Abstract
Septic shock leads to progressive hypoperfusion and tissue hypoxia. Unfortunately, numerous uncertainties exist around the best monitoring strategy, as available techniques are mere surrogates for these phenomena. Nevertheless, central venous oxygen saturation (ScvO2), venous-to-arterial CO2 gap, and lactate normalization have been fostered as resuscitation targets for septic shock. Moreover, recent evidence has challenged the central role of lactate. Following the ANDROMEDA-SHOCK trial, capillary refill time (CRT) has become a promissory target, considering the observed benefits in mortality, treatment intensity, and organ dysfunction. Interpretation of CRT within a multimodal approach may aid clinicians in guiding resuscitative interventions and stop resuscitation earlier, thus avoiding the risk of morbid fluid overload. Integrative assessment of a patient’s perfusion status can be easily performed using bedside clinical tools. Based on its fast kinetics and recent supporting evidence, targeting CRT (within a holistic assessment of perfusion) may improve outcomes in septic shock resuscitation.
Key Points
- Septic Shock Pathophysiology: Characterized by acute circulatory failure, leading to inadequate oxygen utilization and systemic hypoperfusion.
- Lactate as a Marker: Persistent hyperlactatemia indicates poor prognosis but lacks specificity as it may result from stress-related hypermetabolism rather than hypoperfusion.
- 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.
- ANDROMEDA-SHOCK Findings: CRT-targeted resuscitation reduced mortality (34.9% vs. 43.4%) and organ dysfunction compared to lactate-targeted approaches.
- Hemodynamic Coherence: Early resuscitation efforts should aim to restore macrocirculation and microcirculation coherence, as late-stage interventions may worsen outcomes.
- Fluid Overload Risks: Over-resuscitation increases mortality risk, emphasizing the importance of stopping resuscitation once adequate perfusion is restored.
- Multimodal Monitoring: Combining CRT with other markers, such as ScvO₂ and venous-to-arterial CO₂ gap, enhances diagnostic accuracy and patient-specific intervention.
- Peripheral Perfusion Tools: CRT and mottling score offer valuable prognostic insights and guide interventions, especially in resource-limited settings.
- Dynamic Monitoring: Real-time perfusion assessments, including CRT responsiveness to fluid challenges, inform timely and appropriate resuscitation strategies.
- Future Directions: Research is needed to refine CRT measurement techniques, explore optical technologies, and integrate CRT into routine pre-ICU and ED assessments.
