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Huang W, Huang Y, Ke L, Hu C, Chen P, Hu B. Perspectives for capillary refill time in clinical practice for sepsis. Intensive Crit Care Nurs 2024; 84:103743. [PMID: 38896965 DOI: 10.1016/j.iccn.2024.103743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. Recent studies demonstrated the benefits of CRT in guiding fluid therapy for sepsis. However, lack of consistency among physicians in how to perform and interpret CRT has led to a low interobserver agreement for this assessment tool, which prevents its availability in sepsis clinical settings. OBJECTIVE To give physicians a concise overview of CRT and explore recent evidence on its reliability and value in the management of sepsis. RESEARCH DESIGN A narrative review. RESULTS This narrative review summarizes the factors affecting CRT values, for example, age, sex, temperature, light, observation techniques, work experience, training level and differences in CRT measurement methods. The methods of reducing the variability of CRT are synthesized. Based on studies with highly reproducible CRT measurements and an excellent inter-rater concordance, we recommend the standardized CRT assessment method. The threshold of normal CRT values is discussed. The application of CRT in different phases of sepsis management is summarized. CONCLUSIONS Recent data confirm the value of CRT in critically ill patients. CRT should be detected by trained physicians using standardized methods and reducing the effect of ambient-related factors. Its association with severe infection, microcirculation, tissue perfusion response, organ dysfunction and adverse outcomes makes this approach a very attractive tool in sepsis. Further studies should confirm its value in the management of sepsis. IMPLICATIONS FOR CLINICAL PRACTICE As a simple assessment, CRT deserves more attention even though it has not been widely applied at the bedside. CRT could provide nursing staff with patient's microcirculatory status, which may help to develop individualized nursing plans and improve the patient's care quality and treatment outcomes.
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Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China; Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Yiyan Huang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China.
| | - Li Ke
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
| | - Pengyu Chen
- Department of Urology, Shenzhen Children's Hospital, Futian District, Shenzhen 518000, Guangdong, China.
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.
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Yao Z, Chen Y, Li D, Li Y, Liu Y, Fan H. HEMORRHAGIC SHOCK ASSESSED BY TISSUE MICROCIRCULATORY MONITORING: A NARRATIVE REVIEW. Shock 2024; 61:509-519. [PMID: 37878487 DOI: 10.1097/shk.0000000000002242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
ABSTRACT Hemorrhagic shock (HS) is a common complication after traumatic injury. Early identification of HS can reduce patients' risk of death. Currently, the identification of HS relies on macrocirculation indicators such as systolic blood pressure and heart rate, which are easily affected by the body's compensatory functions. Recently, the independence of the body's overall macrocirculation from microcirculation has been demonstrated, and microcirculation indicators have been widely used in the evaluation of HS. In this study, we reviewed the progress of research in the literature on the use of microcirculation metrics to monitor shock. We analyzed the strengths and weaknesses of each metric and found that microcirculation monitoring could not only indicate changes in tissue perfusion before changes in macrocirculation occurred but also correct tissue perfusion and cell oxygenation after the macrocirculation index returned to normal following fluid resuscitation, which is conducive to the early prediction and prognosis of HS. However, microcirculation monitoring is greatly affected by individual differences and environmental factors. Therefore, the current limitations of microcirculation assessments mean that they should be incorporated as part of an overall assessment of HS patients. Future research should explore how to better combine microcirculation and macrocirculation monitoring for the early identification and prognosis of HS patients.
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Affiliation(s)
| | | | | | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, China
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La Via L, Sanfilippo F, Continella C, Triolo T, Messina A, Robba C, Astuto M, Hernandez G, Noto A. Agreement between Capillary Refill Time measured at Finger and Earlobe sites in different positions: a pilot prospective study on healthy volunteers. BMC Anesthesiol 2023; 23:30. [PMID: 36653739 PMCID: PMC9847031 DOI: 10.1186/s12871-022-01920-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/21/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Capillary Refill Time (CRT) is a marker of peripheral perfusion usually performed at fingertip; however, its evaluation at other sites/position may be advantageous. Moreover, arm position during CRT assessment has not been fully standardized. METHODS We performed a pilot prospective observational study in 82 healthy volunteers. CRT was assessed: a) in standard position with participants in semi-recumbent position; b) at 30° forearm elevation, c and d) at earlobe site in semi-recumbent and supine position. Bland-Altman analysis was performed to calculate bias and limits of agreement (LoA). Correlation was investigated with Pearson test. RESULTS Standard finger CRT values (1.04 s [0.80;1.39]) were similar to the earlobe semi-recumbent ones (1.10 s [0.90;1.26]; p = 0.52), with Bias 0.02 ± 0.18 s (LoA -0.33;0.37); correlation was weak but significant (r = 0.28 [0.7;0.47]; p = 0.01). Conversely, standard finger CRT was significantly longer than earlobe supine CRT (0.88 s [0.75;1.06]; p < 0.001) with Bias 0.22 ± 0.4 s (LoA -0.56;1.0), and no correlation (r = 0,12 [-0,09;0,33]; p = 0.27]. As compared with standard finger CRT, measurement with 30° forearm elevation was significantly longer (1.17 s [0.93;1.41] p = 0.03), with Bias -0.07 ± 0.3 s (LoA -0.61;0.47) and with a significant correlation of moderate degree (r = 0.67 [0.53;0.77]; p < 0.001). CONCLUSIONS In healthy volunteers, the elevation of the forearm significantly prolongs CRT values. CRT measured at the earlobe in semi-recumbent position may represent a valid surrogate when access to the finger is not feasible, whilst earlobe CRT measured in supine position yields different results. Research is needed in critically ill patients to evaluate accuracy and precision at different sites/positions.
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Affiliation(s)
- Luigi La Via
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.8158.40000 0004 1757 1969School of Specialization in Anesthesia and Intensive Care, University of Catania, 95123 Catania, Italy
| | - Carlotta Continella
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.411489.10000 0001 2168 2547School of Specialization in Anesthesia and Intensive Care, University Magna Graecia, 88100 Catanzaro, Italy
| | - Tania Triolo
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.411489.10000 0001 2168 2547School of Specialization in Anesthesia and Intensive Care, University Magna Graecia, 88100 Catanzaro, Italy
| | - Antonio Messina
- grid.417728.f0000 0004 1756 8807Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, 20089 Rozzano, Milan, Italy
| | - Chiara Robba
- grid.410345.70000 0004 1756 7871Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, 16100 Genoa, Italy
| | - Marinella Astuto
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero Universitaria “Policlinico – San Marco”, 95123 Catania, Italy ,grid.8158.40000 0004 1757 1969School of Specialization in Anesthesia and Intensive Care, University of Catania, 95123 Catania, Italy
| | - Glenn Hernandez
- grid.7870.80000 0001 2157 0406Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alberto Noto
- grid.10438.3e0000 0001 2178 8421Division of Anesthesia and Intensive Care, University of Messina, Policlinico’’G. Martino’’, 98121 Messina, Italy
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Nickel AJ, Hunter RB, Jiang S, Boulet JR, Hanks J, Napolitano N, Nadkarni VM, Nishisaki A. Comparison of Bedside and Video-Based Capillary Refill Time Assessment in Children. Pediatr Emerg Care 2022; 38:506-510. [PMID: 36083194 DOI: 10.1097/pec.0000000000002836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Capillary refill time (CRT) to assess peripheral perfusion in children with suspected shock may be subject to poor reproducibility. Our objectives were to compare video-based and bedside CRT assessment using a standardized protocol and evaluate interrater and intrarater consistency of video-based CRT (VB-CRT) assessment. We hypothesized that measurement errors associated with raters would be low for both standardized bedside CRT and VB-CRT as well as VB-CRT across raters. METHODS Ninety-nine children (aged 1-12 y) had 5 consecutive bedside CRT assessments by an experienced critical care clinician following a standardized protocol. Each CRT assessment was video recorded on a black background. Thirty video clips (10 with bedside CRT < 1 s, 10 with CRT 1-2 s, and 10 with CRT > 2 s) were randomly selected and presented to 10 clinicians twice in randomized order. They were instructed to push a button when they visualized release of compression and completion of a capillary refill. The correlation and absolute difference between bedside and VB-CRT were assessed. Consistency across raters and within each rater was analyzed using the intraclass correlation coefficient (ICC). A Generalizability study was performed to evaluate sources of variation. RESULTS We found moderate agreement between bedside and VB-CRT observations (r = 0.65; P < 0.001). The VB-CRT values were shorter by 0.17 s (95% confidence interval, 0.09-0.25; P < 0.001) on average compared with bedside CRT. There was moderate agreement in VB-CRT across raters (ICC = 0.61). Consistency of repeated VB-CRT within each rater was moderate (ICC = 0.71). Generalizability study revealed the source of largest variance was from individual patient video clips (57%), followed by interaction of the VB-CRT reviewer and patient video clip (10.7%). CONCLUSIONS Bedside and VB-CRT observations showed moderate consistency. Using video-based assessment, moderate consistency was also observed across raters and within each rater. Further investigation to standardize and automate CRT measurement is warranted.
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Affiliation(s)
| | - Ryan Brandon Hunter
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shen Jiang
- Nihon Kohden Innovation Center, Boston, MA
| | - John R Boulet
- National Board of Osteopathic Medical Examiners, Conshohocken
| | - Jasmine Hanks
- Clinical Research Support Office, Children's Hospital of Philadelphia
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Developing a translational triage research tool: part two-evaluating the tool through a Delphi study among experts. Scand J Trauma Resusc Emerg Med 2022; 30:48. [PMID: 35907858 PMCID: PMC9338674 DOI: 10.1186/s13049-022-01035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background There are different prehospital triage systems, but no consensus on what constitutes the optimal choice. This heterogeneity constitutes a threat in a mass casualty incident in which triage is used during multiagency collaboration to prioritize casualties according to the injuries’ severity. A previous study has confirmed the feasibility of using a Translational Triage Tool consisting of several steps which translate primary prehospital triage systems into one. This study aims to evaluate and verify the proposed algorithm using a panel of experts who in their careers have demonstrated proficiency in triage management through research, experience, education, and practice. Method Several statements were obtained from earlier reports and were presented to the expert panel in two rounds of a Delphi study. Results There was a consensus in all provided statements, and for the first time, the panel of experts also proposed the manageable number of critical victims per healthcare provider appropriate for proper triage management. Conclusion The feasibility of the proposed algorithm was confirmed by experts with some minor modifications. The utility of the translational triage tool needs to be evaluated using authentic patient cards used in simulation exercises before being used in actual triage scenarios.
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Shinozaki M, Shimizu R, Saito D, Nakada TA, Nakaguchi T. Portable measurement device to quantitatively measure capillary refilling time. ARTIFICIAL LIFE AND ROBOTICS 2022. [DOI: 10.1007/s10015-021-00723-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Toto RL, Vorel ES, Tay KYE, Good GL, Berdinka JM, Peled A, Leary M, Chang TP, Weiss AK, Balamuth FB. Augmented Reality in Pediatric Septic Shock Simulation: Randomized Controlled Feasibility Trial. JMIR MEDICAL EDUCATION 2021; 7:e29899. [PMID: 34612836 PMCID: PMC8529461 DOI: 10.2196/29899] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/13/2021] [Accepted: 07/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Septic shock is a low-frequency but high-stakes condition in children requiring prompt resuscitation, which makes it an important target for simulation-based education. OBJECTIVE In this study, we aimed to design and implement an augmented reality app (PediSepsisAR) for septic shock simulation, test the feasibility of measuring the timing and volume of fluid administration during septic shock simulation with and without PediSepsisAR, and describe PediSepsisAR as an educational tool. We hypothesized that we could feasibly measure our desired data during the simulation in 90% of the participants in each group. With regard to using PediSepsisAR as an educational tool, we hypothesized that the PediSepsisAR group would report that it enhanced their awareness of simulated patient blood flow and would more rapidly verbalize recognition of abnormal patient status and desired management steps. METHODS We performed a randomized controlled feasibility trial with a convenience sample of pediatric care providers at a large tertiary care pediatric center. Participants completed a prestudy questionnaire and were randomized to either the PediSepsisAR or control (traditional simulation) arms. We measured the participants' time to administer 20, 40, and 60 cc/kg of intravenous fluids during a septic shock simulation using each modality. In addition, facilitators timed how long participants took to verbalize they had recognized tachycardia, hypotension, or septic shock and desired to initiate the sepsis pathway and administer antibiotics. Participants in the PediSepsisAR arm completed a poststudy questionnaire. We analyzed data using descriptive statistics and a Wilcoxon rank-sum test to compare the median time with event variables between groups. RESULTS We enrolled 50 participants (n=25 in each arm). The timing and volume of fluid administration were captured in all the participants in each group. There was no statistically significant difference regarding time to administration of intravenous fluids between the two groups. Similarly, there was no statistically significant difference between the groups regarding time to verbalized recognition of patient status or desired management steps. Most participants in the PediSepsisAR group reported that PediSepsisAR enhanced their awareness of the patient's perfusion. CONCLUSIONS We developed an augmented reality app for use in pediatric septic shock simulations and demonstrated the feasibility of measuring the volume and timing of fluid administration during simulation using this modality. In addition, our findings suggest that PediSepsisAR may enhance participants' awareness of abnormal perfusion.
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Affiliation(s)
- Regina L Toto
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ethan S Vorel
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Khoon-Yen E Tay
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Grace L Good
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | | | - Adam Peled
- BrickSimple, LLC, Doylestown, PA, United States
| | - Marion Leary
- University of Pennsylvania School of Nursing, Philadelphia, PA, United States
| | - Todd P Chang
- Division of Emergency Medicine & Transport, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Anna K Weiss
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Frances B Balamuth
- Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
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Ballaji HK, Correia R, Liu C, Korposh S, Hayes-Gill BR, Musgrove A, Morgan SP. Optical Fibre Sensor for Capillary Refill Time and Contact Pressure Measurements under the Foot. SENSORS 2021; 21:s21186072. [PMID: 34577279 PMCID: PMC8470683 DOI: 10.3390/s21186072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/11/2021] [Accepted: 08/20/2021] [Indexed: 12/16/2022]
Abstract
Capillary refill time (CRT) refers to the time taken for body tissue to regain its colour after an applied blanching pressure is released. Usually, pressure is manually applied and not measured. Upon release of pressure, simple mental counting is typically used to estimate how long it takes for the skin to regain its colour. However, this method is subjective and can provide inaccurate readings due to human error. CRT is often used to assess shock and hydration but also has the potential to assess peripheral arterial disease which can result in tissue breakdown, foot ulcers and ultimately amputation, especially in people with diabetes. The aim of this study was to design an optical fibre sensor to simultaneously detect blood volume changes and the contact pressure applied to the foot. The CRT probe combines two sensors: a plastic optical fibre (POF) based on photoplethysmography (PPG) to measure blood volume changes and a fibre Bragg grating to measure skin contact pressure. The results from 10 healthy volunteers demonstrate that the blanching pressure on the subject’s first metatarsal head of the foot was 100.8 ± 4.8 kPa (mean and standard deviation), the average CRT was 1.37 ± 0.46 s and the time to achieve a stable blood volume was 4.77 ± 1.57 s. For individual volunteers, the fastest CRT measured was 0.82 ± 0.11 and the slowest 1.94 ± 0.49 s. The combined sensor and curve fitting process has the potential to provide increased reliability and accuracy for CRT measurement of the foot in diabetic foot ulcer clinics and in the community.
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Affiliation(s)
- Hattan K. Ballaji
- Optics and Photonics Group, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (H.K.B.); (R.C.); (C.L.); (S.K.); (B.R.H.-G.)
- Computer Engineering Department, College of Computers and Information System, Umm Al-Qura University, Makkah 24381, Saudi Arabia
| | - Ricardo Correia
- Optics and Photonics Group, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (H.K.B.); (R.C.); (C.L.); (S.K.); (B.R.H.-G.)
| | - Chong Liu
- Optics and Photonics Group, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (H.K.B.); (R.C.); (C.L.); (S.K.); (B.R.H.-G.)
| | - Serhiy Korposh
- Optics and Photonics Group, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (H.K.B.); (R.C.); (C.L.); (S.K.); (B.R.H.-G.)
| | - Barrie R. Hayes-Gill
- Optics and Photonics Group, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (H.K.B.); (R.C.); (C.L.); (S.K.); (B.R.H.-G.)
| | - Alison Musgrove
- Nottingham University Hospitals NHS Trust, Nottingham NG5 1PB, UK;
| | - Stephen P. Morgan
- Optics and Photonics Group, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (H.K.B.); (R.C.); (C.L.); (S.K.); (B.R.H.-G.)
- Correspondence:
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Abstract
PURPOSE OF REVIEW Current goals of resuscitation in septic shock are mainly a fixed volume of fluids and vasopressors to correct hypotension and improve tissue perfusion indicated by decreasing lactate levels. RECENT FINDINGS Abnormal peripheral perfusion by objective and subjective parameters are associated with increased mortality in various phases of the treatment of critically ill patients including patients with septic shock. Ongoing resuscitation in septic shock patients with normal peripheral perfusion is not associated with improved outcome, rather with increased mortality. Mitigation of fluid resuscitation by using parameters of peripheral perfusion in septic shock seems to be safe. SUMMARY Septic shock patients with normal peripheral perfusion represent a different clinical phenotype of patients that might benefit from limited resuscitation efforts. Parameters of peripheral perfusion could be used to guide the individualization of patients with septic shock.
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