Written by Samuel Rouleau
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Personalized hemodynamic resuscitation targeting capillary refill time (PHR-CRT) over a 6-hour intervention period demonstrated less need for organ support in patients with septic shock at 28 days.
Capillary refill: the window to microcirculatory function
The ANDROMEDA-SHOCK-2 RCT is rad. It all starts with ANDROMEDA-SHOCK 1, which compared resuscitation of patients in septic shock based on targeting CRT vs. lactate levels, finding a non-significant mortality benefit and lower SOFA scores in the CRT group. This prompted a flurry of work on CRT, providing insight into the microcirculation of a patient. If the MAP is normal, but the CRT is > 3 seconds, there is a mismatch between the macrocirculation and microcirculation, and the DO2 isn’t optimized at the level of the capillary beds (i.e. your patient is still in shock).
ANDROMEDA-2 randomized 1,501 patients across 86 hospitals in 19 countries to PHR-CRT vs. “usual care” (local and international protocols). The key difference is that ANDROMEDA-1 was not individualized, and the interventions were the same for each patient if the CRT was abnormal. Included patients were adults with septic shock who had received minimum 1 L of IVF, were on norepinephrine, and had a lactate of at least 2.0. Patients randomized to the PHR-CRT group underwent a tiered intervention pathway individualized to their capillary refill and response (see below). The hierarchical, composite outcome favored the PHR-CRT group, win ratio 1.16 (95%CI 1.02-1.33, p = 0.04), primarily driven by lower duration of organ support in the PHR-CRT group (26.4% v 21.1%). On its own, mortality rates were similar and surprisingly low (19.1% vs. 17.8%).
How will this change my practice?
First, this article is a must read. Understanding the tiers/interventions and the assessments of fluid responsiveness are essential to putting this into practice. Check out: https://andromedashock2.com/tutorials/tutorials-english/.
- The protocol is immediately applicable to bedside because it relies on vital signs, physical exam, and bedside ultrasound.
- It standardizes how I check CRT and use it as a marker of shock and response to therapy.
- Incorporate ventilator maneuvers more frequently to assess for fluid responsiveness.
- Because this trial was non-blinded, I’m assuming there was clinical dilution in the effect seen.
Source
Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial. JAMA. 2025 Oct 29:e2520402. doi: 10.1001/jama.2025.20402. Epub ahead of print. PMID: 41159835; PMCID: PMC12573117.
