(1667) Optimization of Angiotensin II Utilization in the Intensive Care Unit

Introduction: Current published literature indicates that angiotensin II achieves a greater hemodynamic response and has a mortality benefit when initiated at norepinephrine-equivalent (NEE) doses below 0.5 mcg/kg/min. However, its place in therapy as an adjunctive vasopressor remains unclear and varies in practice. The purpose of this quality improvement (QI) study is to assess the current usage of angiotensin II and identify areas of optimization.

Methods: Plan-Do-Study-Act (PDSA) methodology was utilized by a multidisciplinary QI team at a large academic medical center. Baseline data was collected via retrospective chart review of patients who received angiotensin II between 2/1/23 and 9/30/23. QI tools used included a process map, cause-and-effect diagram, and priority matrix. Interventions implemented in PDSA cycle 1 include modification of angiotensin II dispensing logic and revision of institutional restriction criteria. The primary outcome measure was NEE at time of angiotensin II initiation and the process measure was preparation time, defined as time from medication dispense to product verification by pharmacist. Post-intervention data was collected and compared to baseline using statistical process control (SPC) charts.

Results: A total of 36 patients received angiotensin II and were included in the baseline assessment. The average NEE at time of initiation was 1.02 mcg/kg/min and average preparation time was 12.8 minutes. Fifteen patients received angiotensin II during PDSA cycle 1 and had an average NEE of 1.17 mcg/kg/min and preparation time of 5.9 minutes. The upper control limit (UCL) of the SPC chart decreased from 3.02 to 2.63 for the primary outcome measure and from 34.7 to 14.2 for the process measure. There was no significant difference in NEE at baseline compared to the PDSA cycle (U=190, p=0.1003), however preparation time was significantly lower in the PDSA cycle compared to baseline (U=439, p=0.0005).

Conclusions: The PDSA methodology was helpful in optimizing the dispensing process of angiotensin II in reducing the length of time for medication preparation. Post-intervention SPC charts show less variability and a more stable process in angiotensin II utilization, however the average NEE remains higher than current literature recommends.