Association of Sublingual Microcirculation Parameters and Capillary Refill Time in the Early Phase of ICU Admission*

Abstract

Objectives: This observational study was conducted to investigate capillary refill time (CRT) during the early phase of ICU admission in relationship with microvascular flow alteration and outcome in critically ill patients. Design: Prospective, observational, pilot study. Setting: ICU in a university hospital. Patients: Two hundred eighty-two critically ill adult patients admitted to the ICU. Interventions: None. Measurements and Main Results: All patients underwent simultaneous measurements by CRT and sidestream dark field imaging within 24 hours of ICU admission. Other clinical data such as demographic characteristics, hemodynamics, laboratory values, treatment, and physiologic parameters were also included simultaneously. Microcirculatory measurements were performed at 10.2 ± 5.7 hours after ICU admission. Of the 282 included patients, 106 (37.6%) were female, the median (interquartile range) age was 63 years (53–74 yr), and the median Sequential Organ Failure Assessment (SOFA) score was 5 (2–7). The primary finding was the association between CRT and simultaneous the condition of peripheral circulation (microvascular flow index [MFI]: r = –0.4430, p < 0.001; proportion of perfused vessels: r = –0.3708, p < 0.001; heterogeneity index: r = 0.4378, p < 0.001; perfused vessel density: r = –0.1835, p = 0.0020; except total vessel density: p = 0.9641; and De Backer score: p = 0.5202) in critically ill patients. In addition, this relationship was also maintained in subgroups. Microcirculatory flow abnormalities, 28-day mortality, and SOFA score appeared to be more severe for increasing CRT. In a multivariable analysis, prolonged CRT was independently associated with microvascular flow abnormalities (MFI < 2.6; odds ratio [OR], 1.608; 95% CI, 2.1–10.2; p < 0.001). Similarly, multivariable analysis identified CRT as an independent predictor of 28-day mortality (OR, 1.296; 95% CI, 1.078–1.558; p = 0.006). Conclusions: In our ICU population, a single-spot prolonged CRT was independently associated with abnormal microcirculation and increased mortality.

Capillary Refill Time Versus Sidestream Dark Field: Think Global, Act Local*

“…However, recent studies have questioned the advantage of these protocols over usual care (2–5). The current study by Huang et al (1) continues to inform our thinking around CRT as both a local and global marker of perfusion in the setting of shock resuscitation. The 2019 Andromeda-Shock trial by Hernández et al (6) used the same CRT-targeted protocols for resuscitation against a lactate-targeted group.…”

“…The current study by Huang et al (1) did have its limitations. Unlike the recent studies, this was not a goal-directed resuscitation study; rather, the CRT and MFI measurements were single-spot recordings obtained on average 10 hours after admission.…”

“…KEY WORDS: communication; critical illness; decision-making; end-of-life care; goals of care I n the wake of severe acute brain injury (SABI), families and loved ones are frequently asked to meet with ICU teams to discuss difficult decisions related to life and death. These conversations ideally employ a shared decision-making (SDM) process, with clinicians engaging surrogate decision-makers regarding major treatment decisions that depend on patients' values and personal preferences (1). A growing body of literature has developed around the need to engage families in timely discussions of prognosis and patient preferences (if known) (2), create communication strategies (3), develop and test decision aids (4), and focus interventions on perceived goal-concordant care.…”

“…I n this issue of Critical Care Medicine, Huang et al (1) report their results from a prospective comparison of capillary refill time (CRT) and microvascular flow index (MFI) using sublingual sidestream dark field (SDF) imaging on 282 critically ill patients within 24 hours of ICU admission. CRT was obtained using a microscope glass slide to compress the distal right index phalanx for 10 seconds and measured after release, recording the average of two sequential attempts over 1 minute and defining an abnormal CRT greater than or equal to 3 seconds.…”

Hemodynamic Support in Sepsis

“…A prolonged time (greater than 3 s) is significantly associated with increased mortality (odds ratio, 1.3). 57 Increased capillary time and mottled skin correlate well with alteration of the microcirculation identified with more advanced tools. 58 The Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status versus Serum Lactate Levels on 28-Day Mortality among Patients with Septic Shock (ANDROMEDA-SHOCK) trial randomized 424 patients with septic shock to an approach guided by capillary refill time normalization (assessed every 30 min) or by 20% or greater decrease in lactate levels per 2 h during an 8-h study period.…”