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Costa-Pinto R, Neto AS, Matthewman MC, Osrin D, Liskaser G, Li J, Young M, Jones D, Udy A, Warrillow S, Bellomo R. Dose equivalence for metaraminol and noradrenaline - A retrospective analysis. J Crit Care 2024; 80:154430. [PMID: 38245376 DOI: 10.1016/j.jcrc.2023.154430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Noradrenaline and metaraminol are commonly used vasopressors in critically ill patients. However, little is known of their dose equivalence. METHODS We conducted a single centre retrospective cohort study of all ICU patients who transitioned from metaraminol to noradrenaline infusions between August 26, 2016 and December 31, 2020. Patients receiving additional vasoactive drug infusion were excluded. Dose equivalence was calculated based on the last hour metaraminol dose (in μg/min) and the first hour noradrenaline dose (in μg/min) with the closest matched mean arterial pressure (MAP). Sensitivity analyses were performed on patients with acute kidney injury (AKI), sepsis and mechanical ventilation. RESULTS We studied 195 patients. The median conversion ratio of metaraminol to noradrenaline was 12.5:1 (IQR 7.5-20.0) for the overall cohort. However, the coefficient of variation was 77% and standard deviation was 11.8. Conversion ratios were unaffected by sepsis or mechanical ventilation but increased (14:1) with AKI. One in five patients had a MAP decrease of >10 mmHg during the transition period from metaraminol to noradrenaline. Post-transition noradrenaline dose (p < 0.001) and AKI (p = 0.045) were independently associated with metaraminol dose. The proportion of variation in noradrenaline dose predicted from metaraminol dose was low (R2 = 0.545). CONCLUSIONS The median dose equivalence for metaraminol and noradrenaline in this study was 12.5:1. However, there was significant variance in dose equivalence, only half the proportion of variation in noradrenaline infusion dose was predicted by metaraminol dose, and conversion-associated hypotension was common.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Dean Osrin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasun Li
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Marcus Young
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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See EJ, Chaba A, Spano S, Maeda A, Clapham C, Burrell LM, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Renin Levels and Angiotensin II Responsiveness in Vasopressor-Dependent Hypotension. Crit Care Med 2024:00003246-990000000-00311. [PMID: 38511994 DOI: 10.1097/ccm.0000000000006273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVES The relationship between renin levels, exposure to renin-angiotensin system (RAS) inhibitors, angiotensin II (ANGII) responsiveness, and outcome in patients with vasopressor-dependent vasodilatory hypotension is unknown. DESIGN We conducted a single-center prospective observational study to explore whether recent RAS inhibitor exposure affected baseline renin levels, whether baseline renin levels predicted ANGII responsiveness, and whether renin levels at 24 hours were associated with clinical outcomes. SETTING An academic ICU in Melbourne, VIC, Australia. PATIENTS Forty critically ill adults who received ANGII as the primary agent for vasopressor-dependent vasodilatory hypotension who were included in the Acute Renal effects of Angiotensin II Management in Shock study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After multivariable adjustment, recent exposure to a RAS inhibitor was independently associated with a relative increase in baseline renin levels by 198% (95% CI, 36-552%). The peak amount of ANGII required to achieve target mean arterial pressure was independently associated with baseline renin level (increase by 46% per ten-fold increase; 95% CI, 8-98%). Higher renin levels at 24 hours after ANGII initiation were independently associated with fewer days alive and free of continuous renal replacement therapy (CRRT) (-7 d per ten-fold increase; 95% CI, -12 to -1). CONCLUSIONS In patients with vasopressor-dependent vasodilatory hypotension, recent RAS inhibitor exposure was associated with higher baseline renin levels. Such higher renin levels were then associated with decreased ANGII responsiveness. Higher renin levels at 24 hours despite ANGII infusion were associated with fewer days alive and CRRT-free. These preliminary findings emphasize the importance of the RAS and the role of renin as a biomarker in patients with vasopressor-dependent vasodilatory hypotension.
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Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Rinaldo Bellomo
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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See EJ, Chaba A, Spano S, Maeda A, Clapham C, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Exploring the norepinephrine to angiotensin II conversion ratio in patients with vasodilatory hypotension: A post-hoc analysis of the ARAMIS trial. J Crit Care 2024; 79:154453. [PMID: 37890357 DOI: 10.1016/j.jcrc.2023.154453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Angiotensin II is approved for catecholamine-refractory vasodilatory shock but the conversion dose ratio from norepinephrine to angiotensin II remains unclear. METHODS We conducted a post-hoc analysis of the Acute Renal effects of Angiotensin II Management in Shock (ARAMIS) trial involving patients with vasodilatory hypotension. We determined the norepinephrine equivalent dose immediately prior to angiotensin II initiation and calculated the conversion dose ratio between norepinephrine and angiotensin II. We performed subgroup analyses based on recent exposure to angiotensin receptor blockers (ARBs) and renin levels at baseline. RESULTS In 37 patients, the median conversion dose ratio between norepinephrine equivalent and angiotensin II was to 10:1 for norepinephrine bitartrate (5:1 for norepinephrine base). The conversion ratio was not affected by the baseline renin, with a median ratio of 10 (7-21) in the high renin group versus 12 (5-22) in the low renin group. Finally, exposure to ARBs prior admission appeared to diminish the conversion ratio with a median ratio of 7 (4-13) in ARB patients vs. 12 (7-22) in non-ARB patients. CONCLUSIONS The norepinephrine to angiotensin II conversion dose ratio is 10:1 in a vasodilatory hypotension population. These findings can guide clinicians and researchers in the use, dosing, and study of angiotensin II in critical care.
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Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia.
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