At six hours, high vasopressor dose plus poor perfusion marked a 74% mortality group

Design

Exploratory secondary analysis of a randomised trial (ANDROMEDA-SHOCK-2)

Population

1,363 patients with early septic shock

Primary outcome

28-day mortality

Effect

73.6% vs 23.7%, aHR 4.68 (3.31–6.64); LR+ 8.12 vs 2.71 for dose alone

ANDROMEDA-SHOCK-2 randomised patients with early septic shock to resuscitation strategies. This exploratory analysis of 1,363 patients asked whether adding markers of tissue perfusion to vasopressor dose, after six hours of protocolised resuscitation, better identifies refractory shock. It was published on 15 July.

A noradrenaline-equivalent dose above 0.5 µg/kg/min at six hours was present in 13.8%, with 47.9% mortality. When that dose was combined with both a capillary refill time over 3 seconds and a lactate that had not fallen, 3.9% of patients qualified, and 73.6% of them died by 28 days, against 23.7% of others (adjusted HR 4.68, 95% CI 3.31–6.64). Combining dose with either marker identified 9.1%, with 55% mortality. The combined definition separated risk much better than dose alone (positive likelihood ratio 8.1 vs 2.7).

The study does not test a treatment for this group, and the authors call it hypothesis-generating. But it supports a bedside habit that costs nothing: at the six-hour review, reassess capillary refill and repeat the lactate rather than judging severity on the vasopressor dose alone. Patients meeting the combined definition are the ones to escalate early.

• Recheck capillary refill time and lactate at about six hours of septic shock resuscitation.
• Treat high vasopressor dose with prolonged capillary refill and a non-falling lactate as a very high-risk state.
• Escalate senior review and consider additional measures early in patients meeting the combined definition.
• Use the combined picture when discussing prognosis with families.

Why it matters

It gives the six-hour review a sharper definition of who is not responding.

Don't overread it

This was an exploratory secondary analysis; it does not show that any treatment improves outcomes in this group.

The statistics, in plain English

A positive likelihood ratio of 8.1 means a patient meeting the combined definition is much more likely to be among those who die than one meeting the dose threshold alone (2.7). The 53 patients in the highest-risk group are few, so the estimate needs confirming elsewhere.

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