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Vasodilatory shock in the ICU and the role of angiotensin II

Wakefield, Brett J.a; Sacha, Gretchen L.b; Khanna, Ashish K.a,c

Current Opinion in Critical Care: August 2018 - Volume 24 - Issue 4 - p 277–285
doi: 10.1097/MCC.0000000000000517
CARDIOVASCULAR SYSTEM: Edited by Stephen M. Pastores

Purpose of review There are limited vasoactive options to utilize for patients presenting with vasodilatory shock. This review discusses vasoactive agents in vasodilatory, specifically, septic shock and focuses on angiotensin II as a novel, noncatecholamine agent and describes its efficacy, safety, and role in the armamentarium of vasoactive agents utilized in this patient population.

Recent findings The Angiotensin II for the Treatment of High-Output Shock 3 study evaluated angiotensin II use in patients with high-output, vasodilatory shock and demonstrated reduced background catecholamine doses and improved ability to achieve blood pressure goals associated with the use of angiotensin II. A subsequent analysis showed that patients with a higher severity of illness and relative deficiency of intrinsic angiotensin II and who received angiotensin II had improved mortality rates. In addition, a systematic review showed infrequent adverse reactions with angiotensin II demonstrating its safety for use in patients with vasodilatory shock.

Summary With the approval and release of angiotensin II, a new vasoactive agent is now available to utilize in these patients. Overall, the treatment for vasodilatory shock should not be a one-size fits all approach and should be individualized to each patient. A multimodal approach, integrating angiotensin II as a noncatecholamine option should be considered for patients presenting with this disease state.

aDepartment of General Anesthesiology, Anesthesiology Institute

bDepartment of Pharmacy

cDepartment of Outcomes Research, Center for Critical Care, Cleveland Clinic, Cleveland, OH, USA

Correspondence to Ashish K. Khanna, MD, FCCP, FCCM, Cleveland Clinic Foundation, 9500 Euclid Avenue – G58, Cleveland, OH 44195, USA. Tel: +1 513 658 5866; e-mail:

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