近日，智利天主教宗座大学Glenn Hernandez团队研究了针对早期感染性休克毛细血管再充盈时间的个性化血流动力学复苏效果。相关论文发表在2025年10月29日出版的《美国医学会杂志》上。

脓毒性休克早期血流动力学复苏的最佳策略尚不确定。

为了确定以毛细血管再充血时间（CRT-PHR）为目标的个性化血流动力学复苏方案对死亡率、生命支持持续时间和住院时间等分层复合结局的影响，研究组在19个国家的86个中心进行了一项随机临床试验。在2022年3月至2025年4月期间纳入感染性休克前4小时内的患者，最后一次随访于2025年7月。患者随机接受CRT-PHR（n=720)，包括评估脉压、舒张动脉压、液体反应性和床边超声心动图，以便与常规护理相比，量身定制液体、血管加压药物和收缩性药物（n = 747）。

主要结局是死亡率、生命支持持续时间（血管活性、机械通气和肾脏替代治疗）和住院时间（28天）的分层复合评估。通过比较所有可能的患者对，从分层中的第一个事件开始，并按入院时APACHE（急性生理和慢性健康评估）II评分中位数分层，计算主要结局的优势比。次要结局是死亡率、无生命支持天数和住院时间（28天）。

从1501名随机患者中，1467名患者被纳入初步分析（平均年龄66[17]岁；43.3%为女性）。在分级复合主要结局中，CRT-PHR组有131131次优势（48.9%），而常规护理组有112787次优势（42.1%），优势率为1.16（95%CI，1.02-1.33；P=0.04）。个人死亡胜率分别为19.1%和17.8%；生命支持持续时间，26.4%比21.1%；干预组和常规护理组的住院时间分别为3.4%和3.2%。

研究结果表明，在早期感染性休克患者中，针对毛细血管再充盈时间的个性化血流动力学复苏方案在主要综合结果方面优于常规护理，主要原因是生命支持持续时间较短。

附：英文原文

Title: Personalized Hemodynamic Resuscitation Targeting Capillary Refill Time in Early Septic Shock: The ANDROMEDA-SHOCK-2 Randomized Clinical Trial

Author: The ANDROMEDA-SHOCK- Investigators for the ANDROMEDA Research Network, Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), and Latin American Intensive Care Network (LIVEN), Fernando Pálizas, Bernardo Lattanzio, Natalia Durandal, Maria Eugenia Alonso, Julio Duque, Nicolas Falcon, Ruben Mesa, Martin Hunter, Mario Pozo, Facundo Gutierrez, Santiago Sac, Nicole Goette, Sebastián Consalvo, Pilar Zamudio, Gaston Murias, Juan Carlos Pendino, Lisandro Bettini, Juan Ignacio Ibarzabal, Valentin Torres, Federico Fiorilli, Walter Sacchi, Valentin Avila, Cecilia Gonzalez, Agustin Traverso, Antonella Lopipi, Giuliana Sterzer, Jesica Rodriguez Louzan, Elisa Estenssoro, Arnaldo Dubin, Glauco Westphal, Matheus Liguori, Lucas Tramujas, Bruna Piotto, Marcelo Romano, Fernando Medrano, Philippe Rola, Ross Prager, John Basmaji, Giorgio Ferri, Leonardo Hernández, Daniel Amigo, Alejandro Barra, Camilo Coba, Luis Valdivia, Juan Pablo Valdivia, Edward Petruska, Roselyn Noguera, Claudio Sarabia, Maria Alicia Cid, Jaime Tapia, Felipe Gonzalez, Felipe Morales, Alex Gomez, Carlos Yarur, Jose Segura, Ruth Rosales, Ronal Pairumani, Carla Araya, Eduardo Caon, Monserrat Vera, Macarena Larroulet, Carlos Gallo, Carlos Mero, Juan Nicolas Medel, Rodrigo Cornejo, Jorge Montoya, Nicolás Carreo, Víctor Illanes, César Cortés, Macarena Amthauer, Cecilia Gonzalez Almonacid, Rose Valerie Philp Sandoval, Pedro Javier Castillo Bascur, Renato Andrés Colima Mendoza, Claudia Beatriz Espinoza Casado

Issue&Volume: 2025-10-29

Abstract:

Importance  The optimal strategy for hemodynamic resuscitation in early septic shock remains uncertain.

Objective  To determine the effect of a personalized hemodynamic resuscitation protocol targeting capillary refill time (CRT-PHR) on a hierarchical composite outcome of mortality, duration of vital support, and length of hospital stay.

Design, Setting, and Participants  This randomized clinical trial was conducted in 86 centers in 19 countries. Patients within the first 4 hours of septic shock were included between March 2022 and April 2025, with last follow-up in July 2025.

Interventions  Patients were randomized to undergo CRT-PHR (n=720), including assessment of pulse pressure, diastolic arterial pressure, fluid responsiveness, and bedside echocardiography, to tailor fluids, vasopressors, and inotropes, vs usual care (n = 747).

Main Outcomes and Measures  The primary outcome was a hierarchical composite of mortality, duration of vital support (vasoactives, mechanical ventilation, and kidney replacement therapy), and length of hospital stay assessed at 28 days. A win ratio was calculated for the primary outcome by comparing all possible patient pairs, starting with the first event in the hierarchy and stratified by median APACHE (Acute Physiology and Chronic Health Evaluation) II score at admission. Secondary outcomes were mortality, vital support–free days, and length of hospital stay at 28 days.

Results  From 1501 randomized patients, 1467 were included in the primary analysis (mean age, 66 [17] years; 43.3% female). There were 131131 wins (48.9%) in the CRT-PHR group vs 112787 (42.1%) in the usual care group for the hierarchical composite primary outcome, with a win ratio of 1.16 (95% CI, 1.02-1.33; P=.04). Individual wins for death were 19.1% vs 17.8%; duration of vital support, 26.4% vs 21.1%; and length of hospital stay, 3.4% vs 3.2% in the intervention vs usual care groups, respectively.

Conclusions and Relevance  Among patients with early septic shock, a personalized hemodynamic resuscitation protocol targeting capillary refill time was superior to usual care for the primary composite outcome, primarily due to a lower duration of vital support.

DOI: 10.1001/jama.2025.20402

Source: https://jamanetwork.com/journals/jama/fullarticle/2840823