- Design
- Systematic review with frequentist and Bayesian meta-analysis of randomised trials
- Population
- 7 trials, 2,408 adults with septic shock
- Primary outcome
- 28-day mortality
- Effect
- RR 0.87 (95% CI 0.76 to 1.01), I² 0%; posterior probability of benefit 97.2%
Peripheral perfusion-guided resuscitation, mainly using capillary refill time, targets the skin's circulation rather than serum lactate when deciding whether more fluid or vasopressor is needed. This meta-analysis pooled seven randomised trials (2,408 adults with septic shock), searched to November 2025.
The pooled 28-day mortality risk ratio was 0.87 (95% CI 0.76 to 1.01, p = 0.06), with no heterogeneity between trials (I² 0%) and moderate certainty. A prespecified Bayesian analysis estimated a 97.2% probability that the true effect favours perfusion-guided resuscitation, consistent across different prior assumptions. The two largest, lowest-risk trials were each non-significant on their own.
The practical point is that capillary refill time is free, fast and repeatable at the bedside, and the evidence suggests it is at least as good a target as lactate, and possibly better. It also avoids chasing lactate that may stay high for reasons unrelated to perfusion. A definitive trial is still needed, so this is a reason to use capillary refill as a resuscitation target, not to abandon lactate monitoring.
- Measure capillary refill time in a standard way (fingertip, 10 seconds' pressure, good light) at presentation and repeatedly.
- Consider using normalisation of capillary refill as a resuscitation target in septic shock.
- Consider stopping fluid escalation once capillary refill has normalised, even if lactate is still falling.
- Keep monitoring lactate; it remains useful for prognosis and for spotting deterioration.
Why it matters
A free bedside sign may be as good a target as a laboratory test, and possibly better.
Don't overread it
The primary result was not statistically significant; this is a strong signal, not proof of benefit.
The statistics, in plain English
A risk ratio of 0.87 suggests about 13% fewer deaths, but the interval reaches 1.01, so the frequentist result just misses significance. The Bayesian 97% figure says benefit is likely; it does not say how big it is. No heterogeneity means the trials pointed the same way.
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