Improvement in Mortality Linked to Protocol Compliance Guiding Angiotensin II Use
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Pharmacology, Shock Non Sepsis, 2021
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The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Nicholas Barker


Introduction/Hypothesis: The novel non-catecholamine vasopressor angiotensin II (Ang II) has recently been approved for high output shock, though a standardized approach for use has yet to be firmly established. We developed and trained all appropriate providers over a two-week period on a proprietary protocol at Emory Healthcare (Emory Protocol), which includes guidance on (i) background norepinephrine equivalent dose, (ii) documentation of high output shock, (iii) use of vasopressin, and (iv) starting dose of Ang II. We sought to evaluate whether adherence to the Emory Protocol resulted in an improvement in ICU mortality.

Methods: We recorded ICU mortality and protocol compliance for sequential patient encounters where Ang II was used, which we measured on a point system. Points were awarded for appropriateness of background catecholamine dose (scored 1 to 5), presence of vasopressin (scoreed 1 or 2), documentation of high output shock (scored 1 to 4), and starting dose of Ang II (scored 1 or 2). Compliant was classified as a score of 6 or less and moderately compliant if 7 to 8. A score of 9 or greater was classified as poorly compliant. We further separated all encounters into those that occurred before protocol training and those that occurred after training to compare average compliance score and associated mortality between these two cohorts.

Results: Of the 196 consecutive patients who received Ang II, average SOFA score was 10.8 and overall ICU mortality was 59%, with an average compliance score of 6.8. Of the 112 patient encounters before protocol education, the average compliance score was 7.2, with an associated ICU mortality of 69%. However, in the 74 patient encounters that occurred after protocol education, the average compliance score improved to 6.3, with an associated ICU mortality of 49%. The odds ratio for death in patients who were treated with Ang II prior to protocol training was 2.32 (95% CI: 1.27 to 4.26, P=0.0064).

Conclusions: Compliance with the Emory Protocol was shown to be associated with a statistically significant reduction in ICU mortality in critically ill patients receiving Ang II. A standardized approach emphasizing multi-modal therapy including early Ang II use and correct patient identification, coupled with rigorous protocol training, may be essential for improving outcomes.


Meta Tag
Content Type Presentation
Knowledge Area Pharmacology
Knowledge Area Shock Non Sepsis
Knowledge Level Advanced
Membership Level Select
Tag Vasoactive Agents
Tag Pharmacokinetics Pharmacodynamics
Tag Shock
Year 2021
angiotensin II
distributive shock
alternative therapy
Emory St. Joseph Hospital


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