A Patient With Tricyclic Antidepressant Overdose With Catecholamine-Resistant Hypotension Rescued With Angiotensin II

Ferdowsali, Jacqueline; Ferdowsali, Kameron

doi:10.1097/dcc.0000000000000414

Dimens Crit Care Nurs

2020

DOI: 10.1097/dcc.0000000000000414

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A Patient With Tricyclic Antidepressant Overdose With Catecholamine-Resistant Hypotension Rescued With Angiotensin II

Jacqueline Ferdowsali

Kameron Ferdowsali

Abstract: This case report explores the novel use of angiotensin II (Giapreza) for the treatment of vasodilation in the setting of a tricyclic overdose. The purpose of this case is to describe how the use of angiotensin II can improve hemodynamic parameters and result in a dose reduction of other catecholamine vasopressors in vasodilatory shock. The use of angiotensin II is new to clinical practice and has the potential to change outcomes for patients.

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The Role of Angiotensin II in Poisoning-Induced Shock—a Review

Chen

Wong

2022

J. Med. Toxicol.

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Background Shock in drug poisoning is a life-threatening condition and current management involves fluid resuscitation and vasopressor therapy. Management is limited by the toxicity of high-dose vasopressors such as catecholamines. Clinical trials have shown the efficacy of angiotensin II as an adjunct vasopressor in septic shock. The aim of this review is to assess the use of angiotensin II in patients with shock secondary to drug overdose. Methods Medline (from 1946), Embase (from 1947) and PubMed (from 1946) databases were searched until July 2021 via OVID. Included studies were those with shock due to drug poisoning and received angiotensin II as part of their treatment regimen. Of the 481 articles identified, 13 studies (case reports and scientific abstracts) were included in the final analysis with a total of 14 patients. Extracted data included demographics, overdose drug and dosage, angiotensin II dosage, time of angiotensin II administration, haemodynamic changes, length of hospital stay, mortality, complications, cardiac function and other treatment agents used. Results Thirteen studies were included consisting of 6 case reports, 6 scientific abstracts and 1 case series. Overdose drugs included antihypertensives (n = 8), psychotropics (n = 4), isopropanol (n = 1) and tamsulosin (n = 1). Out of a total of 14 patients, 3 patients died. Ten patients had their haemodynamic changes reported. In terms of MAP or SBP changes, three patients (30%) had an immediate response to angiotensin II, four patients (40%) had responses within 30 min, one patient (10%) within two hours and two patients (20%) did not have their time reported. Two patients were shown to have direct chronotropic effects within 30 min of angiotensin II administration. The median hospital stay for patients was 5 days (IQR = 4). The time from overdose until angiotensin II administration ranged from 5 to 56 h. Other vasopressors used included phenylephrine, noradrenaline, adrenaline, vasopressin, dobutamine, dopamine, methylene blue and ephedrine. A median of 3 vasopressors were used before initiation of angiotensin II. Twelve patients received angiotensin II as their final treatment. Conclusions Angiotensin II may be useful as an adjunct vasopressor in treating shock secondary to drug poisoning. However, the current literature consisted of only very low-quality studies. To truly assess the utility of angiotensin II use in drug-induced poisoned patients, further well-designed prospective studies are required.

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The Role of Angiotensin II in Poisoning-Induced Shock—a Review

Chen

Wong

2022

J. Med. Toxicol.

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Angiotensin II for the treatment of septic shock in a neutropenic patient with T-cell acute lymphoblastic leukaemia

et al. 2020

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Mortality remains high in septic shock with few new treatment options. Angiotensin II has been recently approved for use in septic shock due to promising results in the ATHOS-3 trial. However, patients with neutropenia were excluded in the trial. This patient population is becoming increasingly common in the intensive care unit as there is an increase in novel biologic therapies and stem cell transplantations for haematological and solid organ malignancies. We present a case of a patient with T-cell acute lymphoblastic leukaemia who received chemotherapy, resulting in neutropenia and septic shock. There was persistent hypotension despite initiating multiple conventional vasopressors. Angiotensin II was attempted with immediate improvement in the blood pressure which resulted in weaning of other vasopressors. This positive haemodynamic response suggests that angiotensin II can successfully be used in neutropenic patients without increasing the overall catecholamine burden of septic shock.

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A Patient With Tricyclic Antidepressant Overdose With Catecholamine-Resistant Hypotension Rescued With Angiotensin II

Cited by 2 publications

References 12 publications

The Role of Angiotensin II in Poisoning-Induced Shock—a Review

The Role of Angiotensin II in Poisoning-Induced Shock—a Review

Angiotensin II for the treatment of septic shock in a neutropenic patient with T-cell acute lymphoblastic leukaemia

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