Episode Details

Date: November 27, 2025  Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are looking after a 65-year-old man who appears to be in septic shock. He presented after five days of fever and cough, and is now severely lethargic and hypotensive on arrival. You give him antibiotics and IV fluids immediately, but an hour later, his lactate comes back at 5, and you need to start norepinephrine to keep his MAP above 65. You put in a call to the intensive care unit (ICU) to get him transferred, and the intensivist asks you whether you have started personalized hemodynamic resuscitation targeting capillary refill time. You don’t want to sound dumb, but what the heck is personalized hemodynamic resuscitation protocol targeting capillary refill time? Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is the most severe end of that spectrum. Patients with sepsis have persistent hypotension requiring vasopressors to maintain MAP ≥65 mm Hg and a lactate >2 mmol/L despite adequate volume resuscitation (Sepsis‑3). In high-income countries, mortality has fallen but remains substantial.  In many settings, mortality can be between 30% to 70%. High-quality ED care requires early recognition, IV antibiotics, source control, hemodynamically directed fluids, and vasopressors. The management of septic shock has changed dramatically since the time that Ken and I started practice. We went through a period in which a very aggressive bundle of care was proposed, based on work by Dr. Emanuel Rivers, published in the NEJM in 2001. Then, we ran big trials on the components of that bundle, and found that none of them helped individually (ARISE, ProCESS & ProMISe). It was clear that these patients benefited from close attention and clinical reassessments, but aside from early antibiotics, the exact interventions needed were unclear. For a while, many people focused on trending lactate levels. We then saw the original ANDROMEDA SHOCK study, which showed that a resuscitation strategy focused on clinical assessments of capillary refill time was at least as good as a strategy focused on trending lactates. We have been left with the question of exactly how to improve capillary refill and which other targets are important. There has been a question about whether a higher MAP target might help (SGEM#90), especially in elderly patients with more baseline hypertension.  But the recent OPTRESS study showed worse outcomes with a higher MAP target in elderly septic shock patients. Therefore, aside from the consensus that providing early antibiotics is a good idea, there remain many questions about the ideal initial resuscitation strategy for septic shock patients. Clinical Question: In adult patients with septic shock, can death, duration of vital support, and/or hospital length of stay be improved by a “personalized hemodynamic resuscitation protocol targeting capillary refill time? Reference:  Hernandez et al. Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct Population: Adults (≥18 y) with septic shock per Sepsis‑3 (vasopressors after ≥1 L IV fluid and lactate >2 mmol/L), within 4 hours of shock onset. Key Exclusions: >4 h from shock onset; anticipated surgery or dialysis within 6 h; expected survival <90 days; refractory shock; DNAR; Child‑Pugh B/C; severe ARDS; active bleeding; pregnancy; inability to assess CRT (peripheral vascular disease, hypothermia, very dark skin tone, Raynaud phenomenon). Intervention: A personalized hemodynamic resuscitation protocol targeting capillary refill time (CRT) using a 6-hour stepwise algorithm (see below). Comparison: Usual care per local protocols/guidelines. Outcome: Primary Outcome: A hierarchical composite tested with a stratified win rat