Catecholamine-Sparing Effect of Angiotensin II in an Anephric Patient With Mixed Shock After Cardiac Revascularization Surgery: A Case Report

The Efficacy and Safety of Angiotensin II for Treatment of Vasoplegia in Critically Ill Patients: A Systematic Review

OBJECTIVES

To summarize evidence regarding intravenous angiotensin II administration in critical illness and provide an updated understanding of its effects on various organ dysfunction and renin-angiotensin system (RAS) biomarkers.

DESIGN

A systematic review.

SETTING

A search of PubMed, Embase, and the Cochrane Library from inception to May 3, 2024. Randomized controlled trials (RCTs), nonrandomized trials, quasi-randomized trials, observational studies, case reports, and case series were included. Comparative studies (RCTs and observational studies with comparator) were used for the main analysis.

PARTICIPANTS

Critically ill adults and children.

INTERVENTIONS

Intravenous angiotensin II administration.

MEASUREMENTS AND MAIN RESULTS

Fifty-nine studies with a total of 2,918 participants (5 RCTs, 15 observational studies, and 39 case reports or case series) were analyzed. Septic shock and cardiac surgery were the most common clinical conditions (14 studies for each). In 14 comparative studies (5 RCTs and 9 observational studies), mortality was not different from that in controls, except in 1 observational study. Several studies reported decreased renal replacement therapy use, improved oxygenation and blood pressure response, and decreased rate of myocardial injury with angiotensin II therapy. There was no increase in thrombotic events or adverse events. Angiotensin II therapy reduced renin and angiotensin I levels without affecting other RAS biomarkers.

CONCLUSIONS

Intravenous angiotensin II has been reported in almost 3000 critically ill patients with diverse types of shock. Despite unclear mortality impacts, angiotensin II seems to confer beneficial effects on several organ systems and RAS derangements, without increasing adverse events.

Angiotensin-II for vasoplegia following cardiac surgery

INTRODUCTION

The objective of this study was to describe the implementation and outcomes of a protocol outlining angiotensin-II utilization for vasoplegia following cardiac surgery.

METHODS

This was a retrospective chart review at a single-center university hospital. Included patients received angiotensin-II for vasoplegia refractory to standard interventions, including norepinephrine 20 mcg/min and vasopressin 0.04 units/min, following cardiac surgery between April 2021 and April 2022.

RESULTS

30 patients received angiotensin-II for refractory vasoplegia. Adjunctive agents at angiotensin-II initiation included corticosteroids (26 patients; 87%), epinephrine (26 patients; 87%), dobutamine (17 patients; 57%), dopamine (9 patients; 30%), milrinone (2 patients; 7%), and hydroxocobalamin (4 patients; 13%). At 3 hours, the median mean arterial pressure increased from baseline (70 vs 61.5 mmHg, p = .0006). Median norepinephrine doses at angiotensin-II initiation, 1 hour, 3 hours, and angiotensin-II discontinuation were 0.22, 0.16 (p = .0023), 0.10 (p < .0001), and 0.07 (p < .0001) mcg/kg/min. Median dobutamine doses decreased throughout angiotensin-II infusion from eight to six mcg/kg/min (p = .0313). Other vasoactive medication doses were unchanged. Three patients (10%) subsequently received hydroxocobalamin. Thirteen (43.3%) and five (16.7%) patients experienced mortality by day 28 and venous or arterial thrombosis events, respectively.

CONCLUSIONS

The administration of angiotensin-II to vasoplegic patients following cardiac surgery was associated with increased mean arterial pressure, reduced norepinephrine dosages, and reduced dobutamine dosages.

Angiotensin II: A Review of Current Literature

Up to one-third of all patients admitted to intensive care units carry a diagnosis of shock. The use of angiotensin II is becoming widespread in all forms of shock, including cardiogenic, after the U.S. Food and Drug Administration's (FDA's) initial approval for vasoplegic shock in 2017. Here, the authors review the literature on angiotensin II's mechanism of action, benefits, and future therapeutic opportunities.