Peripheral perfusion-targeted resuscitation does not lower mortality in septic shock patients

1. In this randomized controlled trial, there was no difference in 28-day mortality in patients with early septic shock between peripheral perfusion-targeted resuscitation and lactate level-target resuscitation strategies.

2. There was significantly less organ dysfunction at 72 hours in the peripheral perfusion group.

Evidence Rating Level: 2 (Good)

Study Rundown: Early resuscitation helps fight multiple organ dysfunction and death in septic shock patients, and the Surviving Sepsis Campaign proposed to guide hemodynamic resuscitation by repeated measurement of blood lactate levels every 2 to 4 hours. However, a peripheral perfusion strategy utilizing capillary refill time (CRT) is an easy-to-use surrogate for peripheral perfusion and may be easier to implement and more efficacious than serial lactates. In this randomized clinical trial of patients with early septic shock, a peripheral perfusion strategy did not result in lower 28-day mortality compared a lactate-level targeted strategy. However, there was less organ dysfunction at 72 hour in patients managed using the peripheral perfusion strategy.

The use of CRT can be problematic because it is dependent on age, sex, ambient temperature, light, pressure, and interrater reliability, although it seems to be at least as effective a strategy as serial lactates. The study is limited by its non-blind design and low power ,which may have affected its ability to show a meaningful difference between groups. Further, interrater variability for CRT was not evaluated, and randomization was not stratified by sites.

Click to read the study in JAMA

Click to read an accompanying editorial in JAMA

Relevant Reading: Relationship between Central and Peripheral Venous Oxygen Saturation and Lactate Levels: A Prospective Study.

In-Depth [randomized controlled trial]: 424 adult patients in septic shock were recruited for the ANDROMEDA-SHOCK trial from 28 hospitals in 5 countries (Argentina, Chile, Colombia, Ecuador, and Uruguay). Septic shock was defined as suspected or confirmed infection, hyperlactatemia (>=2mmol/L), and requirements of vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or higher after a fluid bolus of at least 20mL/kg over 60 minutes. Patients were randomized to peripheral perfusion-targeted resuscitation utilizing CRT to guide management or lactate level-targeted resuscitation utilizing reduction in lactate by 20% every 2 hours to guide management. The primary outcome was all-cause mortality at 28 days. Secondary outcomes were death within 90 days; organ dysfunction during the first 72 hours after randomization assessed by Sequential Organ Failure Assessment (SOFA) score, mechanical ventilation-free days within 28 days; renal replacement therapy-free days within 28 days; and ICU and hospital length of stay. By day 28, a total of 74 patients (34.9%) in peripheral perfusion group and 92 (43.4%) in lactate group had died (Hazard Ratio 0.75; CI₉₅ 0.55 to 1.02). The risk difference was -8.5% (CI₉₅ -18.2 to 1.2%). There was less organ dysfunction at 72 hours after randomization in the peripheral perfusion group (mean difference in SOFA score -1.00, CI₉₅ -1.97 to -0.02).

Image: PD

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