which and how much? Curr Opin Crit Care. 2019;25(4):384–90.

    Article  PubMed  Google Scholar 

  16. Tarvasmaki T, Lassus J, Varpula M, Sionis A, Sund R, Kober L, et al. Current real-life use of vasopressors and inotropes in cardiogenic shock - adrenaline use is associated with excess organ injury and mortality. Crit Care. 2016;20(1):208.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Koster G, Wetterslev J, Gluud C, Zijlstra JG, Scheeren TW, van der Horst IC, et al. Effects of levosimendan for low cardiac output syndrome in critically ill patients: systematic review with meta-analysis and trial sequential analysis. Intensive Care Med. 2015;41(2):203–21.

    Article  CAS  PubMed  Google Scholar 

  18. Putzu A, Clivio S, Belletti A, Cassina T. Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. Int J Cardiol. 2018;251:22–31.

    Article  PubMed  Google Scholar 

  19. Landoni G, Lomivorotov VV, Alvaro G, Lobreglio R, Pisano A, Guarracino F, et al. Levosimendan for Hemodynamic Support after Cardiac Surgery. N Engl J Med. 2017;376(21):2021–31.

    Article  CAS  PubMed  Google Scholar 

  20. Cholley B, Caruba T, Grosjean S, Amour J, Ouattara A, Villacorta J, et al. Effect of Levosimendan on Low Cardiac Output Syndrome in Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting With Cardiopulmonary Bypass: The LICORN Randomized Clinical Trial. JAMA. 2017;318(6):548–56.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Mehta RH, Leimberger JD, van Diepen S, Meza J, Wang A, Jankowich R, et al. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. N Engl J Med. 2017;376(21):2032–42.

    Article  CAS  PubMed  Google Scholar 

  22. Gordon AC, Perkins GD, Singer M, McAuley DF, Orme RM, Santhakumaran S, et al. Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis. N Engl J Med. 2016;375(17):1638–48.

    Article  CAS  PubMed  Google Scholar 

  23. Schumann J, Henrich EC, Strobl H, Prondzinsky R, Weiche S, Thiele H, et al. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev. 2018;1:CD009669.

    PubMed  Google Scholar 

  24. Djogovic D, MacDonald S, Wensel A, Green R, Loubani O, Archambault P, et al. Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines. CJEM. 2015;17(Suppl 1):1–16.

    Article  PubMed  Google Scholar 

  25. Belletti A, Benedetto U, BiondiZoccai G, Leggieri C, Silvani P, Angelini GD, et al. The effect of vasoactive drugs on mortality in patients with severe sepsis and septic shock. A network meta-analysis of randomized trials. J Crit Care. 2017;37:91–8.

    Article  CAS  PubMed  Google Scholar 

  26. Bhattacharjee S, Soni KD, Maitra S, Baidya DK. Levosimendan does not provide mortality benefit over dobutamine in adult patients with septic shock: A meta-analysis of randomized controlled trials. J Clin Anesth. 2017;39:67–72.

    Article  CAS  PubMed  Google Scholar 

  27. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, et al. The RAND/UCLA Appropriateness Method User's Manual. RAND Corporation. 2001.

  29. World Bank. World Bank country and lending groups. https://datahelpdeskworldbankorg/knowledgebase/articles/906519-world-bank-country-and-lending-groups.

  30. Koster G, Bekema HJ, Wetterslev J, Gluud C, Keus F, van der Horst IC. Milrinone for cardiac dysfunction in critically ill adult patients: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Intensive Care Med. 2016;42(9):1322–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Vincent JL. Improved survival in critically ill patients: are large RCTs more useful than personalized medicine? No Intensive Care Med. 2016;42(11):1778–80.

    Article  PubMed  Google Scholar 

  32. Lamontagne F, Meade MO, Hebert PC, Asfar P, Lauzier F, Seely AJE, et al. Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Med. 2016;42(4):542–50.

    Article  CAS  PubMed  Google Scholar 

  33. Hamzaoui O, Georger JF, Monnet X, Ksouri H, Maizel J, Richard C, et al. Early administration of norepinephrine increases cardiac preload and cardiac output in septic patients with life-threatening hypotension. Crit Care. 2010;14(4):R142.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Hamzaoui O, Jozwiak M, Geffriaud T, Sztrymf B, Prat D, Jacobs F, et al. Norepinephrine exerts an inotropic effect during the early phase of human septic shock. Br J Anaesth. 2018;120(3):517–24.

    Article  CAS  PubMed  Google Scholar 

  35. Hernandez G, Teboul JL, Bakker J. Norepinephrine in septic shock. Intensive Care Med. 2019;45(5):687–9.

    Article  PubMed  Google Scholar 

  36. Annane D, Ouanes-Besbes L, de Backer D, Du B, Gordon AC, Hernandez G, et al. A global perspective on vasoactive agents in shock. Intensive Care Med. 2018;44(6):833–46.

    Article  CAS  PubMed  Google Scholar 

  37. Leopold V, Gayat E, Pirracchio R, Spinar J, Parenica J, Tarvasmaki T, et al. Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients. Intensive Care Med. 2018;44(6):847–56.

    Article  CAS  PubMed  Google Scholar 

  38. Levy B, Clere-Jehl R, Legras A, Morichau-Beauchant T, Leone M, Frederique G, et al. Epinephrine Versus Norepinephrine for Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol. 2018;72(2):173–82.

    Article  CAS  PubMed  Google Scholar 

  39. Neumann I, Alonso-Coello P, Vandvik PO, Agoritsas T, Mas G, Akl EA, et al. Do clinicians want recommendations? A multicenter study comparing evidence summaries with and without GRADE recommendations. J Clin Epidemiol. 2018;99:33–40.

    Article  PubMed  Google Scholar 

  40. Boerma EC, Ince C. The role of vasoactive agents in the resuscitation of microvascular perfusion and tissue oxygenation in critically ill patients. Intensive Care Med. 2010;36(12):2004–18.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Stolk RF, Kox M, Pickkers P. Noradrenaline drives immunosuppression in sepsis: clinical consequences. Intensive Care Med. 2020;46(6):1246–8.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Schmittinger CA, Dünser MW, Torgersen C, Luckner G, Lorenz I, Schmid S, et al. Histologic pathologies of the myocardium in septic shock: a prospective observational study. Shock. 2013;39(4):329–35.

    Article  CAS  PubMed  Google Scholar 

  43. Antcliffe DB, Santhakumaran S, Orme RML, Ward JK, Al-Beidh F, O’Dea K, et al. Levosimendan in septic shock in patients with biochemical evidence of cardiac dysfunction: a subgroup analysis of the LeoPARDS randomised trial. Intensive Care Med. 2019;45(10):1392–400.

    Article  CAS  PubMed  Google Scholar 

  44. Lannemyr L, Ricksten SE, Rundqvist B, Andersson B, Bartfay SE, Ljungman C, et al. Differential Effects of Levosimendan and Dobutamine on Glomerular Filtration Rate in Patients With Heart Failure and Renal Impairment: A Randomized Double-Blind Controlled Trial. J American Heart Association. 2018;7(16):e008455.

    Article  Google Scholar 

  45. Morici N, Oliva F, Ajello S, Stucchi M, Sacco A, Cipriani MG, et al. Management of cardiogenic shock in acute decompensated chronic heart failure: The ALTSHOCK phase II clinical trial. Am Heart J. 2018;204:196–201.

    Article  CAS  PubMed  Google Scholar 

  46. Fredholm M, Jorgensen K, Houltz E, Ricksten SE. Inotropic and lusitropic effects of levosimendan and milrinone assessed by strain echocardiography—A randomised trial. Acta Anaesthesiol Scand. 2018;62(9):1246–54.

    Article  CAS  PubMed  Google Scholar 

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This work has received the endorsement of the European Society of Intensive Care Medicine. The authors would like to thank Hannah Wunsch and Anders Perner, who provided their expertise as experts but abstained from being listed as co-author of this paper.


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Author notes

  1. ^ Claude Martin participated as expert but deceased before final submission

    • Claude Martin


TWLS and JLT developed the survey. TWLS, IVDH and JLT developed the questions to experts. SVT analyzed the data. TWLS, IVDH, STV, MD, MS and JLT were major contributors in writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Thomas W. L. Scheeren.

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A.M. received speaker’s honoraria from Novartis, Orion, and Servier and fees as a member of the advisory board or steering committee from Adrenomed, Sanofi, Roche, Abbott, and 4TEEN4. The other authors have no competing interest to declare regarding this paper.

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Supplementary Information

Additional file 1: Table S1.

Baseline characteristics of survey respondents.

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Scheeren, T.W.L., Bakker, J., Kaufmann, T. et al. Current use of inotropes in circulatory shock. Ann. Intensive Care 11, 21 (2021).

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