What are the roles of phenylephrine and angiotensin II in the management of multiple organ dysfunction syndrome (MODS) in sepsis?

Updated: Jan 27, 2020
  • Author: Ali H Al-Khafaji, MD, MPH, FACP, FCCP, FCCM; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Phenylephrine is a selective alpha1 -adrenergic receptor agonist that is primarily used in anesthesia to increase blood pressure. Although the data are limited, phenylephrine has been found to increase MAP in patients with sepsis who are hypotensive with an increase in oxygen consumption and potential to reduce cardiac output. Phenylephrine may be a good choice when tachyarrhythmias limit therapy with other vasopressors.

Angiotensin II targets the renin-angiotensin-aldosterone system (RAAS), a powerful mediator of arterial blood pressure. Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial was conducted to determine whether the addition of angiotensin II to background vasopressors would improve blood pressure in patients with catecholamine-resistant vasodilatory shock. [23] In that study, 321 patients with vasodilatory shock were randomized to receive either angiotensin II (163 patients) or placebo (158 patients). Enrolled patients had shock despite receiving more than 0.2 μg/kg/min of norepinephrine or another vasopressor in a similar dose. The primary endpoint was a response with respect to MAP at hour 3 after the start of infusion, with response defined as an increase from baseline of at least 10 mm Hg or an increase to at least 75 mm Hg, without an increase in the dose of background vasopressors. The primary endpoint was reached by more patients in the angiotensin II group than in the placebo group. At 48 hours, the mean improvement in the cardiovascular Sequential Organ Failure Assessment (SOFA) score was greater in the angiotensin II group than in the placebo group. There was no statistically significant difference in mortality between the two groups.

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