Angiotensin Ii Therapy in Refractory Septic Shock: Which Patient Can Benefit Most? A Narrative Review

Overview

Journal J Anesth Analg Crit Care

Date 2024 Feb 21

PMID 38383521

Authors

Irene Coloretti

Andrea Genovese

J Pedro Teixeira

Anusha Cherian

Ricard Ferrer

Giovanni Landoni

Marc Leone

Massimo Girardis

Nathan D Nielsen

Affiliations

Soon will be listed here.

Abstract

Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.

Citing Articles

Understanding, assessing and treating immune, endothelial and haemostasis dysfunctions in bacterial sepsis.

Girardis M, David S, Ferrer R, Helms J, Juffermans N, Martin-Loeches I Intensive Care Med. 2024; 50(10):1580-1592.

PMID: 39222142 DOI: 10.1007/s00134-024-07586-2.

Current perspectives in the management of sepsis and septic shock.

Chiscano-Camon L, Ruiz-Sanmartin A, Bajana I, Bastidas J, Lopez-Martinez R, Franco-Jarava C Front Med (Lausanne). 2024; 11:1431791.

PMID: 39211340 PMC: 11358069. DOI: 10.3389/fmed.2024.1431791.

The use of angiotensin II for the management of distributive shock: expert consensus statements.

Landoni G, Cortegiani A, Bignami E, De Pascale G, Donadello K, Donati A J Anesth Analg Crit Care. 2024; 4(1):56.

PMID: 39152516 PMC: 11328364. DOI: 10.1186/s44158-024-00186-y.

References

Zhong L, Ji X, Wang H, Zhao G, Zhou Q, Xie B . Non-catecholamine vasopressors in the treatment of adult patients with septic shock-evidence from meta-analysis and trial sequential analysis of randomized clinical trials. J Intensive Care. 2020; 8(1):83. PMC: 7603734. DOI: 10.1186/s40560-020-00500-0. View

Tovar J, Bujons I, Ruiz J, Ibanez L, Salgado A . Treatment of severe combined overdose of calcium antagonists and converting enzyme inhibitors with angiotensin II. Nephron. 1997; 77(2):239. DOI: 10.1159/000190280. View

Montgomery M, Gross C, Lin H, Ouyang Y, Levin M, Corkill H . Plasma Renin Activity Increases With Cardiopulmonary Bypass and is Associated With Vasoplegia After Cardiac Surgery. J Cardiothorac Vasc Anesth. 2022; 37(3):367-373. DOI: 10.1053/j.jvca.2022.11.019. View

Khanna A, English S, Wang X, Ham K, Tumlin J, Szerlip H . Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017; 377(5):419-430. DOI: 10.1056/NEJMoa1704154. View

Ruiz-Ortega M, Ruperez M, Lorenzo O, Esteban V, Blanco J, Mezzano S . Angiotensin II regulates the synthesis of proinflammatory cytokines and chemokines in the kidney. Kidney Int Suppl. 2002; (82):S12-22. DOI: 10.1046/j.1523-1755.62.s82.4.x. View

Newby D, Lee M, Gray A, Boon N . Enalapril overdose and the corrective effect of intravenous angiotensin II. Br J Clin Pharmacol. 1995; 40(1):103-4. PMC: 1365039. DOI: 10.1111/j.1365-2125.1995.tb04546.x. View

Coulson T, Miles L, Zarbock A, Burrell L, Patel S, von Groote T . Renin-angiotensin-aldosterone system dynamics after targeted blood pressure control using angiotensin II or norepinephrine in cardiac surgery: mechanistic randomised controlled trial. Br J Anaesth. 2023; 131(4):664-672. DOI: 10.1016/j.bja.2023.06.056. View

Quan M, Cho N, Bushell T, Mak J, Nguyen N, Litwak J . Effectiveness of Angiotensin II for Catecholamine Refractory Septic or Distributive Shock on Mortality: A Propensity Score Weighted Analysis of Real-World Experience in the Medical ICU. Crit Care Explor. 2022; 4(1):e0623. PMC: 8769135. DOI: 10.1097/CCE.0000000000000623. View

Coulson T, Miles L, Neto A, Pilcher D, Weinberg L, Landoni G . A double-blind randomised feasibility trial of angiotensin-2 in cardiac surgery. Anaesthesia. 2022; 77(9):999-1009. PMC: 9543254. DOI: 10.1111/anae.15802. View

10.

WEDEEN R, ZUCKER G . Angiotensin II in the treatment of shock. Am J Cardiol. 1963; 11:82-6. DOI: 10.1016/0002-9149(63)90036-5. View

11.

DERRICK J, ANDERSON J, ROLAND B . Adjunctive use of a biologic pressor agent, angiotensin, in management of shock. Circulation. 1962; 25:263-7. DOI: 10.1161/01.cir.25.1.263. View

12.

Brown S, Lanspa M, Jones J, Kuttler K, Li Y, Carlson R . Survival after shock requiring high-dose vasopressor therapy. Chest. 2012; 143(3):664-671. PMC: 3590882. DOI: 10.1378/chest.12-1106. View

13.

Wieruszewski P, Sims C, Daly R, Taner T, Wittwer E . Use of Angiotensin II for Vasoplegic Shock in a Combined Heart and Liver Transplant Recipient with Systolic Anterior Motion Physiology. J Cardiothorac Vasc Anesth. 2019; 33(8):2366-2367. DOI: 10.1053/j.jvca.2019.03.054. View

14.

Wakefield B, Sacha G, Khanna A . Vasodilatory shock in the ICU and the role of angiotensin II. Curr Opin Crit Care. 2018; 24(4):277-285. DOI: 10.1097/MCC.0000000000000517. View

15.

Malato A, Dentali F, Siragusa S, Fabbiano F, Kagoma Y, Boddi M . The impact of deep vein thrombosis in critically ill patients: a meta-analysis of major clinical outcomes. Blood Transfus. 2015; 13(4):559-68. PMC: 4624530. DOI: 10.2450/2015.0277-14. View

16.

Jeyaraju M, McCurdy M, Levine A, Devarajan P, Mazzeffi M, Mullins K . Renin Kinetics Are Superior to Lactate Kinetics for Predicting In-Hospital Mortality in Hypotensive Critically Ill Patients. Crit Care Med. 2021; 50(1):50-60. DOI: 10.1097/CCM.0000000000005143. View

17.

Singer M, Deutschman C, Seymour C, Shankar-Hari M, Annane D, Bauer M . The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016; 315(8):801-10. PMC: 4968574. DOI: 10.1001/jama.2016.0287. View

18.

Kullmar M, Saadat-Gilani K, Weiss R, Massoth C, Lagan A, Cortes M . Kinetic Changes of Plasma Renin Concentrations Predict Acute Kidney Injury in Cardiac Surgery Patients. Am J Respir Crit Care Med. 2020; 203(9):1119-1126. DOI: 10.1164/rccm.202005-2050OC. View

19.

Thomas V, Nielsen M . Administration of angiotensin II in refractory septic shock. Crit Care Med. 1991; 19(8):1084-6. DOI: 10.1097/00003246-199108000-00020. View

20.

Sato R, Duggal A, Sacha G, Rudoni M, Yataco A, Khanna A . The Relationship Between Norepinephrine Equivalent Dose of Vasopressors Within 24 Hours From the Onset of Septic Shock and In-Hospital Mortality Rate. Chest. 2022; 163(1):148-151. DOI: 10.1016/j.chest.2022.07.018. View