(869) The Use of Angiotensin II for Severe Vasodilatory Shock After Verapamil Poisoning

Introduction: Severe vasodilatory shock that is refractory to high-dose vasoactive medications is associated with high mortality. Angiotensin II infusions have demonstrated improvement in vasoactive requirements in adult patients, but there is a paucity of literature of its use in the pediatric population. We present a case of severe vasodilatory shock after verapamil poisoning in a pediatric patient requiring ECMO support and the use of angiotensin II to provide additional blood pressure support and decreased vasoactive needs.

Description: A 14-year-old female with past medical history of depression presented after intentional ingestion of approximately 4080 mg of extended-release verapamil. She was taken to an outside hospital where her initial vital signs were HR: 96, BP: 79/39, and SaO2: 94% on room air. Her initial glucose was 295mg/dL. She was given calcium gluconate, and epinephrine and norepinephrine infusions were initiated. She was intubated and transferred to a tertiary pediatric intensive care unit (PICU), where upon arrival, she was bradycardic and hypotensive despite high dose epinephrine and norepinephrine infusions. High-dose insulin-euglycemic and lipid emulsion therapy was initiated. Due to her refractory hypotension, she was cannulated onto VA-ECMO. After cannulation with ECMO flows of 100 ml/kg/min, she continued to require high vasoactive support with epinephrine of 0.7 mcg/kg/min, norepinephrine of 0.7 mcg/kg/min, vasopressin of 0.06 units/min, insulin of 10 units/kg/hr. She was initiated on angiotensin II infusion for additional hemodynamic support at 10 ng/kg/min, which was increased to 30 ng/kg/min over one hour. Therapeutic plasma exchange was performed to attempt enhanced drug clearance. In the 24 hours after angiotensin II initiation and TPE, the patient’s vasoactive needs were weaned to epinephrine of 0.5 mcg/kg/min, norepinephrine of 0.46 mg/kg/min, vasopressin of 0.025 units/min, and angiotensin II of 20 mg/kg/min. She was decannulated from ECMO after 5 days and ultimately transferred to an inpatient psychiatric facility.

Discussion: Though well documented in the adult literature, the use of angiotensin II is not well defined in the pediatric literature. Further studies are needed to define the clinical role of angiotensin II infusions for refractory vasodilatory shock.