Capillary refill as a resuscitation target: seven trials, and a result that depends on which statistics you read

The edition in brief

Four findings and a pearl for the emergency and critical care desk. An individual patient data meta-analysis of six prospective prehospital studies covering 5,239 patients found HEART-derived risk scores incorporating point-of-care troponin identified low-risk suspected NSTE-ACS with 93.2% sensitivity and 99.8% negative predictive value for 30-day mortality, and 92.8% sensitivity for major adverse cardiac events - performance that held in well-organised services with reliable follow-up for patients not conveyed. A meta-analysis of 19 studies, nine pooled, found admission hypoalbuminaemia in burns associated with in-hospital mortality at an odds ratio of 9.51 (95% CI 3.04 to 29.78) and acute kidney injury at 2.83 (2.49 to 3.22), with no established cut-off value yet. A secondary analysis of the WEAN SAFE cohort described what happens to the 664 of 4,394 patients (15.1%) who enter weaning and fail it by day 90: ICU mortality of 78% against 2% in those who wean, and three distinct phenotypes separated by the number of separation attempts and the timing of decisions to withhold or withdraw life-sustaining therapy - with a failed first attempt strongly linked to those decisions. The practice-changer is a dual frequentist-Bayesian meta-analysis of seven trials in septic shock: peripheral perfusion-guided resuscitation gave a 28-day mortality risk ratio of 0.87 (0.76 to 1.01, p=0.06, moderate certainty, no heterogeneity) with a 97.2% Bayesian posterior probability of benefit, while the two largest and least biased trials were individually null. Plus a pearl on measuring capillary refill so the number means something.