The role of peripheral perfusion markers and lactate in septic shock resuscitation

Kattan E, Hernández G. The role of peripheral perfusion markers and lactate in septic shock resuscitation. J Intensive Med. 2022;2(1):17-21. doi:10.1016/j.jointm.2021.11.002.

Summary of "The Role of Peripheral Perfusion Markers and Lactate in Septic Shock Resuscitation"

Abstract

Septic shock is characterized by progressive hypoperfusion and tissue hypoxia, with various markers used to guide resuscitation. While lactate normalization has traditionally been a target, recent evidence highlights capillary refill time (CRT) as a superior marker for reducing mortality and treatment intensity. This review evaluates the role of CRT, lactate, and other perfusion markers in septic shock resuscitation, emphasizing a multimodal and patient-specific approach.

Key Points

1. Septic Shock Pathophysiology: Characterized by acute circulatory failure, leading to inadequate oxygen utilization and systemic hypoperfusion.
2. Lactate as a Marker: Persistent hyperlactatemia indicates poor prognosis but lacks specificity as it may result from stress-related hypermetabolism rather than hypoperfusion.
3. CRT as a Resuscitation Target: CRT’s faster kinetics and bedside applicability make it a promising alternative to lactate, supported by the ANDROMEDA-SHOCK trial.
4. ANDROMEDA-SHOCK Findings: CRT-targeted resuscitation reduced mortality (34.9% vs. 43.4%) and organ dysfunction compared to lactate-targeted approaches.
5. Hemodynamic Coherence: Early resuscitation efforts should aim to restore macrocirculation and microcirculation coherence, as late-stage interventions may worsen outcomes.
6. Fluid Overload Risks: Over-resuscitation increases mortality risk, emphasizing the importance of stopping resuscitation once adequate perfusion is restored.
7. Multimodal Monitoring: Combining CRT with other markers, such as ScvO₂ and venous-to-arterial CO₂ gap, enhances diagnostic accuracy and patient-specific intervention.
8. Peripheral Perfusion Tools: CRT and mottling score offer valuable prognostic insights and guide interventions, especially in resource-limited settings.
9. Dynamic Monitoring: Real-time perfusion assessments, including CRT responsiveness to fluid challenges, inform timely and appropriate resuscitation strategies.
10. Future Directions: Research is needed to refine CRT measurement techniques, explore optical technologies, and integrate CRT into routine pre-ICU and ED assessments.

Conclusion

Capillary refill time represents a practical and effective resuscitation target in septic shock, offering benefits over lactate in reducing mortality and guiding early interventions. A multimodal approach is critical for optimizing outcomes and avoiding complications like fluid overload.

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Discussion Questions

1. How can CRT-based strategies be integrated into standardized septic shock management protocols?
2. What additional tools or markers could complement CRT in low-resource settings?
3. How might future trials address gaps in CRT application and improve its diagnostic reliability?

Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

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