Contributing to the hidden curriculum: exploring the role of residents and newly graduated physicians.

The hidden curriculum has been investigated as a powerful force on medical student learning and ongoing physician professional development. Previous studies have largely focused on medical students' experiences as 'receivers' of the hidden curriculum. This study examined how residents and newly graduated physicians conceived of their roles as active participants in the hidden curriculum. An interpretative phenomenological study was employed using individual, semi-structured interviews with residents and newly graduated physicians (n = 5) to examine their roles in perpetuating the hidden curriculum. A thematic analysis was conducted using a reflexive approach. Findings include insight into how residents and newly graduated physicians: (a) navigate the hidden curriculum for their own professional development; (b) intervene in others' enactment of the hidden curriculum; and (c) seek to repair the hidden curriculum for the next generation through their teaching. In light of our findings, we argue that: (a) more research is needed to understand how early career physicians navigate their engagement with the hidden curriculum; (b) students and educators be supported to consider how their agency to impact the hidden curriculum is influenced by the sociocultural context; and (c) residents and early career physicians are poised to powerfully impact the hidden curriculum through the learning environments they create.

Navigating Uncertainty in Respiratory Assessment: The Interaction of Culture and Technology During Phase I Postanesthetic Recovery.

PURPOSE: To explore postanesthesia care unit (PACU) nurses' interactions with technology during the critical Phase I recovery period. DESIGN: Interpretive description was used to understand nurses' experiences. METHODS: Nine PACU nurses were recruited from three mid-sized hospitals within the same health authority in a Western Canadian province. Nurse participants were interviewed using a semistructured interview guide. FINDINGS: Nurses' interactions with technology were significantly influenced by PACU culture, as they constantly navigated a level of uncertainly about their patient's respiratory status. Three themes from the study are described. Theme 1 described nurses' confidence and trust in a visual sensory respiratory assessment process and the influence of anesthesia providers. Theme 2 described PACU nurses' guarded trust or rationalized mistrust in technology. Theme 3 highlighted the contextual influences, which sustained nurses' approach to respiratory assessment. CONCLUSIONS: PACU nurses practiced their intuitive sensory assessments with a projected strong sense of expert practice and minimal dependence on technology. PACU nurses expressed frustrations with current PACU bedside technology, particularly the respiratory module and described some experiences with delayed identification of hypoventilation and hypoxia. Rationalized behaviors with technology and alarm suppression were commonplace. Workplace culture sustained PACU nurses' respiratory assessment practices.

(Almost) forgetting to care: an unanticipated source of empathy loss in clerkship.

CONTEXT: The erosion of empathy in medical students is well documented. Both the hidden curriculum associated with poor role modelling and a sense of burnout have been proposed as key factors, but the precise mechanisms by which this loss of empathy occurs have not been elaborated. OBJECTIVES: In the context of a course designed to help students manage the hidden curriculum, we collected data that raised questions about current conceptualisations of the aspects of medical training that lead to loss of empathy. METHODS: We held nine sessions in the first year of clinical clerkship, in which we asked students to bring to the group their experiences of the hidden curriculum for reflection. Course sessions were recorded, transcribed and qualitatively analysed, and themes were generated for further exploration. RESULTS: We identified an identity developmental trajectory in early clerkship in which students started with feelings of excitement, transitioned quickly to 'shock and awe', progressed into 'survival mode' and then passed into a stage of 'recovery'. Interestingly, in the early stages, students' sense of empathic virtuosity was reinforced. It was not until later, when students were more comfortable in their clinical role, that they reported their tendency to connect with the patient only as an afterthought to the encounter, or not at all, and needed to remind themselves to care. CONCLUSIONS: We offer new data for consideration with regard to medical students' loss of empathy during early clinical training that suggest it is the process of making patient care routine that shifts the patient from the status of an individual with suffering to the object of the work of being a physician.

Harnessing the hidden curriculum: a four-step approach to developing and reinforcing reflective competencies in medical clinical clerkship.

Changing the culture of medicine through the education of medical students has been proposed as a solution to the intractable problems of our profession. Yet few have explored the issues associated with making students partners in this change. There is a powerful hidden curriculum that perpetuates not only desired attitudes and behaviors but also those that are less than desirable. So, how do we educate medical students to resist adopting unprofessional practices they see modeled by supervisors and mentors in the clinical environment? This paper explores these issues and, informed by the literature, we propose a specific set of reflective competencies for medical students as they transition from classroom curricula to clinical practice in a four-step approach: (1) Priming-students about hidden curriculum in their clinical environment and their motivations to conform or comply with external pressures; (2) Noticing-educating students to be aware of their motivations and actions in situations where they experience pressures to conform to practices that they may view as unprofessional; (3) Processing-guiding students to analyze their experiences in collaborative reflective exercises and finally; (4) Choosing-supporting students in selecting behaviors that validate and reinforce their aspirations to develop their best professional identity.

Cardiac ischemia in patients with septic shock randomized to vasopressin or norepinephrine.

INTRODUCTION: Cardiac troponins are sensitive and specific biomarkers of myocardial necrosis. We evaluated troponin, CK, and ECG abnormalities in patients with septic shock and compared the effect of vasopressin (VP) versus norepinephrine (NE) on troponin, CK, and ECGs. METHODS: This was a prospective substudy of a randomized trial. Adults with septic shock randomly received, blinded, a low-dose infusion of VP (0.01 to 0.03 U/min) or NE (5 to 15 µg/min) in addition to open-label vasopressors, titrated to maintain a mean blood pressure of 65 to 75 mm Hg. Troponin I/T, CK, and CK-MB were measured, and 12-lead ECGs were recorded before study drug, and 6 hours, 2 days, and 4 days after study-drug initiation. Two physician readers, blinded to patient data and drug, independently interpreted ECGs. RESULTS: We enrolled 121 patients (median age, 63.9 years (interquartile range (IQR), 51.1 to 75.3), mean APACHE II 28.6 (SD 7.7)): 65 in the VP group and 56 in the NE group. At the four time points, 26%, 36%, 32%, and 21% of patients had troponin elevations, respectively. Baseline characteristics and outcomes were similar between patients with positive versus negative troponin levels. Troponin and CK levels and rates of ischemic ECG changes were similar in the VP and the NE groups. In multivariable analysis, only APACHE II was associated with 28-day mortality (OR, 1.07; 95% CI, 1.01 to 1.14; P=0.033). CONCLUSIONS: Troponin elevation is common in adults with septic shock. We observed no significant differences in troponin, CK, and ECGs in patients treated with vasopressin and norepinephrine. Troponin elevation was not an independent predictor of mortality. TRIAL REGISTRATION: Controlled-trials.com ISRCTN94845869.

Vasopressin versus norepinephrine infusion in patients with septic shock.

BACKGROUND: Vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock, but its effect on mortality is unknown. We hypothesized that low-dose vasopressin as compared with norepinephrine would decrease mortality among patients with septic shock who were being treated with conventional (catecholamine) vasopressors. METHODS: In this multicenter, randomized, double-blind trial, we assigned patients who had septic shock and were receiving a minimum of 5 microg of norepinephrine per minute to receive either low-dose vasopressin (0.01 to 0.03 U per minute) or norepinephrine (5 to 15 microg per minute) in addition to open-label vasopressors. All vasopressor infusions were titrated and tapered according to protocols to maintain a target blood pressure. The primary end point was the mortality rate 28 days after the start of infusions. RESULTS: A total of 778 patients underwent randomization, were infused with the study drug (396 patients received vasopressin, and 382 norepinephrine), and were included in the analysis. There was no significant difference between the vasopressin and norepinephrine groups in the 28-day mortality rate (35.4% and 39.3%, respectively; P=0.26) or in 90-day mortality (43.9% and 49.6%, respectively; P=0.11). There were no significant differences in the overall rates of serious adverse events (10.3% and 10.5%, respectively; P=1.00). In the prospectively defined stratum of less severe septic shock, the mortality rate was lower in the vasopressin group than in the norepinephrine group at 28 days (26.5% vs. 35.7%, P=0.05); in the stratum of more severe septic shock, there was no significant difference in 28-day mortality (44.0% and 42.5%, respectively; P=0.76). A test for heterogeneity between these two study strata was not significant (P=0.10). CONCLUSIONS: Low-dose vasopressin did not reduce mortality rates as compared with norepinephrine among patients with septic shock who were treated with catecholamine vasopressors. (Current Controlled Trials number, ISRCTN94845869 [controlled-trials.com].).

Agreement in electrocardiogram interpretation in patients with septic shock.

OBJECTIVE: The reliability of electrocardiogram interpretation to diagnose myocardial ischemia in critically ill patients is unclear. In adults with septic shock, we assessed intra- and inter-rater agreement of electrocardiogram interpretation, and the effect of knowledge of troponin values on these interpretations. DESIGN: Prospective substudy of a randomized trial of vasopressin vs. norepinephrine in septic shock. SETTING: Nine Canadian intensive care units. PATIENTS: Adults with septic shock requiring at least 5 µg/min of norepinephrine for 6 hrs. INTERVENTIONS: Twelve-lead electrocardiograms were recorded before study drug, and 6 hrs, 2 days, and 4 days after study drug initiation. MEASUREMENTS: Two physician readers, blinded to patient data and group, independently interpreted electrocardiograms on three occasions (first two readings were blinded to patient data; third reading was unblinded to troponin). To calibrate and refine definitions, both readers initially reviewed 25 trial electrocardiograms representing normal to abnormal. Cohen's Kappa and the φ statistic were used to analyze intra- and inter-rater agreement. RESULTS: One hundred twenty-one patients (62.2 ± 16.5 yrs, Acute Physiology and Chronic Health Evaluation II 28.6 ± 7.7) had 373 electrocardiograms. Blinded to troponin, readers 1 and 2 interpreted 46.4% and 30.0% of electrocardiograms as normal, and 15.3% and 12.3% as ischemic, respectively. Intrarater agreement was moderate for overall ischemia (κ 0.54 and 0.58), moderate/good for "normal" (κ 0.69 and 0.55), fair to good for specific signs of ischemia (ST elevation, T inversion, and Q waves, reader 1 κ 0.40 to 0.69; reader 2 κ 0.56 to 0.70); and good/very good for atrial arrhythmias (κ 0.84 and 0.79) and bundle branch block (κ 0.88 and 0.79). Inter-rater agreement was fair for ischemia (κ 0.29), moderate for ST elevation (κ 0.48), T inversion (κ 0.52), and Q waves (κ 0.44), good for bundle branch block (κ 0.78), and very good for atrial arrhythmias (κ 0.83). Inter-rater agreement for ischemia improved from fair to moderate (κ 0.52, p = .028) when unblinded to troponin. CONCLUSIONS: In patients with septic shock, inter-rater agreement of electrocardiogram interpretation for myocardial ischemia was fair, and improved with troponin knowledge.

Transforming Disruption Into Innovation: A Partnership Between the COVID-19 Medical Student Response Team and the University of British Columbia.

The COVID-19 pandemic caused substantial disruptions in medical education. The University of British Columbia (UBC) MD Undergraduate Program (MDUP) is the sixth-largest medical school in North America. MDUP students and faculty developed a joint response to these disruptions to address the curriculum and public health challenges that the pandemic posed. After clinical activities were suspended in March 2020, third- and fourth-year MDUP students formed a COVID-19 Medical Student Response Team (MSRT) to support frontline physicians, public health agencies, and community members affected by the pandemic. A nimble organizational structure was developed across 4 UBC campuses to ensure a rapid response to meet physician and community needs. Support from the faculty ensured the activities were safe for the public, patients, and students and facilitated the provision of curricular credit for volunteer activities meeting academic criteria. As of June 19, 2020, more than 700 medical students had signed up to participate in 68 projects. The majority of students participated in projects supporting the health care system, including performing contact tracing, staffing public COVID-19 call centers, distributing personal protective equipment, and creating educational multimedia products. Many initiatives have been integrated into the MDUP curriculum as scholarly activities or paraclinical electives for which academic credit is awarded. This was made possible by the inherent flexibility of the MDUP curriculum and a strong existing partnership between students and faculty. Through this process, medical students were able to develop fundamental leadership, advocacy, communication, and collaboration skills, essential competencies for graduating physicians. In developing a transparent, accountable, and inclusive organization, students were able to effectively meet community needs during a crisis and create a sustainable and democratic structure capable of responding to future emergencies. Open dialogue between the MSRT and the faculty allowed for collaborative problem solving and the opportunity to transform disruption into academic innovation.

Developing a framework to support shared decision making for youth mental health medication treatment.

Medical shared decision making has demonstrated success in increasing collaboration between clients and practitioners for various health decisions. As the importance of a shared decision making approach becomes increasingly valued in the adult mental health arena, transfer of these ideals to youth and families of youth in the mental health system is a logical next step. A review of the literature and preliminary, formative feedback from families and staff at a Midwestern urban community mental health center guided the development of a framework for youth shared decision making. The framework includes three functional areas (1) setting the stage for youth shared decision making, (2) facilitating youth shared decision making, and (3) supporting youth shared decision making. While still in the formative stages, the value of a specific framework for a youth model in support of moving from a client-practitioner value system to a systematic, intentional process is evident.

Interaction of vasopressin infusion, corticosteroid treatment, and mortality of septic shock.

OBJECTIVE: Vasopressin and corticosteroids are often added to support cardiovascular dysfunction in patients who have septic shock that is nonresponsive to fluid resuscitation and norepinephrine infusion. However, it is unknown whether vasopressin treatment interacts with corticosteroid treatment. DESIGN: Post hoc substudy of a multicenter randomized blinded controlled trial of vasopressin vs. norepinephrine in septic shock. SETTING: Twenty-seven Intensive Care Units in Canada, Australia, and the United States. PATIENTS: : Seven hundred and seventy-nine patients who had septic shock and were ongoing hypotension requiring at least 5 microg/min of norepinephrine infusion for 6 hours. INTERVENTIONS: Patients were randomized to blinded vasopressin (0.01-0.03 units/min) or norepinephrine (5-15 microg/min) infusion added to open-label vasopressors. Corticosteroids were given according to clinical judgment at any time in the 28-day postrandomization period. MEASUREMENTS: The primary end point was 28-day mortality. We tested for interaction between vasopressin treatment and corticosteroid treatment using logistic regression. Secondary end points were organ dysfunction, use of open-label vasopressors and vasopressin levels. MAIN RESULTS: There was a statistically significant interaction between vasopressin infusion and corticosteroid treatment (p = 0.008). In patients who had septic shock and were also treated with corticosteroids, vasopressin, compared to norepinephrine, was associated with significantly decreased mortality (35.9% vs. 44.7%, respectively, p = 0.03). In contrast, in patients who did not receive corticosteroids, vasopressin was associated with increased mortality compared with norepinephrine (33.7% vs. 21.3%, respectively, p = 0.06). In patients who received vasopressin infusion, use of corticosteroids significantly increased plasma vasopressin levels by 33% at 6 hours (p = 0.006) to 67% at 24 hours (p = 0.025) compared with patients who did not receive corticosteroids. CONCLUSIONS: There is a statistically significant interaction between vasopressin and corticosteroids. The combination of low-dose vasopressin and corticosteroids was associated with decreased mortality and organ dysfunction compared with norepinephrine and corticosteroids.

Vasoactive drugs for vasodilatory shock in ICU.

PURPOSE OF REVIEW: Vasoactive drugs are the mainstay of hemodynamic management of vasodilatory shock when fluids fail to restore adequate tissue perfusion. In this review, studies published during the past year that increase our understanding of the use of vasoactive drugs in the ICU are discussed. RECENT FINDINGS: The Vasopressin and Septic Shock Trial did not find a difference between low-dose vasopressin and norepinephrine vs. norepinephrine alone in the hemodynamic support of septic shock, suggesting that either approach is reasonable. However, vasopressin may be beneficial in the less severe septic shock subgroup. In this study, patients who were also treated with corticosteroids, vasopressin, compared with norepinephrine, were associated with significantly decreased mortality. Epinephrine, phenylephrine and terlipressin can be used safely in the ICU setting as first-line therapy for septic shock. The incidence of global left ventricular hypokinesia in patients with septic shock is 60%, much higher than previously described. Although dobutamine remains the gold standard therapy for septic myocardial depression, combined milrinone and metoprolol therapy may be an effective alternative therapy. SUMMARY: Current evidence does not support a clear recommendation of one vasopressor over another; indeed norepinephrine, vasopressin, terlipressin, phenylephrine and epinephrine may be used safely with similar survival outcomes.

Understanding Professional Identity Formation in Early Clerkship: A Novel Framework.

PURPOSE: Medical educators should foster students' professional attitudes because individuals are more likely to act in accordance with medicine's professional values if these values have been internalized. Still, there is much to be learned about how students examine and negotiate their emerging identities. This study examined third-year medical students' experiences of professional identity formation (PIF) during clinical clerkship. METHOD: The authors relied on an interpretivist perspective, informed by a grounded theory approach, to analyze data, which were collected from a pilot course designed to support medical students' efforts to "unhide" the hidden curriculum in relation to their development as medical students and emerging professionals. RESULTS: Twelve third-year medical students engaged in 10 collaborative discussions with 3 faculty members, a resident, and a fourth-year student (2015-2016). Discussions facilitated students' reflection on their professional journeys. Analysis of transcribed discussions resulted in a conceptual framework useful for exploring and understanding students' reflections on their PIF. Through analyzing students' experiences, the authors identified 4 components that constituted PIF stories: context, focus, catalyst, process. CONCLUSIONS: The analysis resulted in the development of a conceptual framework and distinct identity formation themes. Discrete reflections focused on either students' current identity (being) or their sense of future self (becoming). The study identified catalysts that sparked participants' introspection about, or their processing of, identity. The moments that generate profound feelings of awareness in students are often moments that would not be recognizable (even post hoc) as remarkable by others.

Vasopressin decreases sepsis-induced pulmonary inflammation through the V2R.

UNLABELLED: The early use of vasopressors in sepsis has been associated with a decrease in immune activation independent of hemodynamic effects, although the mechanism behind this remains unclear. We hypothesize that low dose vasopressin will reduce the pulmonary inflammation associated with sepsis. Our aims were to (1) determine whether vasopressin reduces lipopolysaccharide (LPS)-induced pulmonary inflammation and (2) determine which vasopressin receptor is responsible for pulmonary immune modulation. Mice were treated with intraperitoneal LPS to induce both systemic and pulmonary inflammation. Vasopressin or saline was infused via peritoneal pump and interleukin 6 (IL-6) in lung and serum was measured at 6h. NF-kappaB activation as was determined in the lung through immunoblotting total and phospho-IkappaB. Hemodynamic data was also obtained at the 6h mark. In a separate series of experiments mice received both LPS and vasopressin infusion following pretreatment with vasopressin receptor antagonists to V1R, V2R and OTR. Low dose LPS dramatically raises both serum IL-6 and pulmonary levels of IL-6 and phospho-IkappaB despite no significant changes in mean arterial pressure at 6h. Compared to saline, vasopressin infusion significantly decreases both the pulmonary IL-6 levels and phospho-IkappaB in LPS treated mice without raising arterial pressure. Pretreatment with V2R antagonist results in complete attenuation of vasopressin's immunosuppressive effects, with restoration of pulmonary IL-6 and phospho-IkappaB levels to those seen with LPS alone. CONCLUSIONS: Vasopressin exerts a local anti-inflammatory effect on the lung through the V2R in a model of sepsis.

Reflecting on what? The difficulty of noticing formative experiences in the moment.

INTRODUCTION: In the spirit of enacting an educational model of guided, collective reflection to support positive professional identity construction in healthcare learners, we implemented a reflection-based course for medical students transitioning to clerkship with three goals: to sensitize learners to the hidden curriculum; to provide a safe and confidential forum to discuss their experiences; and to co-construct strategies to deal with the pressures in the clinical environment METHODS: We used a design-based research protocol. Twelve students participated in ten sessions starting during their transition to clerkship. Faculty debriefed after each session, adjusting the format of the subsequent sessions. Data included student logs, transcripts of the course sessions, faculty debriefings, and the course evaluation. Data were analyzed via an iterative process of independent coding and discussion. RESULTS: The main adjustments to the course were to eliminate didactic content in favour of using prompts prior to course sessions and de-emphasizing written reflection. Participants felt the course achieved its three goals and students reported enhanced resiliency during transition to clerkship, although, despite prompting, students offered no examples of their joining in with the negative behaviours around them. CONCLUSIONS: The course was successful in its key objectives. However, a key aspect of reflection, students noticing their own behaviour in the moment as something that needs to be reflected on, was challenging. Future research exploring the value of reflection as an intervention to redress the unwanted aspects of the hidden curriculum might focus on efforts to move the students to explicitly explore the enculturation process in themselves.

Bad medicine: low-dose dopamine in the ICU.

Low-dose dopamine administration (ie, doses < 5 microg/kg/min) has been advocated for 30 years as therapy in oliguric patients on the basis of its action on dopaminergic renal receptors. Recently, a large, multicenter, randomized, controlled trial has demonstrated that low-dose dopamine administered to critically ill patients who are at risk of renal failure does not confer clinically significant protection from renal dysfunction. In this review, we present the best evidence and summarize the effects of low-dose dopamine infusion in critically ill patients. We review the history and physiology of low-dose dopamine administration and discuss the reasons why dopamine is not clinically effective in the critically ill. In addition to the lack of renal efficacy, we present evidence that low-dose dopamine administration worsens splanchnic oxygenation, impairs GI function, impairs the endocrine and immunologic systems, and blunts ventilatory drive. We conclude that there is no justification for the use of low-dose dopamine administration in the critically ill.

Genetic polymorphisms in sepsis and septic shock: role in prognosis and potential for therapy.

Genetic epidemiologic studies suggest a strong genetic influence on the outcome from sepsis, and genetics may explain the wide variation in the individual response to infection that has long puzzled clinicians. Several candidate genes have been identified as important in the inflammatory response and investigated in case-controlled studies, including the tumor necrosis factor (TNF)-alpha and TNF-beta genes, positioned next to each other within the cluster of human leukocyte antigen class III genes on chromosome 6. Other candidate genes for sepsis and septic shock include the interleukin (IL)-1 receptor antagonist gene, the heat shock protein gene, the IL-6 gene, the IL-10 gene, the CD-14 gene, the Toll-like receptor (TLR)-4 gene, and the TLR-2 gene, to name a few. In this review, we summarize the evidence for a genetic susceptibility to development of sepsis and death from sepsis, discuss design of clinical genetics studies relevant to the study of complex disorders, consider the candidate genes likely to be involved in the pathogenesis of sepsis, and discuss the potential for targeted therapy of sepsis and septic shock based on genetic variability.

The evaluation and management of shock.

Shock is an emergency that requires continuous bedside evaluation, resuscitation, and re-evaluation. The initial bedside examination allows the clinician to determine whether the patient exhibits a clinical picture that is consistent with hypovolemic, cardiogenic, or vasodilatory shock. The primary survey dictates urgent initial resuscitation that usually consists of intubation, ventilation, and volume support. Vasoactive therapy is started when the patient is well volume-resuscitated and consists of inotropic support for cardiogenic shock and pressor therapy for vasodilatory shock. The secondary survey is helpful in revealing the cause of shock and necessary to institute early definitive therapy. Early shock has a hemodynamic component, which is often easily reversed. Septic shock and prolonged shock from any cause has an inflammatory component, which is not easily reversed and leads to multiple-system organ failure (MSOF) and death. Success in treatment of shock depends on early recognition of shock and the rapid tempo of resuscitation of its hemodynamic component to prevent or minimize the inflammatory component.

Science Review: Vasopressin and the cardiovascular system part 2 - clinical physiology.

Vasopressin is emerging as a rational therapy for vasodilatory shock states. In part 1 of the review we discussed the structure and function of the various vasopressin receptors. In part 2 we discuss vascular smooth muscle contraction pathways with an emphasis on the effects of vasopressin on ATP-sensitive K+ channels, nitric oxide pathways, and interaction with adrenergic agents. We explore the complex and contradictory studies of vasopressin on cardiac inotropy and coronary vascular tone. Finally, we summarize the clinical studies of vasopressin in shock states, which to date have been relatively small and have focused on physiologic outcomes. Because of potential adverse effects of vasopressin, clinical use of vasopressin in vasodilatory shock should await a randomized controlled trial of the effect of vasopressin's effect on outcomes such as organ failure and mortality.

The effects of vasopressin on acute kidney injury in septic shock.

OBJECTIVE: To compare the effects of vasopressin versus norepinephrine infusion on the outcome of kidney injury in septic shock. DESIGN AND SETTING: Post-hoc analysis of the multi-center double-blind randomized controlled trial of vasopressin versus norepinephrine in adult patients who had septic shock (VASST). PATIENTS AND INTERVENTION: Seven hundred seventy-eight patients were randomized to receive a blinded infusion of either low-dose vasopressin (0.01-0.03 U/min) or norepinephrine infusion (5-15 microg/min) in addition to open-label vasopressors and were included in the outcome analysis. All vasopressors were titrated and weaned to maintain a target blood pressure. MEASUREMENT AND RESULTS: RIFLE criteria for acute kidney injury were used to compare the effects of vasopressin versus norepinephrine. In view of multiple simultaneous comparisons, a p value of 0.01 was considered statistically significant. Kidney injury was present in 464 patients (59.6%) at study entry. In patients in the RIFLE "Risk" category (n = 106), vasopressin as compared with norepinephrine was associated with a trend to a lower rate of progression to renal "Failure" or "Loss" categories (20.8 vs. 39.6%, respectively, p = 0.03), and a lower rate of use of renal replacement therapy (17.0 vs. 37.7%, p = 0.02). Mortality rates in the "Risk" category patients treated with vasopressin compared to norepinephrine were 30.8 versus 54.7%, p = 0.01, but this did not reach significance in a multiple logistic regression analysis (OR = 0.33, 99% CI 0.10-1.09, p = 0.02). The interaction of treatment group and RIFLE category was significant in predicting mortality. CONCLUSIONS: Vasopressin may reduce progression to renal failure and mortality in patients at risk of kidney injury who have septic shock.