The edition · Emergency & Critical Care
Restricted fluids with early vasopressors matched liberal fluids in septic shock, with less pulmonary oedema; persistent hypoperfusion sharpens the refractory shock definition
A 1,000-patient emergency department trial leads an edition that adds a risk-stratification analysis in refractory shock, a target trial emulation of lidocaine versus amiodarone, and two pulmonary embolism assessment studies.
The edition in brief
In ARISE FLUIDS, 1,000 emergency department patients with septic shock were randomised to restricted fluids with early vasopressors or higher-volume fluids with later vasopressors. Days alive and out of hospital at day 90 were identical (median 76 in both groups; difference 0.0 days, 95% CI -2.7 to 2.7), and pulmonary oedema was less frequent with restricted fluids (0.6% vs 5.0%). A secondary analysis of ANDROMEDA-SHOCK-2 (1,363 patients) found that combining a high vasopressor dose with persistent hypoperfusion (abnormal capillary refill and non-falling lactate) after six hours identified 53 patients with 73.6% 28-day mortality, against 23.7% for the rest (adjusted HR 4.68); the authors call this hypothesis-generating. A target trial emulation of 2,451 out-of-hospital cardiac arrests found no statistically significant survival difference between lidocaine and amiodarone (26.2% vs 23.5%; difference 2.8%, 95% CI -0.6 to 6.2). In 194 patients with pulmonary embolism, emergency physician point-of-care ultrasound was 76.8% sensitive and 85.9% specific for right ventricular dysfunction against consultative echocardiography, and a composite shock score had similar associations to sPESI and ESC classes for short-term outcomes. A pearl on reassessing after each fluid bolus closes the edition.
Capillary refill plus lactate sharpened the definition of refractory septic shock
After six hours of resuscitation, check capillary refill and lactate as well as vasopressor dose when judging how sick a patient in shock is.
Lidocaine or amiodarone in shockable arrest: no clear survival difference
No clear survival difference between lidocaine and amiodarone; follow local protocol and avoid delay in either.
Bedside ultrasound for right ventricular dysfunction in PE: 77% sensitive, 86% specific
Treat a negative bedside ultrasound as incomplete in PE risk stratification and confirm with formal echocardiography when it matters.
A composite PE shock score performed similarly to sPESI for short-term outcomes
Keep using established PE risk tools; a shock score may help anticipate advanced intervention but needs prospective validation.
Reassess after every fluid bolus
Treat each bolus as a test: reassess perfusion and breathing before the next one.
ARISE FLUIDS: restricted fluids with early vasopressors matched liberal fluids, with less pulmonary oedema
Early vasopressors with restricted fluids are a reasonable alternative to liberal fluids in septic shock where monitoring allows, with less pulmonary oedema.
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