Angiotensin in ECMO patients with refractory shock

Evaluating the evidence for angiotensin II for the treatment of vasoplegia in critically ill cardiothoracic surgery patients

“…Outside of organized clinical trials, Ang-2 has been used in vasoplegic shock associated with CPB in a number of instances (Table 2). [17][18][19][20][21][22][23][24][25][26][27][28] These case reports have included a wide variety of cardiothoracic surgical procedures, including coronary revascularization with and without valve intervention, isolated valve intervention, heart transplantations, combined heart/liver transplantation, lung transplantation, pneumonectomy, left ventricular assist device insertion, and thoracoabdominal aortic aneurysm repair. [18][19][20][21][22][23][24][25][26] Reported CPB times were variable, ranging from just over an hour to upwards of 7 hours.…”

“…With the efficacy Ang-2 demonstrated in the general distributive shock population, interest has increased in the potential for use in vasodilated patients undergoing mechanical circulatory support. Ostermann and colleagues used 27 Ang-2 in the management of 7 patients undergoing ECMO, with 6 being discharged from the hospital and 1 death. Patients had a variety of etiologies for cardiogenic shock, including sepsis, cardiac arrest, myocardial infarction, drug overdose, pulmonary embolism, and type A aortic dissection.…”

Catecholamine Refractory Vasodilatory Shock: Can Therapy Become Patient Specific?

“…This point is especially important in the growing population of patients requiring mechanical circulatory support, such as extracorporeal membrane oxygenation, percutaneous ventricular assist devices, or durable ventricular support, because thrombotic events in this patient population can be catastrophic. 8 Currently, high quality, robust data on mixing agents (such as the combination of methylene blue and angiotensin II either together or in rapid succession) are lacking in the literature. Even the most well-thought-out approach with the current evidence entails an ad hoc approach to treating vasoplegia.…”

A Safety Initiative for Noncardiac Anesthesia Providers Caring for Patients With Left Ventricular Assist Devices

“…The front of the document describes how to review important facts concerning anesthesia for LVAD patients; steps to provide a safe anesthetic to this unique patient population; 2,8 and perils to avoid in the preoperative, intraoperative, and postoperative periods. 2,8,9 The back side of the document describes common LVAD troubleshooting that can be resolved in a stepwise fashion. 2,8,9 A pictorial example of an LVAD device with settings of the 3 most common brands are inserted into this protocol, too.…”

“…2,8,9 The back side of the document describes common LVAD troubleshooting that can be resolved in a stepwise fashion. 2,8,9 A pictorial example of an LVAD device with settings of the 3 most common brands are inserted into this protocol, too. A survey of anesthesia providers demonstrated improvement of familiarity with LVAD patients, their devices, and ways to improve quality and safety of care.…”