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Abstract：
BACKGROUND: Several studies have validated capillary refill time (CRT) as a marker of tissue hypoperfusion, and recent guidelines recommend CRT monitoring during septic shock resuscitation. Therefore, it is relevant to further explore its kinetics of response to short-term hemodynamic interventions with fluids or vasopressors. A couple of previous studies explored the impact of a fluid bolus on CRT, but little is known about the impact of norepinephrine on CRT when aiming at a higher mean arterial pressure (MAP) target in septic shock. We designed this observational study to further evaluate the effect of a fluid challenge (FC) and a vasopressor test (VPT) on CRT in septic shock patients with abnormal CRT after initial resuscitation. Our purpose was to determine the effects of a FC in fluid-responsive patients, and of a VPT aimed at a higher MAP target in chronically hypertensive fluid-unresponsive patients on the direction and magnitude of CRT response.
METHODS: Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80-85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions).
RESULTS: CRT decreased significantly with both tests (from 5 [3.5-7.6] to 4 [2.4-5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3-5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin.
CONCLUSIONS: Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research.
METHODS: Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80-85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions).
RESULTS: CRT decreased significantly with both tests (from 5 [3.5-7.6] to 4 [2.4-5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3-5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin.
CONCLUSIONS: Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research.
摘要：
背景：一些研究已经验证了毛细血管再充盈时间（CRT）作为组织灌注不足的标志，最近的指南建议在感染性休克复苏期间进行CRT监测。因此,这与进一步探讨其对液体或血管加压药短期血流动力学干预的反应动力学有关.先前的几项研究探讨了流体推注对CRT的影响，但在脓毒性休克中,以更高的平均动脉压(MAP)为目标时,对去甲肾上腺素对CRT的影响知之甚少.我们设计了这项观察性研究，以进一步评估初次复苏后出现CRT异常的感染性休克患者的液体激发（FC）和血管加压试验（VPT）对CRT的影响。我们的目的是确定FC对流体反应性患者的影响，在慢性高血压液体无反应患者中，针对CRT反应的方向和幅度，VPT旨在提高MAP目标。
方法：纳入34例脓毒性休克患者。在基线时评估液体反应性，和FC（500毫升/30分钟）在9例流体反应的患者。通过增加去甲肾上腺素剂量使MAP达到80-85mmHg30分钟，对25例患者进行了VPT。患者在至少两个时间点（基线，并在干预结束时)。
结果：CRT在两次测试中都显着降低（从5[3.5-7.6]到4[2.4-5.1]秒，FC后p=0.008；从4.0[3.3-5.6]到3[2.6-5]秒，VPT后p=0.03。在FC后的7/9患者中观察到CRT反应，在VPT后的14/25分中，但在后一组中有4名患者CRT恶化，他们都同时接受低剂量加压素。
结论：我们的研究结果支持液体推注可以改善持续低灌注的液体反应性脓毒性休克患者的CRT或产生中性效应。相反，在以前的高血压患者中提高NE剂量以靶向更高的MAP引起更异质的反应，在大多数情况下改善CRT，但是一些患者的皮肤灌注恶化，一个值得进一步研究的事实。
方法：纳入34例脓毒性休克患者。在基线时评估液体反应性，和FC（500毫升/30分钟）在9例流体反应的患者。通过增加去甲肾上腺素剂量使MAP达到80-85mmHg30分钟，对25例患者进行了VPT。患者在至少两个时间点（基线，并在干预结束时)。
结果：CRT在两次测试中都显着降低（从5[3.5-7.6]到4[2.4-5.1]秒，FC后p=0.008；从4.0[3.3-5.6]到3[2.6-5]秒，VPT后p=0.03。在FC后的7/9患者中观察到CRT反应，在VPT后的14/25分中，但在后一组中有4名患者CRT恶化，他们都同时接受低剂量加压素。
结论：我们的研究结果支持液体推注可以改善持续低灌注的液体反应性脓毒性休克患者的CRT或产生中性效应。相反，在以前的高血压患者中提高NE剂量以靶向更高的MAP引起更异质的反应，在大多数情况下改善CRT，但是一些患者的皮肤灌注恶化，一个值得进一步研究的事实。
