Clinical assessment of peripheral circulation

Lima, Alexandre; Bakker, Jan

doi:10.1097/mcc.0000000000000194

Cited by 41 publications

(26 citation statements)

References 32 publications

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“…Peripheral perfusion can be assessed by different techniques [ 11 ]. Nevertheless, we preferred to focus our study on a parameter easily measurable in almost any condition with even minimal training.…”

Section: Discussionmentioning

confidence: 99%

“…During circulatory dysfunction, compensatory mechanisms redistribute flow away from non-vital regions like the skin, making this a window for clinical assessment of circulatory dysfunction [ 2 , 3 , 9 , 10 ]. Parameters of peripheral perfusion can be easily evaluated at the bedside [ 11 ] and are used as triggers for fluid resuscitation (FR) in patients with sepsis-related acute circulatory dysfunction [ 12 , 13 ]. In addition, persistent abnormal peripheral perfusion has been associated with increased morbidity and mortality in patients with sepsis and septic shock [ 12 – 16 ] after intensive care resuscitation but this has not been explored at earlier stages.…”

Section: Introductionmentioning

confidence: 99%

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Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality

et al. 2017

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IntroductionAcute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome.MethodsWe performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered.ResultsNinety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7–7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9–16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality.ConclusionsHyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality

et al. 2017

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“…However, when analysing only patients with septic shock, this relationship was not significant. The association between MOF-related mortality and toe-to-room gradient temperature measured at H6 was unaffected by stratification on known arterial disease (defined as a previous vascular event, symptomatic or requiring therapeutic intervention) or by stratification on room temperature [ 28 ]. It is noteworthy that we applied no exclusion criteria in order to be as close as possible to the “real life”, and to identify a parameter that could be widely used in critically ill patients.…”

Section: Discussionmentioning

confidence: 99%

Toe-to-room temperature gradient correlates with tissue perfusion and predicts outcome in selected critically ill patients with severe infections

Bourcier

Pichereau

Boëlle

et al. 2016

Ann. Intensive Care

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BackgroundMicrocirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in severe sepsis and septic shock. As microcirculatory disorders have been identified as strong predictive factors of unfavourable outcome, there is a need to develop accurate parameters at the bedside to evaluate tissue perfusion. We evaluated whether different body temperature gradients could relate to sepsis severity and could predict outcome in critically ill patients with severe sepsis and septic shock.MethodWe conducted a prospective observational study in a tertiary teaching hospital in France. During a 10-month period, all consecutive adult patients with severe sepsis or septic shock who required ICU admission were included. Six hours after initial resuscitation (H6), we recorded the hemodynamic parameters and four temperature gradients: central-to-toe, central-to-knee, toe-to-room and knee-to-room.ResultsWe evaluated 40 patients with severe sepsis (40/103, 39 %) and 63 patients with septic shock (63/103, 61 %). In patients with septic shock, central-to-toe temperature gradient was significantly higher (12.5 [9.2; 13.8] vs 6.9 [3.4; 12.0] °C, P < 0.001) and toe-to-room temperature gradient significantly lower (1.2 [−0.3; 5.2] vs 6.0 [0.6; 9.5] °C, P < 0.001) than in patients with severe sepsis. Overall ICU mortality rate due to multiple organ failure (MOF) was 21 %. After initial resuscitation, toe-to-room temperature gradient was significantly lower in patients dead from MOF than in the survivors (−0.2 [−1.1; +1.3] °C vs +3.9 [+0.5; +7.2] °C, P < 0.001) and the difference in gradients increased during the first 24 h. Furthermore, toe-to-room temperature gradient was related to tissue perfusion parameters such as arterial lactate level (r = −0.54, P < 0.0001), urine output (r = 0.37, P = 0.0002), knee capillary refill time (r = −0.42, P < 0.0001) and mottling score (P = 0.001).ConclusionsToe-to-room temperature gradient reflects tissue perfusion at the bedside and is a strong prognosis factor in critically ill patients with severe infections.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0164-2) contains supplementary material, which is available to authorized users.

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“…Third, anemia and bleeding likely cause decreased hemoglobin levels, which again may result in a lower Δ A b . Finally, shock, strong and sharp pain, or hypothermia under certain conditions can cause decreased peripheral circulation blood volume and constricted peripheral arteries, causing lower Δ A b . Therefore, Δ A b could indicate the level of oxygen saturation and blood flow in a patient.…”

Section: Discussionmentioning

confidence: 99%

Association between venous blood lactate levels and differences in quantitative capillary refill time

Sato

Nogaki

et al. 2018

Acute Medicine & Surgery

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AimCapillary refill time has been widely adopted for clinical assessment of the circulatory status of patients in emergency settings. We previously introduced quantitative capillary refill time and found a positive association between longer quantitative capillary refill time and higher lactate levels in the intensive care units, but not in the emergency department. In this study, we aimed to identify a quantitative and clinically applicable index of circulatory status (ΔA b) that can be measured with quantitative capillary refill time, then evaluated the linear association between this index and lactate levels in the emergency department.MethodsWe undertook a prospective single‐center observational study at a university hospital from November 2015 to July 2016. We included 139 patients with endogenous diseases to test the association between quantitative capillary refill time, ΔA b (measured with a pulse oximeter), and lactate levels.ResultsΔA b was independently and significantly associated with high lactate levels (odds ratio [95% confidence interval]: 0.16 [0.05–0.45]).ConclusionsWe introduced ΔA b, measured using quantitative capillary refill time, as a surrogate index of lactate levels to overcome the shortcomings of capillary refill time. We showed that ΔA b is a feasible, non‐invasive, and rapid assessment of patients with high lactate levels in emergency primary care settings. Future multicenter studies with a longitudinal design should be undertaken to verify our findings.

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Clinical assessment of peripheral circulation

Cited by 41 publications

References 32 publications

Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality

Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality

Toe-to-room temperature gradient correlates with tissue perfusion and predicts outcome in selected critically ill patients with severe infections

Association between venous blood lactate levels and differences in quantitative capillary refill time

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