Bedside Angiotensin II Admixture Improves Time to Administration and Cost in Critically Ill Adults

Introduction: Timely vasopressor initiation is essential in shock management, as delays are associated with increased mortality. Angiotensin II (ATII), used for refractory hypotension, is typically compounded in a sterile pharmacy setting. This multi-step process can delay administration and may increase drug waste. To address these inefficiencies, our institution implemented the Vial2Bag (V2B) admixture system, enabling sterile bedside preparation of ATII. While V2B has shown operational benefits for other medications, its impact on vasopressors like ATII has not been evaluated. We hypothesized that V2B implementation would reduce time to ATII administration and drug waste without adversely affecting clinical outcomes.


Methods: This retrospective, observational pre-post cohort study was conducted at UChicago Medicine. Adult ICU patients who received ATII between August 1, 2023, and February 14, 2024 (preV2B), and August 1, 2024 and February 14, 2025 (postV2B) were included. The primary endpoint was time from pharmacist order verification to ATII administration. Secondary endpoints included change in norepinephrine equivalents (NEE) at 3 and 6 hours post-ATII, in-hospital mortality, and ATII drug waste cost. Waste cost was estimated comparing dispensed-to-administered ATII doses and acquisition pricing. Descriptive statistics were used to compare outcomes between groups.


Results: A total of 321 patients were screened and 98 were eligible for inclusion (47 preV2B, 51 postV2B). Baseline characteristics, including NEE, were similar between groups. Median time from order verification to ATII administration was significantly reduced post-V2B: 19 minutes (IQR 4–64) vs 44 minutes (IQR 2–109) in the preV2B group (p=0.012). Comparison of NEE at 3 and 6 hours following ATII initiation were not significantly different. In-hospital mortality was also similar between groups (83% postV2B vs 90% preV2B; p=0.376). Reduced ATII waste following V2B implementation led to an estimated institutional cost savings of $137,670.


Conclusions: Bedside preparation with V2B system significantly reduced time to ATII initiation without increasing vasopressor use or mortality, while lowering drug costs. These findings support the use of point-of-care admixture to improve efficiency in delivery of time sensitive vasoactive medications.