1. The administration of angiotensin II among patients with refractory shock was associated with improved hemodynamic stability and decreased total vasopressor requirement at three hours.
Evidence Level Rating: 2 (Good)
Vasodilatory shock that is refractory to catecholamine- and arginine-based vasopressors is common in critical illness and associated with significant mortality, often exceeding 90%. The U.S. Food and Drug Administration and the European Medicines Agency recently approved the use of angiotensin II, a synthetic analogue of the endogenous human peptide that results in potent vasoconstriction and increased blood pressure. Though promising, there is a scarcity of data to provide insight into the drug’s applicability. This multicenter, retrospective observational study included 270 patients (mean [SD] age = 60  years, 66% male) who received an angiotensin II infusion as part of their treatment. The primary outcome was hemodynamic responsiveness three hours following angiotensin II administration, defined by a mean arterial pressure (MAP) ≥ 65 mmHg with a stable or reduced total vasopressor dose. The study population was severely ill; mean APACHE II and SOFA scores among patients were 30±9 and 12±4, respectively, while baseline lactate concentration was 7.5±6.0 mmol/L. 67% of patients were classified as responders to angiotensin II, and exhibited a significantly greater increase in MAP (+10.3 vs. +1.6 mmHg, p < 0.001) and reduction in vasopressor requirement as measured in norepinephrine equivalents (-0.20 vs. +0.04 mcg/kg/min, p < 0.001) at three hours. Lower lactate concentration and active infusion of vasopressin at the time of angiotensin II administration were associated with significantly higher odds of responsiveness to angiotensin II. Furthermore, hemodynamic responsiveness was found to be associated with increased 30-day survival (41% vs. 25%, p = 0.001). The most common adverse effects noted among patients were transaminitis and thrombocytopenia. In all, this study showed that angiotensin II was associated with increased hemodynamic stability and decreased total vasopressor requirement among patients with refractory shock. More work is needed, however, to delineate optimal dosages and timing of administration in order to maximize patient outcomes.
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