Patrick Wieruszewski, BCCCP, PharmD
Assistant Professor of Anesthesiology and Pharmacy
Mayo Clinic
Rochester, Minnesota
Disclosure information not submitted.
Troy Seelhammer, MD
Assistant Professor of Anesthesiology
Mayo Clinic, United States
Disclosure information not submitted.
Ashish Khanna, MD, FCCP, FASA,FCCM
Anesthesiologist & Intensivist, Associate Professor of Anesthesiology
Wake Forest Baptist Medical Center
Winston Salem, North Carolina
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Bhavita Gaglani, MD
Critical Care Fellow
Wake Forest Baptist Medical Center
Winston-Salem, North Carolina, United States
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Danielle Davison, MD
Associate Professor of Anesthesiology and Critical Care Medicine and of Medicine
George Washington University Medical Center, United States
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Jonathan Chow, MD
Department of Anesthesiology and Critical Care Medicine
George Washington University School of Medicine, United States
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Laurence Busse, MBA, MD, FCCM
Assistant Professor
Emory University School of Medicine, United States
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Caitlin Ten Lohuis, ACNP
Acute Care Nurse Practitioner
Emory University
Atlanta, Georgia
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Erin Barreto, MSc, PharmD, FCCM
Associate Professor of Pharmacy and Medicine
Mayo Clinic
Rochester, Minnesota
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Erica Wittwer, MD, PhD
Associate Professor of Anesthesiology
Mayo Clinic, United States
Disclosure information not submitted.
Title:Synthetic Angiotensin II Use During Mechanical Circulatory Support
Introduction: Mechanical circulatory support (MCS) devices are increasingly utilized for rescue of cardiac and/or pulmonary failure in the critically ill. Select patients treated with MCS may exhibit relative angiotensin-converting enzyme deficiency which may potentiate positive response to synthetic angiotensin II (AngII), a recently approved vasopressor. The objective of this study was to describe the safety and effectiveness of AngII when used in patients treated with MCS devices.
Methods: This retrospective multicenter study included adults (≥18 years) receiving AngII during temporary MCS at 4 academic medical centers between May 2018 and July 2021. Data were summarized with descriptive statistics.
Results: The 40 included patients had a median (IQR) age of 60 (48, 71) years, 34 (85%) were male, and the SOFA score was 12 (11, 14). MCS devices included venovenous (n = 9) or venoarterial (n = 13) ECMO, right ventricular assist device with oxygenator (n = 2), right (n = 1) or left (n = 6) sided Impella, and right (n = 2) or left (n = 7) sided TandemHeart with oxygenator. Primary MCS indications were separation from cardiopulmonary bypass (n = 13, 33%), cardiogenic shock (n = 13, 33%), acute respiratory distress syndrome (n = 9, 23%), cardiac arrest (n = 4, 10%), and other (n = 1). Device flow at time of AngII initiation was 4.7 (3.9, 5.4) L/min. AngII was given for postoperative vasoplegic (n = 22), septic (n = 12), cardiogenic (n = 11), hemorrhagic (n = 6), or obstructive (n = 3) shock, with nearly half (n = 18, 45%) of the group having multifactorial shock. AngII was started in the operating room in 9 (23%) patients. At initiation, MAP was 60 (57, 77) mmHg maintained with 0.46 (0.35, 0.65) mcg/kg/min norepinephrine-equivalent. After 3 hours, MAP changed by +4.5 (-11.5, +13.3) mmHg and vasopressors changed by -0.05 (0, -0.18) mcg/kg/min. Mesenteric ischemia was suspected in 3 (7.5%) patients, but not confirmed. The ICU and hospital lengths of stay were 11 (4, 33) and 16 (5, 40) days, respectively. Overall, 25 (62.5%) patients died in the ICU, a median of 3 (1, 11) days from AngII initiation.
Conclusion: In this profoundly ill cohort requiring MCS for acute cardiac and/or pulmonary failure, AngII increased MAP and reduced concomitant vasopressor doses quickly. The effects of AngII on outcomes in MCS remains unclear.