A Retrospective Analysis of Patients With Septic Shock Treated With Angiotensin II

Introduction: Patients diagnosed with septic shock require vasopressors to maintain an adequate mean arterial pressure (MAP). The current vasopressor of choice is norepinephrine (NE) with vasopressin (VP) as second-line. Angiotensin II (ATII) was FDA-approved in December 2017 for septic shock or other vasodilatory shock states, but its place in therapy remains unclear. The purpose of this study was to assess the use of ATII at a large community hospital in relation to vasopressor sequencing, timing, dosing, its effect on the dosing of other vasopressors, and its effect on MAP.


Methods: In this single-center, observational, retrospective study, all adult patients admitted in 2019 through 2023 who received ATII were identified. Data collected included sequencing of vasopressors, timing of ATII initiation, vasopressor dosing, MAP, and hospital mortality. Statistical analysis was conducted in SPSS.


Results: A total of 53 patients who received ATII were included in this study. The most common first and second vasopressor was NE (n=47, 89%) and VP (n=42, 79%), respectively. All patients were on at least two vasopressors before ATII administration. ATII was the third vasopressor in 18 patients (34%), fourth vasopressor in 25 patients (47%), and fifth vasopressor in 10 patients (19%). The median time to ATII initiation was 18.7 hours after the most recent ICU admission, 11.3 hours from the first vasopressor, and 7.6 hours from the second vasopressor. The most common starting and maximum rates for ATII were 20 ng/kg/min (n=46, 87%) and 80 ng/kg/min (n=19, 36%), respectively. The mean NE equivalent (NEE) dose was 0.935 mcg/kg/min at ATII initiation and 0.821 mcg/kg/min at 3 hours. The mean MAP was 65.0 mmHg at ATII initiation and 67.8 mmHg at 3 hours. In-hospital mortality occurred in 43 patients (81%). Ten patients (19%) survived hospitalization.


Conclusions: Few patients who received ATII for treatment of septic shock survived. NE and VP sequencing was consistent with septic shock guidelines. ATII was most used as a fourth-line vasopressor in patients refractory to other therapies. Although the effects were modest, ATII use decreased NEE dosing and increased MAP. Future research should seek to expand upon these findings to optimize ATII use, such as the appropriate timing and sequencing of ATII initiation.