{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T17:45:51Z","timestamp":1786470351598,"version":"build-2736575974"},"reference-count":39,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T00:00:00Z","timestamp":1780963200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T00:00:00Z","timestamp":1780963200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Pediatric Anesthesia"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>In pediatric\u2010aged patients, distributive (vasoplegic) shock is commonly caused by sepsis, anaphylaxis, or the humoral\/immunologic response following cardiopulmonary bypass. In general, the first\u2010line vasoactive agent for children is epinephrine or norepinephrine. In cases of fluid\u2010refractory shock requiring escalating doses of catecholamines, adjunct therapies such as vasopressin, hydrocortisone, hydroxycobalamin\u2010ascorbic acid, and methylene blue may be introduced. In 2017, the FDA approved a synthetic human angiotensin II (AT\u2010II) infusion preparation for treating adult patients with refractory vasodilatory shock. The following educational review examines the role of AT\u2010II as a vasoactive agent in the treatment of distributive shock with a focus on pediatric patients. A systematic search of the literature was performed to identify key publications regarding the therapeutic use of AT\u2010II for the treatment of distributive shock in adult and pediatric patients. Prospective studies in adult patients demonstrate the efficacy of AT\u2010II to treat refractory vasodilatory shock when escalating doses of conventional vasoactive agents (norepinephrine \u2265\u20090.2\u20130.3\u2009\u03bcg\/kg\/min) have failed. In these scenarios, AT\u2010II has been added as the third or fourth medication. There are limited trials evaluating AT\u2010II as the primary agent for vasodilatory shock in adults. The majority of studies have shown an improvement in mean arterial pressure (MAP); however, there has been limited impact on long\u2010term survival. Pediatric evidence to date has included 5 case reports and two larger retrospective case series encompassing a total of 44 patients. Although AT\u2010II was generally effective in increasing the MAP, given the non\u2010randomized and non\u2010prospective nature of these studies, information regarding the impact on long\u2010term outcomes is not available. Both adult and pediatric reports have outlined the potential utility of AT\u2010II in treating vasodilatory shock as primarily a rescue agent when conventional vasoactive agents fail or dose requirements escalate. To date, evidence\u2010based medicine demonstrates an increase in MAP with the ability to wean other vasoactive agents. The current studies do not appear to uniformly and clearly define a survival benefit. Future studies should focus on the potential survival impact of this novel vasoactive agent, further define dosing strategies, and more clearly outline its role as a primary agent or when other vasoactive agents fail.<\/jats:p>","DOI":"10.1002\/pan.70237","type":"journal-article","created":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T10:27:13Z","timestamp":1781000833000},"page":"1029-1040","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Role of Angiotensin\n                    <scp>II<\/scp>\n                    as a Vasoactive Agent to Treat Distributive Shock With a Focus on Preliminary Data in Pediatric\u2010Aged Patients"],"prefix":"10.1002","volume":"36","author":[{"given":"Shinya","family":"Ito","sequence":"first","affiliation":[{"name":"Department of Anesthesiology &amp; Pain Medicine Nationwide Children's Hospital  Columbus Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Spellman","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology &amp; Pain Medicine Nationwide Children's Hospital  Columbus Ohio USA"},{"name":"Department of Anesthesiology &amp; Pain Medicine The Ohio State University College of Medicine  Columbus Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Khan","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology &amp; Pain Medicine Nationwide Children's Hospital  Columbus Ohio USA"},{"name":"Department of Anesthesiology &amp; Pain Medicine The Ohio State University College of Medicine  Columbus Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0550-6951","authenticated-orcid":false,"given":"Joseph D.","family":"Tobias","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology &amp; Pain Medicine Nationwide Children's Hospital  Columbus Ohio USA"},{"name":"Department of Anesthesiology &amp; Pain Medicine The Ohio State University College of Medicine  Columbus Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,6,9]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00134-019-05878-6"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1542\/pir.2022-005630"},{"key":"e_1_2_11_4_1","doi-asserted-by":"publisher","DOI":"10.2147\/PHMT.S458438"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2024.0179"},{"key":"e_1_2_11_6_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13613-017-0261-x"},{"key":"e_1_2_11_7_1","doi-asserted-by":"publisher","DOI":"10.3389\/fmed.2022.826446"},{"key":"e_1_2_11_8_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.jvca.2018.08.017"},{"key":"e_1_2_11_9_1","doi-asserted-by":"publisher","DOI":"10.1097\/PCC.0000000000002295"},{"key":"e_1_2_11_10_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005344-199016004-00007"},{"key":"e_1_2_11_11_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1704154"},{"key":"e_1_2_11_12_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.jvca.2020.08.001"},{"issue":"1","key":"e_1_2_11_13_1","first-page":"199","article-title":"Outcomes in Patients With Vasodilatory Shock and Renal Replacement Therapy: A Post Hoc Analysis of ATHOS\u20103","volume":"22","author":"Tumlin J. 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