Exploring the relationship between capillary refill time, skin blood flow and microcirculatory reactivity during early resuscitation of patients with septic shock: a pilot study

Contreras, Roberto; Hernández, Glenn; Valenzuela, Emilio Daniel; González, Cecilia; Ulloa, Rodrigo; Soto, Dagoberto; Castro, Ricardo; Guzmán, Camila; Oviedo, Vanessa; Alegría, Leyla; Vidal, Diego Bravo; Morales, Sebastián; Ospina-Tascón, Gustavo Adolfo; Bakker, Jan; Kattan, Eduardo

doi:10.1007/s10877-022-00946-7

Cited by 10 publications

(7 citation statements)

References 41 publications

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“…Our observation of an association between arterial lactate level and CRT was consistent with the literature [ 1 ]. Even though CRT is related to skin blood flow [ 14 , 30 ], we found no independent association between CRT absolute value on the one side and MAP and CVP values, corroborating the fact that it has other determinants than the macrocirculatory variables.…”

Section: Discussionsupporting

confidence: 52%

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Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

Fage,

Moretto,

Rosalba

et al. 2023

Crit Care

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Background Capillary refill time (CRT) has been suggested as a variable to follow during the course of septic shock. We systematically investigated the effects on CRT of volume expansion and norepinephrine. Methods In 69 septic shock patients, we recorded mean arterial pressure (MAP), cardiac index (CI), and 5 consecutive CRT measurements (video method, standardized pressure applied on the fingertip) before and after a 500-mL saline infusion in 33 patients and before and after an increase of the norepinephrine dose in 36 different patients. Fluid responders were defined by an increase in CI ≥ 15%, and norepinephrine responders by an increase in MAP ≥ 15%. Results The least significant change of CRT was 23%, so that changes in CRT were considered significant if larger than 23%. With volume expansion, CRT remained unchanged on average in patients with baseline CRT < 3 s (n = 7) and in all but one patient with baseline CRT ≥ 3 s in whom fluid increased CI < 15% (n = 13 “fluid non-responders”). In fluid responders with baseline CRT ≥ 3 s (n = 13), CRT decreased in 8 patients and remained unchanged in the others, exhibiting a dissociation between CI and CRT responses. The proportion of patients included > 24 h after starting norepinephrine was higher in patients with such a dissociation than in the other ones (60% vs. 0%, respectively). Norepinephrine did not change CRT significantly (except in one patient) if baseline CRT was ≥ 3 s and the increase in MAP < 15% (n = 6). In norepinephrine responders with prolonged baseline CRT (n = 11), it increased in 4 patients and remained unchanged in the other ones, which exhibited a dissociation between MAP and CRT responses. Conclusions In septic shock patients with prolonged CRT, CRT very rarely improves with treatment when volume expansion increases cardiac output < 15% and increasing norepinephrine increases MAP < 15%. When the effects of fluid infusion on cardiac output and of norepinephrine on MAP are significant, the response of CRT is variable, as it decreases in some patients and remains stable in others which exhibit a dissociation between changes in macrohemodynamic variables and in CRT. In this regard, CRT behaves as a marker of microcirculation. Trial registration: ClinicalTrial.gov (NCT04870892). Registered January15, 2021. Ethics committee approval CE SRLF 21-25.

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Section: Discussionsupporting

confidence: 52%

“…However, the physiological determinants of CRT are not well defined. CRT reflects skin perfusion and vascular reactivity [ 14 ]. It should thus be influenced by the microcirculation structure and function, and by some macrocirculatory variables, such as mean arterial pressure (MAP) and cardiac output.…”

Section: Introductionmentioning

confidence: 99%

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

Fage,

Moretto,

Rosalba

et al. 2023

Crit Care

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“…A recent pilot study in septic shock patients went one step further by evaluating the relationship between capillary refill time (CRT) and SBF both during a VOT and a thermal challenge. SBF and microvascular reactivity assessments were lower in septic shock patients compared with healthy volunteers and were strongly associated with abnormal CRT [67 ▪ ]. Finally, in patients with circulatory shock, SBF increased regardless of increases in CO [68].…”

Section: Laser-based Techniquesmentioning

confidence: 79%

Devices for assessing microcirculation

Edul

Gutiérrez

2023

Current Opinion in Critical Care

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Purpose of reviewDevices for assessing microcirculation at the bedside have been a technological breakthrough in the critical care field. Thanks to this technology, a large body of scientific evidence has highlighted the relevance of microcirculatory disruptions during critical illness. The goal of this review is to analyze the current knowledge concerning microcirculation monitoring, mainly focused on clinically available devices. Recent findingsNew evidence in oxygenation monitoring, advances in hand-held vital microscopes, and improvements in laser-based techniques ensure the possibility of detecting poor resuscitation, testing vascular reactivity, and assessing the effect of therapy during shock and resuscitation. SummaryCurrently, there are several methods for microcirculatory monitoring. To properly apply and correctly interpret the information they provide, clinicians should know the fundamental principles and the strengths and weaknesses of the clinically available devices.

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“…Variation of the reflected laser light is captured by the transducer, thus measuring red blood cell velocity and skin blood flow. A recent study by Contreras et al [39] demonstrated a significant correlation between CRT, skin blood flow and microvascular reactivity.…”

Section: Technical Aspects Of Peripheral Perfusion Assessmentmentioning

confidence: 94%

Perspectives on peripheral perfusion assessment

Kattan

Ibarra‐Estrada

Ospina-Tascón

et al. 2023

Current Opinion in Critical Care

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Purpose of review The ANDROMEDA-SHOCK trial positioned capillary refill time (CRT) assessment as a novel resuscitation target for septic shock. The purpose of this article is to summarize pathophysiological determinants of CRT, review new technical developments on peripheral perfusion assessment, and explore recent evidence on the role of CRT monitoring in septic shock and other critical conditions. Recent findings A growing body of evidence supports the role of peripheral perfusion assessment as a warning and prognostic signal in a variety of clinical conditions among severely ill patients. Recent physiological studies demonstrated a rapid improvement of CRT after a single fluid bolus or a passive leg raising maneuver, a fact which may have diagnostic and therapeutic implications. Moreover, a couple of posthoc analyses of ANDROMEDA-SHOCK trial, reinforce that a normal CRT at the start of septic shock resuscitation, or its rapid normalization, thereafter may be associated with significant better outcomes. Summary Recent data confirm the relevance of peripheral perfusion assessment in septic shock and other conditions in critically ill patients. Future studies should confirm these findings, and test the potential contribution of technological devices to assess peripheral perfusion.

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Exploring the relationship between capillary refill time, skin blood flow and microcirculatory reactivity during early resuscitation of patients with septic shock: a pilot study

Cited by 10 publications

References 41 publications

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

Devices for assessing microcirculation

Perspectives on peripheral perfusion assessment

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