Adult Critical Care Medicine by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783319944241
Publisher: Springer International Publishing

Future Aims

The future of shock management involves earlier detection of end-organ dysfunction, monitoring of cardiovascular performance, and pharmacologic and mechanical support. As newer noninvasive devices are developed, the reliability of these tools will need to be evaluated. While drug therapy most often includes norepinephrine as the vasopressor of choice, literature comparing combination therapy of vasopressors is limited. Individualized treatment regimens and choices in drug and fluid delivery will likely be tailored to each patient based on physiologic makeup and response to therapy.

Angiotensin II (ATII) has been recently added to the list of FDA-approved vasopressors available in the treatment of distributive shock. ATII is a naturally occurring hormone which interacts with the renin-angiotensin-aldosterone system (RAAS) causing both venous and arterial vasoconstriction. It is a pure vasopressor. Recently, the ATHOS-3 trial randomized 321 patients with distributive shock to receive ATII vs placebo [32]. Prior to enrollment, patients were required to be receiving 0.2 μg/kg/min of norepinephrine or equivalent dose of another vasopressor. The primary outcome was MAP response defined as a MAP increase of 10 mmHg or at least 75 mmHg at 3 h. 69.9% of the ATII group versus 23.4% of the control group reached this primary endpoint (Fig. 11.2). While secondary outcomes did show decreased all-cause mortality at days 7 and 28, these did not reach statistical significance [31]. Although the authors reported an improvement in the cardiovascular sequential organ failure assessment (SOFA) scores at 48 h without a difference in the total SOFA, this is somewhat misleading since this improvement is achieved simply by giving a vasopressor to the active treatment group and a placebo to the control arm.

Figure 11.2Comparison of ATII versus placebo on mean arterial pressure (MAP) in patients in distributive shock on vasopressors. (Reprinted/adapted with permission from New England Journal of Medicine Khanna et al. [32])

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