Cap Refill and Lactate
During quantitative resuscitation, the EM physician collects data points to guide their actions. These include lab values (lactate, blood gasses, markers of end-organ function), hemodynamic values, POCUS echocardiograms, etc. But during reassessments, the physical exam continues to demonstrate an important role. 2019’s ANDROMEDA-SHOCK trial showed that targeting capillary refill was useful in improving organ dysfunction measures and had a non-significant reduction in mortality.1 A number of the same investigators just published another, much smaller, randomized control trial evaluating capillary refill versus lactate targeted resuscitation strategies.2
In this trial, 42 patients were randomized to targeting capillary refill time (CRT, standardized by blanching the palmar surface of the right index finger with a glass microscope slid for 10 seconds and then releasing the pressure and observing for return of color within 3 seconds) or lactate clearance time (LAC-T, <2 or a reduction of > 20%). Patients randomized to the CRT group achieved their assigned resuscitation endpoint faster and had equivalent improvement in hemodynamic and oxygenation markers. There was a non-significant decrease in volume administration and fluid balance as well.
Ultimately, this trial does not demonstrate the superiority of capillary refill compared with a lactate clearance strategy. But it does show us that a simple, bedside physical exam maneuver can reliably assess how a patient is improving during resuscitation.
1. Hernández G, Ospina-Tascón GA, Damiani LP, et al. 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: The Journal of the American Medical Association. 2019;321(7):654-664. doi:10.1001/jama.2019.0071
2. Castro R, Kattan E, Ferri G, et al. Effects of capillary refill time-vs. lactate-targeted fluid resuscitation on regional, microcirculatory and hypoxia-related perfusion parameters in septic shock: a randomized controlled trial. Ann Intensive Care. 2020;10(1):150. doi:10.1186/s13613-020-00767-4