Use of Angiotensin II for Post Cardiopulmonary Bypass Vasoplegic Syndrome

doi:10.1016/j.athoracsur.2018.11.047

The Annals of Thoracic Surgery

Volume 108, Issue 1, July 2019, Pages e5-e7

https://doi.org/10.1016/j.athoracsur.2018.11.047 Get rights and content

Angiotensin II is a novel vasopressor recently approved for the treatment of vasodilatory shock. We describe a case in which Angiotensin II was used to treat post–cardiopulmonary bypass vasoplegic syndrome in a patient who was refractory to standard vasopressors and other rescue therapies. Despite requiring high-dose vasopressors, the patient was extubated within 24 hours and has met key quality metrics defined by The Society of Thoracic Surgeons.

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Use of ANG-2 has been reinvigorated after significantly positive results emerged from the ATHOS-3 trial. The study found that patients treated with ANG-2 attained the MAP target more often than those treated with standard of care (SOC) vasopressors (69.9% ANG-2 vs 23.4% SOC; odds ratio, 7.95; p < 0.001) and benefited from a significant improvement in background NEpi dose (–0.03 ANG-2 vs +0.03 SOC; p < 0.001) [1]. Although ATHOS-3 was not powered to detect mortality, there was a trend toward

References (8)

A.D. Shapeton et al.
Hydroxocobalamin for the treatment of vasoplegia: a review of current literature and considerations for use
J Cardiothorac Vasc Anesth
(2019)
M. Egi et al.
Selecting a vasopressor drug for vasoplegic shock after adult cardiac surgery: a systematic literature review
Ann Thorac Surg
(2007)
A. Khanna et al.
Angiotensin II for the treatment of vasodilatory shock
N Engl J Med
(2017)
J.A. Tumlin et al.
Outcomes in patients with vasodilatory shock and renal replacement therapy treated with intravenous angiotensin II
Crit Care Med
(2018)

There are more references available in the full text version of this article.

Cited by (35)

Efficacy and safety of angiotensin II in cardiogenic shock: A systematic review
2023, American Journal of Emergency Medicine
Cardiogenic shock (CS) is associated with high morbidity and mortality. In recent times, there is increasing interest in the role of angiotensin II in CS. We sought to systematically review the current literature on the use of angiotensin II in CS.
PubMed, EMBASE, Medline, Web of Science, PubMed Central, and CINAHL databases were systematically searched for studies that evaluated the efficacy of angiotensin II in patients with CS during 01/01/2010–07/07/2022. Outcomes of interest included change in mean arterial pressure (MAP), vasoactive medication requirements (percent change in norepinephrine equivalent [NEE] dose), all-cause mortality, and adverse events.
Of the total 2,402 search results, 15 studies comprising 195 patients were included of which 156 (80%) received angiotensin II. Eleven patients (84.6%) in case reports and case series with reported MAP data at hour 12 noted an increase in MAP. Two studies noted a positive hemodynamic response (defined a priori) in eight (88.9%) and five (35.7%) patients. Eight studies reported a reduction in NEE dose at hour 12 after angiotensin II administration and one study noted a 100% reduction in NEE dose. Out of 47 patients with documented information, 13 patients had adverse outcomes which included hepatic injury (2), digital ischemia (1), ischemic optic neuropathy (1), ischemic colitis (2), agitated delirium (1), and thrombotic events (2).
In this first systematic review of angiotensin II in CS, we note the early clinical experience. Angiotensin II was associated with improvements in MAP, decrease in vasopressor requirements, and minimal reported adverse events.
Predicting the Response of Hydroxocobalamin in Postoperative Vasoplegia in Recipients of Cardiopulmonary Bypass
2022, Journal of Cardiothoracic and Vascular Anesthesia
The primary aim of this study was to identify predictors of response to hydroxocobalamin.
A retrospective cohort study.
A single large academic medical center within the cardiovascular surgery intensive care unit.
Postoperative cardiovascular surgery patients within 96 hours of cardiopulmonary bypass separation between May 7, 2018, and August 1, 2020.
None.
Of the 66 administrations, 43 administrations yielded hemodynamic improvements (65.2%). Comparing responders to nonresponders, nonresponders had a greater median cardiopulmonary bypass duration (223 v 131 minutes; p < 0.001) and a prolonged median cross-clamp time (153 v 77 minutes; p = 0.014). Multivariate modeling demonstrated a reduction in the odds of being a responder by 57% for every 60 minutes of cardiopulmonary bypass duration (odds ratio, 0.43; 95% confidence interval, 0.28-0.68; p < 0.001), but there was no significant difference based on time from intensive care unit admission to hydroxocobalamin administration (odds ratio, 0.95; 95% confidence interval, 0.88-1.03; p = 0.20).
Shorter total bypass duration and more rapid utilization after bypass of hydroxocobalamin were associated with a higher likelihood of response to refractory vasoplegic shock.
Clinical management of postcardiotomy shock in adults
2022, Medicina Intensiva
El shock cardiogénico poscardiotomía representa la situación clínica más grave del síndrome de bajo gasto poscirugía cardiaca. Aunque infrecuente, su fisiopatología específica y compleja y su elevada morbimortalidad lo convierten en una entidad especialmente relevante en el contexto de la medicina intensiva. El diagnóstico requiere un elevado índice de sospecha clínica y monitorización multimodal, con un papel fundamental para la ecocardiografía y el catéter de arteria pulmonar. Su manejo debe ser precoz, escalonado y dinámico, multisistémico, multidisciplinar, basado en resolver potenciales complicaciones mecánicas y optimizar los determinantes del gasto cardiaco mediante aporte de volumen o tratamiento deplectivo, fármacos inotrópicos y vasopresores/vasodilatadores y, en ausencia de respuesta, soporte circulatorio mecánico precoz. El objetivo de este artículo es presentar una revisión narrativa y una actualización de la fisiopatología, el diagnóstico y el manejo clínico del shock poscardiotomía. Además, se proponen pautas de actuación que faciliten el manejo clínico diario.
Postcardiotomy cardiogenic shock represents the most serious expression of low cardiac output syndrome after cardiac surgery. Although infrequent, it is a relevant condition due to its specific and complex pathophysiology and important morbidity-mortality. The diagnosis requires a high index of suspicion and multimodal hemodynamic monitoring, where echocardiography and the pulmonary arterial catheter play a main role. Early and multidisciplinary management should focus on the management of postoperative or mechanical complications and the optimization of determinants of cardiac output through fluid therapy or diuretic treatments, inotropic drugs and vasopressors/vasodilators and, in the absence of a response, early mechanical circulatory support. The aim of this paper is to review and update the pathophysiology, diagnosis and management of postcardiotomy cardiogenic shock.
Evaluating the evidence for angiotensin II for the treatment of vasoplegia in critically ill cardiothoracic surgery patients
2022, Journal of Thoracic and Cardiovascular Surgery
Effects of a single bolus of hydroxocobalamin on hemodynamics in vasodilatory shock
2022, Journal of Critical Care
Citation Excerpt :
In patients undergoing cardiac surgery, hydroxocobalamin given as an extended infusion over a median of 6 h has been shown to significantly decrease NED by hour 10 [26]. During liver transplantation, two cases describe a rapid increase in blood pressure and decrease in vasopressor requirements after its administration, but other reports in abdominal and cardiac surgery found that hydroxocobalamin did not result in meaningful responses [14,23,34,35]. Prior to our study, the largest case series of hydroxocobalamin involved 33 patients undergoing cardiac surgery [24].
Hydroxocobalamin has been observed to cause transient hypertension in healthy subjects, but rigorous studies examining its efficacy are lacking.
Adults in shock who received hydroxocobalamin from 2017 to 2021 were analyzed retrospectively. Hourly hemodynamics from 24 h before and after treatment were collected, and the difference and hourly change of mean arterial pressure (MAP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and norepinephrine-equivalent dose (NED) were examined in mixed-effects models.
This study included 3992 hemodynamic data points from 35 patients and is the largest case series to date. In the mixed effects model, there was no difference in MAP 24-h after hydroxocobalamin administration (estimated fixed effect [EFE] −0.2 mmHg, p = 0.89). A two-piecewise mixed model found that the hourly change in MAP was not different from zero in either the pre-administration (EFE 0.0 mmHg/h, p = 0.80) or post-administration segments (EFE 0.0 mmHg/h, p = 0.55). Analysis of the SBP, DBP, and NED also found similar insignificant results.
Although hydroxocobalamin has been observed to cause hypertension in healthy subjects, our results suggest that in patients with shock, hydroxocobalamin may not be effective in improving hemodynamics at 24 h after administration.
Angiotensin II for Critically Ill Patients With Shock After Heart Transplant
2021, Journal of Cardiothoracic and Vascular Anesthesia
Patients undergoing heart transplant are at high risk for vasodilatory shock in the postoperative period, due to a combination of vascular dysfunction from end-stage heart failure and inflammatory response to cardiopulmonary bypass and, increasingly, long-term exposure to nonpulsatile blood flow in those who have received a left ventricular assist device as a bridge to transplant. Patients who have this vasoplegic syndrome, which may be refractory to traditional agents used in the treatment of shock, are vulnerable to organ dysfunction and death. Angiotensin II (ANG-2) is of increasing interest as an adjunct to traditional therapy, both for improvement in blood pressure and for sparing the use of high-dose catecholamine vasopressors. This case series describes the use of ANG-2 in 4 clinical scenarios for the treatment of shock due to heart transplant surgery, supporting its use in this role and justifying further prospective studies to clarify the appropriate place for ANG-2 in the hierarchy of adjunctive therapies.

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Case reportUse of Angiotensin II for Post Cardiopulmonary Bypass Vasoplegic Syndrome

Section snippets

Comment

J Cardiothorac Vasc Anesth

Ann Thorac Surg

Angiotensin II for the treatment of vasodilatory shock

N Engl J Med

Outcomes in patients with vasodilatory shock and renal replacement therapy treated with intravenous angiotensin II

Crit Care Med

Case report
Use of Angiotensin II for Post Cardiopulmonary Bypass Vasoplegic Syndrome