Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial

Annals of Intensive Care

Ricardo Castro¹  Glenn Hernández¹  Vanessa Oviedo¹  Dagoberto Soto¹  Eduardo Kattan¹  Leyla Alegría¹  Sebastian Bravo¹  Emilio Daniel Valenzuela¹  Magdalena Vera¹  Jan Bakker²  Nicolás Pavez³  Gustavo Ospina-Tascón⁴  César Santis⁵  Brusela Astudillo⁵  Giorgio Ferri⁵  María Alicia Cid⁵  Ronald Pairumani⁵ 

[1] Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile;Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, Santiago, Chile;Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA;Department Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, CA, The Netherlands;Division of Pulmonary, and Critical Care Medicine, New York University-Langone, New York, USA;Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Chile;Department of Intensive Care Medicine, Fundación Valle del Lili, Universidad ICES, Cali, Colombia;Unidad de Cuidados Intensivos, Hospital Barros Luco-Trudeau, Santiago, Chile;

关键词: Sepsis;    Septic shock;    Lactate;    Hypoxia;    Capillary refill time;   

DOI  :  10.1186/s13613-020-00767-4

来源: Springer

【 摘 要 】

BackgroundPersistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates.ResultsForty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed.ConclusionsCRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion.Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)

【 授权许可】

CC BY