Using Capillary Refill Time to Guide Sepsis Resuscitation

Authors: Hernández G et al.

JAMA 2019 Feb 19

We don’t know the best markers to assess adequate resuscitation of patients with sepsis. Although the Surviving Sepsis guidelines endorse using lactate clearance as guidance, it is a weak recommendation with low-quality evidence (NEJM JW Emerg Med Jun 2018 and Intensive Care Med 2018; 44:925). Current Centers for Medicare & Medicaid Services sepsis reporting (i.e., SEP-1) requires measuring lactate and repeating assessment if lactate is >2 mmol/L.

Investigators from South America randomized 424 patients with early septic shock to resuscitation guided by peripheral perfusion evaluation at 30-minute intervals (using capillary refill time [CRT])^* or by lactate level measured every 2 hours. Patient care was protocolized for stepwise interventions, including additional fluid boluses if fluid responsive (most commonly assessed by pulse pressure variation or straight-leg raise) and trials of inotropes and higher blood pressure goal for vasopressor titration.

Researchers found no significant differences in 28-day mortality, mechanical ventilation–free days, and renal replacement–free days between groups, but the mortality difference almost reached statistical significance (35% with CRT and 43% with lactate; P=0.06). The lactate-guided group received significantly more fluid. In a subgroup analysis among patients with lower sequential organ failure assessment (SOFA) scores, CRT-guided therapy was associated with lower mortality and less organ dysfunction.