Adding Dobutamine During Source-Control Surgery Cut Kidney Injury in Septic Shock. Mortality Did Not Differ Significantly.
In a 584-patient JAMA trial from 39 Chinese hospitals, published Oct. 14, new or worsening acute kidney injury within 7 days fell from 34.7 percent to 22.8 percent when intraoperative dobutamine was added to norepinephrine. Tachycardia was more common.
International sepsis guidelines recommend dobutamine for septic shock with cardiac dysfunction and persistent hypoperfusion, but the recommendation rests on very low-certainty evidence, and randomized data in the operating room have been lacking. A trial published Oct. 14 in JAMA tested the drug in a defined setting: adults with septic shock undergoing surgical source control.
Adding dobutamine to norepinephrine during surgery reduced new-onset or worsening acute kidney injury (AKI) within seven postoperative days to 22.8 percent (66 of 290) from 34.7 percent (102 of 294) with norepinephrine alone. The adjusted risk ratio was 0.64 (95% CI, 0.49 to 0.83; P = .001).
What the trial tested
The Chinese Perioperative Septic Shock Investigators ran the open-label trial at 39 tertiary hospitals in China between June 2024 and August 2025; outcome assessors and statisticians were blinded. Adults meeting Sepsis-3 criteria for septic shock who needed surgical source control expected to last more than an hour were randomized within 24 hours. Most operations were abdominal: gastrointestinal perforation accounted for roughly 40 to 44 percent and obstruction for about 29 to 31 percent, with necrotizing soft tissue infection, abscesses, cholangitis and ischemic bowel among the rest. Patients with chronic kidney disease or preoperative AKI were eligible. Cardiac dysfunction was not an entry requirement.
Dobutamine started at 5 µg/kg/min during surgery, alongside norepinephrine titrated to a mean arterial pressure of 65 mm Hg. It was cut to 2.5 µg/kg/min for a heart rate above 130/min or an arrhythmia with hemodynamic effect. Median infusion time was 155 minutes, and the protocol did not continue it after surgery. The primary outcome used KDIGO criteria.
Secondary outcomes and safety
Nine of 11 secondary outcomes did not differ. The day-1 Sequential Organ Failure Assessment score was lower with dobutamine (adjusted difference, -0.53) and urine output one hour after starting was higher (0.55 mL/kg/h), but SOFA scores on days 3 and 7 were similar. In post hoc analyses, stage 2 AKI was 4.8 percent vs. 9.9 percent and stage 3 was 7.9 percent vs. 13.6 percent, while stage 1 did not differ. Kidney replacement therapy within seven days was 9.0 percent vs. 10.9 percent (risk ratio 0.82; 95% CI, 0.52 to 1.27). Mortality at 28 days was 16.2 percent vs. 20.4 percent (risk ratio 0.75; 95% CI, 0.55 to 1.04), and at 90 days 18.6 percent vs. 23.1 percent; neither difference was statistically significant.
Tachycardia above 100/min occurred in 41.0 percent with dobutamine and 29.9 percent without (adjusted risk ratio 1.42). Rates of ventricular tachycardia, cardiac arrest and atrial fibrillation were low and similar between groups.
The kidney signal is real and sizable, but it came from an open-label trial with a short, intraoperative exposure and no proven change in dialysis or survival.
Limits
The design was open-label. Advanced hemodynamic monitoring was used in only some patients, so the authors could not say whether the benefit depends on baseline cardiac function. The intervention ran only during surgery, some patients received intraoperative starch or gelatin, and dobutamine was not compared with other inotropes. The results apply to surgical source control, not to medical septic shock. The trial was powered on an assumed 48 percent AKI rate in the control group; the observed rate was lower. The study was funded by Chinese government research grants, and the authors reported no conflicts, according to the paper.
What it means in clinic
For anesthesiologists, surgeons and intensivists sharing a septic patient headed to the operating room, this trial offers randomized evidence that a modest, fixed intraoperative dose of dobutamine added to norepinephrine protects the kidney. It is a reason to discuss the approach in perioperative sepsis protocols, with heart-rate limits written in, and a reason to watch for replication outside China and in patients with measured cardiac output. It sits alongside a sobering ICU result published the same day, SAVE-ICU's null mortality finding for inhaled sedation, and our earlier look at sepsis alerts physicians trust.
Reported, fact-checked and edited by The Script Pad's editorial staff.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
