Roles of angiotensin II as vasopressor in vasodilatory shock

Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid and catecholamine therapy to maintain adequate mean arterial pressure and organ perfusion. Norepinephrine is recommended as first-line vasopressor, but other agents are available. Angiotensin II is an alternative potent vasoconstrictor without chronotropic or inotropic properties. Several studies, including a large randomized controlled trial have demonstrated its ability to increase blood pressure with catecholamine-sparing effects. Angiotensin II was consequently approved by the US FDA in 2017 and the EU in 2019 as an add-on vasopressor in vasodilatory shock. This review aims to discuss its basic pharmacology, clinical efficacy, safety and future perspectives.

Dying in the Intensive Care Unit (ICU): A Retrospective Descriptive Analysis of Deaths in the ICU in a Communal Tertiary Hospital in Germany

Background. Modern intensive care methods led to an increased survival of critically ill patients over the last decades. But an unreflected application of modern intensive care measures might lead to prolonged treatment for incurable diseases, and an inadaequate or too aggressive therapy can prolong the dying process of patients. In this study, we analysed end-of-life decisions regarding withholding and withdrawal of intensive care measures in a German intensive care unit (ICU) of a communal tertiary hospital. Methods. Patient datasets of all adult patients dying in an ICU or an intermediate care unit (IMC) in a tertiary communal hospital (Klinikum Hanau, Germany) between 01.01.2011 and 31.12.2012 were analysed for withholding and withdrawal of intensive care measures. Results. During the two-year period, 1317 adult patients died in Klinikum Hanau. Of these, 489 (37%) died either in an ICU/IMC unit. The majority of those deceased patients (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 222), invasive (n = 121) and noninvasive (n = 40) ventilation followed by renal replacement therapy (n = 71) and catecholamine therapy (n = 66) were withheld. More invasive measures as ventilation or renal replacement therapy were withdrawn in 18 and 22 patients only. After withholding/withdrawal of therapy, most patients died within two days. More than 20% of patients dying in ICU/IMC did not have an analgesic medication. Conclusions. About one-third of patients dying in the hospital died in ICU/IMC. At least one life-sustaining therapy was limited/withdrawn in more than 60% of those patients. Withholding of a therapy was more common than active therapy withdrawal. Ventilation and renal replacement therapy were withdrawn in less than 5% of patients, respectively.

Single-Pass Albumin Dialysis in the Treatment of Children with Liver Failure

Background and Aims: Acute and acute on chronic liver failure are life-threatening conditions, and bridging to transplantation is complicated by a paucity of suitable organs for children. While different modalities of extracorporeal liver support exist, their use in children is complicated by a large extracorporeal volume, and data on their use in children is limited. The aim of this analysis was to investigate the efficacy and safety of single-pass albumin dialysis (SPAD) in children with liver failure. Methods: Retrospective medical chart review of pediatric patients with liver failure treated with SPAD. The decrease in hepatic encephalopathy (HE) and the serum levels of bilirubin and ammonia were measured to determine efficacy. Adverse events were documented to assess safety. Results: Nineteen pediatric patients with a median age of 25.5 months and a median body weight of 11.9 kg were treated with SPAD between January 2011 and March 2018. Total bilirubin (p < 0.001) and ammonia (p = 0.02) significantly decreased after treatment with SPAD. As clinical outcome parameter, HE significantly improved (p = 0.001). Twelve patients were bridged successfully to liver transplantation. In all patients, 71 SPAD sessions were run. Clotting in the dialysis circuit was observed in 49% of all sessions. Heparin and citrate were used for anticoagulation and were significantly superior to dialysis without any anticoagulation (p= 0.03). Transfusion of packed blood cells (57%) and catecholamine therapy (49%) were frequently necessary. Conclusions: Treatment with SPAD was effective in detoxification, as measured by significant improvement of HE and clearance from surrogate laboratory parameters.

Abstract 3380: Levosimendan Improves Right Ventricular Function In Cardiogenic Shock Following Myocardial Infarction

Background: Levosimendan, a novel inodilator, has been shown to improve hemodynamic function in acute heart failure and cardiogenic shock following acute myocardial infarction. Limited data are available on its use in patients with impaired right ventricular function. We hypothesised that levosimendan, due to its vasodilating and positiv inotropic profile, could ameliorate right ventricular hemodynamic function in critically ill patients with cardiogenic shock following myocardial infarction. Methods: Patients (n=25) with cardiogenic shock received initial conventional inotropic therapy after reperfusion of infarct related artery. After insufficient hemodynamic improvement patients received levosimendan (2μg/kgbw/h) over 24 hours. Hemodynamic measurements were routinely performed initially i.e., − 24 hours, at baseline (prior to levosimendan infusion) at 3 hours, 24 and 48 hours after start of levosimendan infusion using a Swan-Ganz thermodilution catheter. Results: With conventional catecholamine therapy (i.e., norepinephrine and/or dobutamine) we observed only marginal change of right ventricular perfomance parameters. In contrast, upon levosimendan infusion there was a significant decrease in pulmonary vascular resistance, while right ventricular Cardiac Power Index, a new measure of right ventricular performance similar to left ventricular CPI, significantly increased. Central venous pressure did not change which makes a significant dependency on preload unlikely. Conclusion: Levosimendan infusion in patients with cardiogenic shock following acute MI and PCI seems to improves substantially and persistently right ventricular hemodynamic parameters, superior to conventional catecholamine therapy. Further studies addressing the benefit of levosimendan in right ventricular failure like in cardiogenic shock due to right myocardial infarction or acute pulmonary embolism are warranted. Hemodynamic Parameters With Catecholamine Teatment and Additional Levosimendan