A new treatment protocol for septic shock, a serious condition that kills about 40% of infected patients, is able to reduce the time patients need to remain on life support in the intensive care unit. The Andromeda-Shock-2 study, published in JAMA, shows that a simple test, such as capillary refill time — where you press on your fingertip and see how long it takes to return to normal color — can guide treatment.
Septic shock is a medical emergency in which an infection causes an uncontrolled inflammatory response in the body, leading to multiple organ failure and a dangerous drop in blood pressure. In Brazil, the number of cases is estimated at about 400,000 cases annually.
The research was conducted in 86 intensive care units in 19 countries, including Brazil, and included 1,467 patients. The customized protocol guided by capillary refill time was compared to conventional treatment, showing that the new method reduced the need for vasopressors (drugs to maintain blood pressure), mechanical ventilation and dialysis.
“For more than a decade we had no evidence of a protocol that could change the clinical outcomes of patients with septic shock,” explains Alexandre Biasi, MD, Intensive Care Physician, Director of Research and Teaching at Hcor and one of the leaders of the study in Brazil. The Brazilian institution was responsible for data management and statistical analysis of the results. The general coordination is the Pontifical Catholic University of Chile.
The developed protocol works in two steps. First, doctors evaluate your blood pressure. If there is a change, they give fluids or adjust vasopressors (which narrow the vessels) as needed in each case. If the capillary refill time does not return to normal, they move to the second phase, which includes echocardiographic tests to evaluate the heart’s function and administering dobutamine to improve the force of the heart’s contraction.
The new protocol had an overall performance of 16% better than the standard treatment, taking into account different potential outcomes. Specifically, patients treated with the new approach had, on average, 16.5 days free of life support in the first four weeks, compared with 15.4 days in the standard group.
Return of capillary refill time to normal in the first six hours was achieved by 85.9% of protocol patients, compared to 61.7% in conventional treatment. Patients also received less intravenous fluids — 595 mL versus 847 mL — an important finding because excess fluid can worsen the clinical condition.
While the traditional method relies primarily on the lactate test, which can take up to two hours to be ready in the laboratory, the capillary filling time provides instant results. “It is a test that responds quickly to therapeutic interventions. If you do not have adequate organ perfusion, capillary refilling becomes slow. As perfusion improves, tissue oxygenation improves, and capillary refilling begins to normalize,” Biasi explains.
He explains the limitations of lactate: “When adequate oxygen does not reach the organs, glucose cannot be adequately converted into energy, and lactate builds up. The problem is that lactate has limitations: it takes time to respond to treatment and there are other conditions that can increase it in addition to lack of oxygen.”
The first six hours after the diagnosis of septic shock are critical, and are the period when interventions have the greatest chance of changing the patient’s clinical progression. The new protocol allows doctors to make faster and more accurate decisions specifically in this critical window. One promising aspect is that the protocol does not require complex technology, and relies only on simple clinical assessments performed at the bedside.
In addition to publication in JAMA, the work was presented at the European Society of Intensive Care Congress, in Munich (Germany), and at the Brazilian Congress of Intensive Care Medicine. “This will certainly impact new treatment guidelines. Many ICUs and local groups may already decide to change their own protocols,” says Biasi.
“Our mission now is to get this off the ground and apply it in real life for people with septic shock. Usually the time between publishing something new and putting it into practice is years. We want to accelerate this process, especially here in Brazil, where we have a high incidence of sepsis.” Hcor plans to implement the protocol in the coming weeks, and other Brazilian institutions are expected to do so as well.