(1639) A Retrospective Analysis of Angiotensin II Use at a Tertiary Care Academic Medical Center

Introduction: Distributive shock is a medical emergency with a high incidence of mortality. Recommended therapy includes the prompt administration of intravenous fluids and vasopressors and reversal of the underlying cause. Vasopressin and angiotensin II are non-catecholamine vasopressors that target the renin-angiotensin-aldosterone-system pathway. The 2021 Surviving Sepsis Campaign Guidelines provide a weak recommendation with moderate-quality evidence for vasopressin as a second line agent, but despite its approval in 2017, do not elaborate on the role of angiotensin II. Given the lack of consensus and variable practice, the aim of this study was to conduct a retrospective review of angiotensin II use at a tertiary care academic medical center.

Methods: This was a single center, retrospective chart review of critically ill adult patients who received angiotensin II for > 1 hour during April 1, 2022 - January 31, 2024. The primary outcome was the proportion of patients with achievement of their mean arterial pressure (MAP) goal after three consecutive hours of angiotensin II infusion. Secondary endpoints included change in median vasopressor dose at hour three of angiotensin II infusion and all-cause mortality.

Results: Of 27 patients, 21 received ≥ 3 consecutive hours of angiotensin II. Of these, 12 (57.1%) patients achieved their MAP goal at hour three. There was no change in median norepinephrine dose requirement and a median increase of 0.02 units/minute of vasopressin. There was a median decrease of 0.07 micrograms per kilogram per minute (mcg/kg/min) and 1 mcg/kg/min of epinephrine and phenylephrine dose requirements, respectively. All-cause mortality occurred in 24 (88.9%) patients.

Conclusions: The addition of angiotensin II led to a majority of patients achieving their MAP goal after three hours of administration with an overall decrease in background catecholamine use. Angiotensin II was added as a fourth and fifth vasopressor in 59.3% and 22.2% of patients, respectively, indicating its high use as salvage therapy in this population. Based on these findings, we hypothesize that angiotensin II may be more beneficial with earlier initiation. Future studies are needed to further characterize its place in therapy.