I did an initial EMCrit episode on Angiotensin II when the Athos 3 trial was fist published. Today, now that the drug has been available for a while, I wanted to hear from someone smart, with no financial conflicts of interest, on when to actually use this medication.
Rinaldo Bellomo MD PhD
Dr. Bellomo's Bio is too extensive to place here, please check out his Monash Page. Suffice it to say that he is a total badass as a clinical intensivist and a critical care researcher.
Renin Angiotensin Aldosterone System (RAAS)
Who Should Get Angio II
- Renin > 175 (or round up to 200)
- Septic Pts on RRT or about to need it
- Patients on pre-illness ACE-I
Rinaldo's Paper in AJRCCM
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thank you so very much, Scott, and Dr.Bellomo. very cool, informative pod. What Dr. Bellomo says seems quite reasonable. it is interesting to me how another part of the world sometimes has a different “take” or approach in certain scenarios, as here, Dr. B describes his early choice of milrinone as an inotrope. when i was at ResusTO (toronto), they chucked (politely) when i said “body scan” regarding a trauma case (they are more selective with CT’s generally., i think). likewise, the australians have a slightly different approach perhaps ( early vasopressin, milrinone,and steroids) for shock. one more thing, Scott:… Read more »
In our real world setting, where we use it as a last ditch effort in septic shock (already on high dose norepi/vaso or epi/vaso) I will tell you guys that we have found that it has increased the MAP in 100% of the patients. However, this has translated into only a small percentage of saved lives. Obviously, we are very thankful we had it available for those few patients though.
Excellent podcast – very interesting and provocative information. I would like to give two criticisms of the discussion with the caveat that I mean no disrespect in any way. The work being done an ang II is great and I really hope that the drugs pans out to improve outcomes when we have more data. Scott’s statement at the beginning that you needed to find an “unbiased person with no financial conflicts” was a little misleading. Again, I mean no disrespect in pointing this out but Dr. Bellomo’s institution has received funding from La Jolla (the company that makes ang… Read more »
Devin, Some great comments!!! Being part of a trial group is not in and of itself a conflict of interest. As to his institution receiving money–that is a super gray area, but my personal belief is that is not generally something I would feel compelled to consider a personal COI. Angio II is def. prothrombotic and I am eagerly awaiting additional info on this. Even pts without elevated renin seem to increase their BP with Angio II. I believe the question was with the hypothetical of cost not being an issue (and we can add in the additional caveat re:… Read more »
Hi!
Patients with liver failure often have a fatally refractory vasoplegia, the pathogenesis of which was never fully clear to me (but certainly is multifactorial). Considering that angiotensinogen is synthesized in the liver, angiotensin 2 could be a wonderdrug for these patients. I couldn´t find any data on this. And as the drug is effectively unavailable at our end of the stick, I was wondering who tried it in this subset of patients and what happened…?