Written by Caitlin Nicholson
In septic shock patients, time from first hypotension to vasopressor initiation showed no association with 90-day mortality or vasopressor-free days.
The early vasopressor bird doesn’t always get the worm.
This large retrospective cohort study examined whether the timing of vasopressor initiation after the first documented hypotensive episode (SBP ≤100 mmHg) influenced outcomes in adults with septic shock using the OneFlorida Data Trust (2012–2018). Patients received vasopressors within 24 hours and had ICD-coded sepsis or infection plus IV antibiotics; illness severity was assessed with labSOFA, lactate, and mechanical ventilation. The primary outcome was 90-day mortality, with vasopressor-free days as a secondary measure. Using multivariable logistic regression, time to vasopressor initiation, both continuously and in 2-hour intervals, showed no association with 90-day mortality or vasopressor-free days. Among 4,699 patients, median time to vasopressors was 2.7 hours, and mortality was 34%. Mortality correlated with age, mechanical ventilation, elevated lactate, higher labSOFA, and liver disease, while hypertension history was associated with lower mortality. Sensitivity analyses using alternative blood pressure thresholds, inclusion of patients with incomplete timing data, and a high-lactate subgroup did not change results. Limitations include the retrospective design, reliance on documented timing of hypotension and interventions, lack of dynamic hemodynamic assessments, surrogate respiratory SOFA measurement, ICD-based inclusion, and single-state data.
How will this change my practice?
This study highlights the nuance of resuscitation in patients with septic shock and supports a more personalized approach to treatment. I will continue to treat sepsis aggressively, but instead of reflexively starting pressors, I will focus on assessing fluid responsiveness, prioritizing early antibiotics and overall hemodynamic stabilization, while considering the patient-specific factors (lactate, organ dysfunction, and ventilation needs), which also contribute significantly to mortality.
Source
Time to Vasopressor Initiation Is Not Associated With Increased Mortality in Patients With Septic Shock. Ann Emerg Med. 2025 Nov 3:S0196-0644(25)01238-7. doi: 10.1016/j.annemergmed.2025.09.024. Epub ahead of print. PMID: 41186550.
