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• W4387248741 abstract "SESSION TITLE: Critical Care Case Report Posters 23 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: We present a case of a patient with refractory hypotension despite maximum vasopressor therapy after toxic injection of multiple substances including lisinopril that resolved after trial of angiotensin II. CASE PRESENTATION: A 54-year-old woman with depression with previous intentional overdose, bipolar disorder, substance abuse, Parkinson's disease, CKD stage II, and hypertension presenting after an intentional overdose of 450mg of amlodipine, an unknown amount of lisinopril, and large volume ethanol ingestion about one hour prior to arrival. She presented alert and oriented but became increasingly lethargic. She was hypotensive with blood pressure in 70s/40s with MAPs in the 50s that was refractory to 3L NSS. Activated charcoal was given via nasogastric tube with pill fragments noted on return. IV glucagon and calcium gluconate were given empirically for calcium-channel blocker (CCB) toxicity. Bedside echocardiogram found normal cardiac contractility so high-dose insulin was held. She was started on phenylephrine then norepinephrine given persistent hypotension and admitted to the ICU. The patient then developed rapid facial swelling consistent with angioedema from lisinopril toxicity and was treated with steroids and antihistamines. She remained hypotensive despite maximum doses of current vasopressors, so an epinephrine infusion was started resulting in angioedema resolution but persistent hypotension. An angiotensin II infusion was trialed with dramatic improvement of hypotension and subsequent weaning from phenylephrine and epinephrine overnight, followed by norepinephrine and finally angiotensin II in the morning. The patient was observed in the ICU without recurrence of symptoms before discharge home after Psychiatry evaluation. DISCUSSION: ACE inhibitors (ACE-I) are common antihypertensives that disrupt the renin-angiotensin-aldosterone system by inhibiting angiotensin converting enzyme (ACE) and thereby blocking the conversion of angiotensin I to angiotensin II. ACE-I overdose is usually well tolerated, but significant toxicity can occur with co-ingestion of other antihypertensives. CCB toxicity alone can cause severe hypotension but usually responds to vasopressors, calcium, glucagon, and fluid resuscitation. Given the onset of angioedema, refractory hypotension, and rapid response to angiotensin II, lisinopril toxicity likely had a significant additive effect. We theorize that our patient's dramatic improvement with angiotensin II resulted from ACE blockade bypass. A case series from 1994 by Trilli et al. also suggested angiotensin II could be a physiologically reasonable therapy for ACE-I overdose. CONCLUSIONS: As far as we know, no trials examining the role of angiotensin II in acute ACE-I overdose exist. Further studies should investigate its use in cases when traditional therapy fails in critically ill patients. REFERENCE #1: Khanna A, English SW, Wang XS, Ham K, Tumlin J, Szerlip H, Busse LW, Altaweel L, Albertson TE, Mackey C, McCurdy MT, Boldt DW, Chock S, Young PJ, Krell K, Wunderink RG, Ostermann M, Murugan R, Gong MN, Panwar R, Hästbacka J, Favory R, Venkatesh B, Thompson BT, Bellomo R, Jensen J, Kroll S, Chawla LS, Tidmarsh GF, Deane AM; ATHOS-3 Investigators. Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017 Aug 3;377(5):419-430. doi: 10.1056/NEJMoa1704154. Epub 2017 May 21. PMID: 28528561. REFERENCE #2: Huang J, Buckley NA, Isoardi KZ, Chiew AL, Isbister GK, Cairns R, Brown JA, Chan BS. Angiotensin axis antagonists increase the incidence of haemodynamic instability in dihydropyridine calcium channel blocker poisoning. Clin Toxicol (Phila). 2021 Jun;59(6):464-471. doi: 10.1080/15563650.2020.1826504. Epub 2020 Oct 6. PMID: 33021397. REFERENCE #3: Trilli LE, Johnson KA. Lisinopril overdose and management with intravenous angiotensin II. Ann Pharmacother. 1994 Oct;28(10):1165-8. doi: 10.1177/106002809402801006. PMID: 7841571. DISCLOSURES: No relevant relationships by Jacob Gries No relevant relationships by Austin Hellings No relevant relationships by Joshua Long No relevant relationships by Emely Pimentel" @default.
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• W4387248741 date "2023-10-01" @default.
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• W4387248741 title "REFRACTORY HYPOTENSION FROM TOXIC INGESTION OF ACE-INHIBITOR AND DIHYDROPYRIDINE CALCIUM-CHANNEL BLOCKER TREATED WITH ANGIOTENSIN II" @default.
• W4387248741 doi "https://doi.org/10.1016/j.chest.2023.07.1459" @default.
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