Colin McCloskey, MD
Assistant Professor
University Hospitals Cleveland Medical Center, United States
Disclosure information not submitted.
Marc Popovich, MD, FCCM
Chair, Department of Anesthesiology & Perioperative Medicine
University Hospitals Cleveland Medical Center
Novelty, Ohio
Disclosure information not submitted.
Title: Successful Use of Angiotensin II for Shock in a Patient on VV ECMO After Recent Liver Transplant
Case Report Body:
Introduction: Vasodilatory shock refractory to vasopressors can be clinically problematic. Angiotensin II (ATII) is an endogenous peptide that acts to produce vasoconstriction. The synthetic form of angiotensin II can be used as a treatment option in vasodilatory dilatory shock.
Description: A 66-year-old male with history of primary sclerosing cholangitis underwent orthotopic liver transplant with roux-en-y hepaticojejunostomy. Postoperative course was complicated by a circumferential ulcer at the jejunal anastomosis managed with clipping on POD 14. CT abdomen and pelvis, obtained on POD 19 for concerning abdominal exam demonstrated pneumatosis intestinalis. He proceeded to the operating room (OR) for bowel resection. Upon rapid sequence induction, the patient had emesis prior to intubation. The airway was suctioned prior to positive pressure ventilation. Bronchoscopy showed minimal emesis near the carina. Postoperatively the patient developed hypoxic respiratory failure with a PaO2 of 52 mmHg on volume control ventilation despite 100% FiO2 and PEEP 15, neuromuscular blockade, and inhaled epoprostenol. CXR showed bilateral diffuse infiltrates. Echocardiogram showed normal cardiac contractile function. In addition, he had significant hypotension managed with escalating vasopressor doses (0.4 mcg/kg/min norepinephrine (NE), 0.06 U/min vasopressin), stress dose steroids, and a methylene blue bolus. Given the rapid escalation in medical management for hypoxic respiratory failure the patient was cannulated for VV ECMO. ATII infusion was started for management of refractory vasodilatory shock. It was titrated to 80 ng/kg/min. Within three hours of initiation of ATII, NE dose was halved. Vasopressors were weaned off on ECMO day 3. Respiratory function improved with ECMO decannulation on day 5.
Discussion: This case demonstrates the successful use of ATII to reduce vasopressor requirements in a patient with refractory vasodilatory shock status post orthotopic liver transplant and new onset hypoxic respiratory failure necessitating VV ECMO. While previous literature has shown successful use of ATII in select patients, the ATHOS III study specifically excluded those with liver failure and those recently cannulated for ECMO. This case demonstrates the potential of ATII outside the ATHOS III inclusion and exclusion criteria.