Mortality Effect of Peripheral Perfusion-Guided Resuscitation in Vasodilatory Shock: A Systematic Review and Dual Frequentist-Bayesian Meta-Analysis of Randomized Trials.

Summary

This preregistered systematic review included seven randomized trials involving 2,408 patients with septic shock. Peripheral-perfusion-guided resuscitation produced a mortality risk ratio of 0.87, which narrowly missed frequentist significance, while the Bayesian analysis estimated a 97.2% probability that the effect favored the intervention; the magnitude remains uncertain.

Key Findings

• Seven randomized controlled trials comprising 2,408 patients were included, with no detected statistical heterogeneity.
• The primary frequentist pooled risk ratio for 28-day mortality was 0.87 (95% confidence interval 0.76–1.01; P=0.06).
• The prespecified Bayesian analysis estimated a 97.2% posterior probability that the mortality risk ratio was below 1.
• The two largest and lowest-risk trials were individually nonsignificant, supporting uncertainty about the true treatment effect.

Clinical Implications

Peripheral perfusion measures may be reasonable adjuncts to current resuscitation assessment, but the evidence does not justify replacing standard care or lactate-based strategies. Clinicians should await adequately powered trials before changing mortality-focused protocols.

Limitations

• Only seven trials were available, and the confidence interval crossed the line of no effect.
• The included trials may differ in peripheral perfusion targets, co-interventions, patient selection, and adherence, limiting direct protocol generalizability.

Future Directions

Future multicenter randomized trials should use standardized peripheral perfusion targets, protocolized co-interventions, and sufficient power for mortality. Individual-patient-data analyses could identify phenotypes most likely to benefit and clarify interactions with lactate-guided resuscitation.