by Ricardo Castro, Eduardo Kattan, Giorgio Ferri, Ronald
Pairumani, Emilio Daniel Valenzuela, Leyla Alegría, Vanessa Oviedo, Nicolás
Pavez, Dagoberto Soto, Magdalena Vera, César Santis, Brusela Astudillo, María
Alicia Cid, Sebastian Bravo, Gustavo Ospina-Tascón, Jan Bakker
Annals of Intensive Care volume 10,
Article number: 150 (2020)
Background
Persistent 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.
Results
Forty-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.
Conclusions
CRT-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)
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