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ANDROMEDA-SHOCK – Capillary Refill vs. Lactate

March 13, 2019

Written by Clay Smith

Spoon Feed
Capillary-refill time (CRT) guided resuscitation was better than lactate clearance in patients with septic shock in regard to improving organ dysfunction at 72 hours (SOFA score) and barely missed statistical significance in reducing 28-day mortality.

Why does this matter?
Lactate clearance is a common resuscitation goal in septic shock. Would a low-tech, physical exam finding, CRT*, do just as well? It has been shown in a small RCT to decrease fluid administration compared to standard treatment in patients with septic shock.

Andromeda: I’d like to see Poseidon try to chain me naked to a rock!
This was a multicenter RCT with 424 patients with septic shock randomized to a step-by-step resuscitation protocol** guided by improvement in peripheral perfusion (CRT) or lactate clearance. For the primary outcome, mortality at 28-days was 34.9% (74 patients) in the CRT group and 43.4% (92 patients) in the lactate group; hazard ratio (HR), 0.75 (95% CI, 0.55-1.02; p = 0.06; risk difference, -8.5% (95% CI, -18.2%-1.2%). The mean SOFA score dropped by 1 point at 72 hours in the CRT group and was statistically significant. Even though the results didn’t quite reach statistical significance for the primary outcome of mortality, it was really close with just checking CRT. In per-protocol analysis, the HR was 0.72 (0.56 to 0.93), p = 0.01.

Another Spoonful
Remember, a p value of 0.05 as “significant” means a 5% chance that if the null hypothesis is true, those results were obtained. To quote Bryan Cotton on Twitter, “When are we gonna accept p<0.05 was pulled out of nowhere? No diff w/ p=0.06? Please…I know which freakin group I wanna be in! How about you?”

*”CRT was measured by applying firm pressure to the ventral surface of the right index finger distal phalanx with a glass microscope slide. The pressure was increased until the skin was blank and then maintained for 10 seconds. The time for return of the normal skin color was registered with a chronometer, and a refill time greater than 3 seconds was defined as abnormal.”

**Here is the protocol.

From cited article, Supplement 2

From cited article, Supplement 2

Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):654-664. doi: 10.1001/jama.2019.0071.

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What are your thoughts?