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Background: Capillary refill time (CRT) is the gold standard for evaluating peripheral organ perfusion; however, intraoperative CRT measurement is rarely used because it cannot be conducted continuously, and it is difficult to perform during general anesthesia. The peripheral perfusion index (PI) is another noninvasive method for evaluating peripheral perfusion. The PI can easily and continuously evaluate peripheral perfusion and could be an alternative to CRT for use during general anesthesia. This study aimed to determine the cutoff PI value for low peripheral perfusion status (prolonged CRT) by exploring the relationship between CRT and the PI during general anesthesia., Methods: We enrolled 127 surgical patients. CRT and the PI were measured in a hemodynamically stable state during general anesthesia. A CRT >3 s indicated a low perfusion status., Results: Prolonged CRT was observed in 27 patients. The median PI values in the non-prolonged and prolonged CRT groups were 5.0 (3.3-7.9) and 1.5 (1.2-1.9), respectively. There was a strong negative correlation between the PI and CRT ( r = -0.706). The area under the receiver operating characteristic curve generated for the PI was 0.989 (95% confidence interval, 0.976-1.0). The cutoff PI value for detecting a prolonged CRT was 1.8., Conclusion: A PI <1.8 could accurately predict a low perfusion status during general anesthesia in the operating room. A PI <1.8 could be used to alert the possibility of a low perfusion status in the operating room., Trial Registration: University Hospital Medical Information Network (UMIN000043707; retrospectively registered on March 22, 2021, https://center6.umin.ac.jp/cgi-open-bin/ctr&#95;e/ctr&#95;view.cgi?recptno = R000049905)., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Saudi Journal of Anesthesia.)

Resuscitation of septic shock is a complex issue because the cardiovascular disturbances that characterize septic shock vary from one patient to another and can also change over time in the same patient. Therefore, different therapies (fluids, vasopressors, and inotropes) should be individually and carefully adapted to provide personalized and adequate treatment. Implementation of this scenario requires the collection and collation of all feasible information, including multiple hemodynamic variables. In this review article, we propose a logical stepwise approach to integrate relevant hemodynamic variables and provide the most appropriate treatment for septic shock., Competing Interests: Prof Jean-Louis Teboul is a member of the Medical Advisory Board of Pulsion Medical Systems., (© 2022 The Author(s).)

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Copyright of Revista Chilena de Pediatría is the property of Revista Chilena de Pediatria and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: To evaluate the risk factors associated with fatality in mechanically ventilated neonates using multiple regression analysis. Design & settings: Prospective study conducted at Neonatal ICU at New Civil Hospital, Surat – a tertiary care centre, from December, 2007 to May, 2008 for 6 months. Methods: Fifty neonates in NICU consecutively put on mechanical ventilator during study period were enrolled in the study. The pressure limited time cycled ventilator was used. All admitted neonates were subjected to an arterial blood gas analysis along with a set of investigations to look for pulmonary maturity, infections, renal function, hyperbilirubinemia, intraventricular hemorrhage and congenital anomalies. Different investigation facilities were used as and when required during ventilation of neonates. Multiple logistic regression analysis was done to find out the predictors of fatality among these neonates. Results: Various factors suspected as predictors of fatality of mechanically ventilated neonates were assessed. Hypothermia, prolonged capillary refill time (CRT), initial requirement of oxygen fraction (FiO2) >0.6, alveolar to arterial PO2 difference (AaDO2) >250, alveolar to arterial PO2 ratio (a/A) 10 were found statistically highly significant predictors of mortality among mechanically ventilated neonates. Conclusion: Hypothermia and prolonged capillary refill time were independent predictors of fatality in neonatal mechanical ventilation. Risk of fatality can be identified in mechanically ventilated neonates

Purpose: Near-infrared spectroscopy has been used as a noninvasive monitoring tool for tissue oxygen saturation (StO) in acutely ill patients. This study aimed to investigate whether local vasoconstriction induced by body surface cooling significantly influences thenar StO as measured by InSpectra model 650. Methods: Eight healthy individuals (age 26 ± 6 years) participated in the study. Using a cooling blanket, we aimed to cool the entire body surface to induce vasoconstriction in the skin without any changes in central temperature. Thenar StO was noninvasively measured during a 3-min vascular occlusion test using InSpectra model 650 with a 15-mm probe. Measurements were analyzed for resting StO values, rate of StO desaturation (RdecStO, %/min), and rate of StO recovery (RincStO, %/s) before, during, and after skin cooling. Measurements also included heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), stroke volume (SV), capillary refill time (CRT), forearm-to-fingertip skin-temperature gradient (Tskin-diff), perfusion index (PI), and tissue hemoglobin index (THI). Results: In all subjects MAP, CO, SV, and core temperature did not change during the procedure. Skin cooling resulted in a significant decrease in StO from 82% (80-87) to 72% (70-77) ( P < 0.05) and in RincStO from 3.0%/s (2.8-3.3) to 1.7%/s (1.1-2.0) ( P < 0.05). Similar changes in CRT, Tskin-diff, and PI were also observed: from 2.5 s (2.0-3.0) to 8.5 s (7.2-11.0) ( P < 0.05), from 1.0°C (−1.6-1.8) to 3.1°C (1.8-4.3) ( P < 0.05), and from 10.0% (9.1-11.7) to 2.5% (2.0-3.8), respectively. The THI values did not change significantly. Conclusion: Peripheral vasoconstriction due to body surface cooling could significantly influence noninvasive measurements of thenar StO using InSpectra model 650 with 15-mm probe spacing. [ABSTRACT FROM AUTHOR]

Aim: Despite being widely recognized, the cephalocaudal progression of jaundice in newborns (Kramer's Rule) has never been satisfactorily explained. The aim of this study was to test the hypothesis that the cephalocaudal progression of jaundice in newborns is related to regional differences in skin temperature and skin perfusion. Methods: A convenience sample of 50 infants was included in the study. On each infant, a transcutaneous bilirubin, skin temperature and capillary refill time measurement was made at five sites; the forehead, sternum, lower abdomen, mid thigh and sole. The relationship between the three variables was studied by analysis of variance. Results: The transcutaneous bilirubin measurements upheld Kramer's observation, being significantly higher at the head and chest than at the thigh and sole ( P < 0.001). A similar pattern was found for both skin temperature and capillary refill, both significantly different at the head compared to the sole ( P < 0.001). Conclusion: The results of the study support the hypothesis that the cephalocaudal progression of jaundice in newborns is a consequence of diminished capillary blood flow in distal parts of the body. It is hypothesized that newborn infants preferentially perfuse their head and proximal parts of their body in the first few days of life, leading to higher temperatures and increased bilirubin deposition at these sites. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To test the hypothesis that pediatric shock is a common cause of death and functional morbidity and that pediatric advanced life support (PALS)/advanced pediatric life support (APLS) resuscitation in the community hospital setting improves child health outcomes. METHODS: This study included all children consecutively transported to 5 regional, tertiary care children's hospitals over 4 years, and is a prospective cohort study comparing outcomes in children who did or did not receive PALS/APLS resuscitation in the community hospital. RESULTS: Shock occurred in 37% of the patients transferred to the tertiary centers. Regardless of trauma status, children with shock had an increased mortality rate compared with those without shock (all patients: 11.4% vs 2.6%), trauma patients (28.3% vs 1.2%), and nontrauma patients (10.5% vs 2.8%). Early shock reversal was associated with reduced mortality (5.06% vs 16.37%) and functional morbidity (1.56% vs 4.11%) rates. Early use of PALS/APLS-recommended interventions was associated with reduced mortality (8.69% vs 15.01%) and functional morbidity (1.24% vs 4.23%) rates. After controlling for center, severity of illness, and trauma status, early reversal of shock and use of PALS/APLS-recommended interventions remained associated with reduced morbidity and mortality rates. CONCLUSIONS: Shock is common in children who are transferred for tertiary care. Pediatric shock recognition and resuscitation in the community hospital improves survival and functional outcome regardless of diagnostic category. The development of shock/trauma systems for children with and without trauma seems prudent. [ABSTRACT FROM AUTHOR]

We aimed to assess the relationship between the clinical and biochemical parameters of perfusion and superior vena cava (SVC) flow in a prospective observational cohort study of very low birth weight (VLBW) infants. Newborns with congenital heart disease were excluded. Echocardiographic evaluation of SVC flow was performed in the first 24 h of life. Capillary refill time (forehead, sternum and toe), mean blood pressure, urine output and serum lactate concentration were also measured simultaneously. Thirty-eight VLBW infants were examined. Eight patients (21%) had SVC flow less than 40 ml/kg/min. There was a poor correlation between the capillary refill time (in all sites), mean blood pressure, urine output and SVC flow. The correlation coefficient for the serum lactate concentration was r = -0.28, p = 0.15. The median serum lactate concentration was 3.5 (range 2.8-8.5) vs. 2.7 (range 1.2-6.9) mmol/l (p = 0.01) in low flow versus normal flow states. A serum lactate concentration of >2.8 was 100% sensitive and 60% specific for detecting a low flow state. Combining a capillary refill time of >4 s with a serum lactate concentration of >4 mmol/l had a specificity of 97% for detecting a low SVC flow state. Serum lactate concentrations are higher in low SVC flow states. A capillary refill time of >4 s combined with serum lactate concentrations >4 mmol/l increased the specificity and positive and negative predictive values of detecting a low SVC flow state. [ABSTRACT FROM AUTHOR]

The aim of the study was to assess the short-term cardiorespiratory effects of a standard red cell transfusion in very low birth weight (<1500 g) infants undergoing intensive care. A total of 37 infants (birth weight 920±230 g, gestational age 27.8±2.1 weeks, age at study 6.1±3.9 days) with indwelling arterial lines were studied when 10 ml/kg of packed donor red cells were transfused based on clinical judgment. Infants with patent ductus arteriosus and/or inotropic treatment were excluded from the study. Oxygen saturation, left ventricular output, stroke volume, systolic, diastolic and mean arterial pressure, heart rate, and capillary refill time were assessed immediately prior to the transfusion and within an hour after the transfusion was completed. Capillary refill time after the transfusion was significantly shorter than prior to the transfusion (2.1±0.9 versus 2.4±1.0 s, P =0.033). Left ventricular output, stroke volume and arterial pressures remained unaltered. Oxygen saturation after the transfusion was lower than before the transfusion (94.0±3.8 versus 95.3±2.5%, P =0.014) despite unaltered oxygen supply. Conclusion: the data suggest that although a red cell transfusion of 10 ml/kg may marginally improve peripheral perfusion, it does not influence cardiac output and arterial blood pressure in normotensive preterm infants. It may, however, cause a transient decrease in oxygen saturation. [ABSTRACT FROM AUTHOR]

Capillary refill time (CRT) has become universally used in paediatrics; it however has a number of limitations to its use as a marker of peripheral perfusion. These limitations include the effects of ambient temperature, environmental lighting conditions as well as different values being recorded at different sites of assessment; these have all been shown to have a bearing on its value. In older patients its range varies from 2 seconds to 4 seconds. All these variations have led to the removal of CRT from the trauma score. This paper reviews the influences on paediatric CRT. CRT does have a role as one of the physiological assessments of peripheral perfusion in combination with other markers such as heart rate, respiratory rate and level of consciousness. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Septic shock leads to progressive hypoperfusion and tissue hypoxia. Unfortunately, numerous uncertainties exist around the best monitoring strategy, as available techniques are mere surrogates for these phenomena. Nevertheless, central venous oxygen saturation (ScvO 2 ), venous-to-arterial CO 2 gap, and lactate normalization have been fostered as resuscitation targets for septic shock. Moreover, recent evidence has challenged the central role of lactate. Following the ANDROMEDA-SHOCK trial, capillary refill time (CRT) has become a promissory target, considering the observed benefits in mortality, treatment intensity, and organ dysfunction. Interpretation of CRT within a multimodal approach may aid clinicians in guiding resuscitative interventions and stop resuscitation earlier, thus avoiding the risk of morbid fluid overload. Integrative assessment of a patient's perfusion status can be easily performed using bedside clinical tools. Based on its fast kinetics and recent supporting evidence, targeting CRT (within a holistic assessment of perfusion) may improve outcomes in septic shock resuscitation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors. Published by Elsevier B.V. on behalf of Chinese Medical Association.)

Pulse examination, which reveals information about bodily qi and blood circulation, is an essential diagnostic tool in traditional Chinese medicine. Capillary refill time (CRT) is a simple test parameter for assessing circulation status. Examining the root of pulse and measuring CRT are extremely similar procedures. The objective of this study was to evaluate the effect of acupuncture on CRT. Three acupoints were selected to evaluate the effects of CRT. CRT, quantitative CRT, heart rate, core body temperature, and blood pressure were measured before acupuncture and immediately after removal of needles and 30 min after removal of needles. A total of 15 healthy adults representing both sexes were prospectively included in the study. The acupoints selected were bilateral Taixi (KI3), Hegu (LI4), and Zusanli (ST36). Each participant received acupuncture three times, interventions were separated by at least 2 days, and acupuncture was performed on only one acupoint at each intervention. CRT decreased significantly after acupuncture on only KI3. Quantitative CRT decreased significantly after acupuncture on KI3 and LI4. Heart rate changed significantly after acupuncture on KI3 and ST36. Acupuncture on KI3 can reduce CRT in health adults. • This is the first prospective study to demonstrate that acupuncture contributed to the reduction of capillary refill time. • To prevent observer bias, a new device that uses monitoring translucence was applied for measuring capillary refill time. • The PORH mode of a laser Doppler blood flow monitor was employed as a quantitative measurement tool. [ABSTRACT FROM AUTHOR]

Background: Capillary refill time (CRT) may improve more rapidly than lactate in response to increments in systemic flow. Therefore, it can be assessed more frequently during septic shock (SS) resuscitation. Hyperlactatemia, in contrast, exhibits a slower recovery in SS survivors, probably explained by the delayed resolution of non-hypoperfusion-related sources. Thus, targeting lactate normalization may be associated with impaired outcomes. The ANDROMEDA-SHOCK trial compared CRT- versus lactate-targeted resuscitation in early SS. CRT-targeted resuscitation associated with lower mortality and organ dysfunction; mechanisms were not investigated. CRT was assessed every 30 min and lactate every 2 h during the 8-h intervention period, allowing a first comparison between groups at 2 h (T2). Our primary aim was to determine if SS patients evolving with normal CRT at T2 after randomization (T0) exhibited a higher mortality and organ dysfunction when allocated to the LT arm than when randomized to the CRT arm. Our secondary aim was to determine if those patients with normal CRT at T2 had received more therapeutic interventions when randomized to the LT arm. To address these issues, we performed a post hoc analysis of the ANDROMEDA-SHOCK dataset. Results: Patients randomized to the lactate arm at T0, evolving with normal CRT at T2 exhibited significantly higher mortality than patients with normal CRT at T2 initially allocated to CRT (40 vs 23%, p = 0.009). These results replicated at T8 and T24. LT arm received significantly more resuscitative interventions (fluid boluses: 1000[500–2000] vs. 500[0–1500], p = 0.004; norepinephrine test in previously hypertensive patients: 43 (35) vs. 19 (19), p = 0.001; and inodilators: 16 (13) vs. 3 (3), p = 0.003). A multivariate logistic regression of patients with normal CRT at T2, including APACHE-II, baseline lactate, cumulative fluids administered since emergency admission, source of infection, and randomization group) confirmed that allocation to LT group was a statistically significant determinant of 28-day mortality (OR 3.3; 95%CI[1.5–7.1]); p = 0.003). Conclusions: Septic shock patients with normal CRT at baseline received more therapeutic interventions and presented more organ dysfunction when allocated to the lactate group. This could associate with worse outcomes. [ABSTRACT FROM AUTHOR]

The widely applied capillary refill time (CRT) measurement is currently performed by manually applying pressure and using a stopwatch to record the time taken for the skin to recover its normal colour after a blanching pressure is applied. This method is highly subjective and observer-dependent. This paper presents a new, integrated optical sensor probe, combining monitoring of the capillary refilling process with the blanching pressure applied. The sensor consists of an optical fibre-based reflectance photoplethysmography (PPG) sensor to measure the reflected light signal, as well as a fibre Bragg grating (FBG) to measure the applied blanching pressure and to indicate the time when pressure is released. This sensor was applied to calculate the CRT (1.38 ± 0.66 s) of 10 healthy adult volunteers with (55.2 ± 21.8 kPa) blanching pressures. The form of the capillary refilling data was investigated by fitting using an exponential regression model (R2 > 0.96). The integrated probe has the potential to improve the reliability of CRT measurements by standardising the optimum duration and magnitude of the pressure. [ABSTRACT FROM AUTHOR]

Purpose: To assess the presence of sublingual microcirculatory and skin perfusion alterations in COVID-19 pneumonia., Materials and Methods: This is a preliminary report of a prospective observational study performed in four teaching intensive care units. We studied 27 mechanically ventilated patients with acute respiratory distress syndrome secondary to COVID-19. Sublingual microcirculation was assessed by hand-held videomicroscopy. A software-assisted analysis of videos was performed. We also measured capillary refill time., Results: Patients were hemodynamically stable with normal lactate (1.8 [1.6-2.5] mmol/L) and high D-dimer (1.30 [0.58-2.93] μg/mL). Capillary refill time was prolonged (3.5 [3.0-5.0] s). Compared to previously reported normal values, total and perfused vascular density (21.9 ± 3.9 and 21.0 ± 3.5 mm/mm 2 ) and heterogeneity flow index (0.91 ± 0.24) were high; and the proportion of perfused vessels (0.96 ± 0.03), microvascular flow index (2.79 ± 0.10), and red blood cell velocity (1124 ± 161 μm/s) were reduced. The proportion of perfused vessels was inversely correlated with total vascular density (Pearson r = -0.41, P = 0.03)., Conclusions: COVID-19 patients showed an altered tissue perfusion. Sublingual microcirculation was characterized by decreases in the proportion of perfused vessel and flow velocity along with high vascular densities. This last finding might be related to enhanced angiogenesis or hypoxia-induced capillary recruitment., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2020. Published by Elsevier Inc.)

Capillary refill time (CRT) is yet to be established as a specific clinical sign of peripheral circulation in neonates. This study was conducted to assess the influence of four body sites used for measurement, interobserver variability, sex, birth weight, age at assessment and room temperature on CRT recorded in healthy term neonates, at bedside. Two observers measured CRT in four different body sites (forehead, chest, palm and heel) of each of 155 healthy term neonates. Significant differences occurred between the mean CRT recorded by the two observers in forehead (mean +/- SD: 2.62 +/- 0.8 s and 1.88 +/- 0.57 s; p < 0.001), palm (2.99 +/- 0.61 s and 2.75 +/- 1.12 s; p < 0.05) and heel (3.08 +/- 0.79 s and 4.24 +/- 1.84 s; p < 0.001). Only CRT in chest (2.7 +/- 0.42 s and 2.62 +/- 0.74 s) produced no significant differences in the means with a statistically significant and clinically fair, but not strong, interobserver agreement (r = 0.4; p < 0.001). No significant associations occurred between CRT and sex or birth weight. The associations of chest CRT with age at assessment (r = -0.23; p < 0.01) and room temperature (r = 0.27; p < 0.01) were clinically not important. In conclusion, CRT in neonates needs to be validated further before it can be useful as a specific clinical sign of peripheral circulation. [ABSTRACT FROM AUTHOR]

Measures of peripheral perfusion can be used to assess the hemodynamic status of critically ill patients. By monitoring peripheral perfusion status, clinicians can promptly initiate life-saving therapy and reduce the likelihood of shock-associated death. Historically, abnormal perfusion has been indicated by the observation of pale, cold, and clammy skin with increased capillary refill time. The utility of these assessments has been debated given that clinicians may vary in their clinical interpretation of body temperature and refill time. Considering these constraints, current sepsis bundles suggest the need to revise resuscitation guidelines. New technologies have been developed to calculate capillary refill time in the hopes of identifying a new gold standard for clinical care. These devices measure either light reflected at the surface of the fingertip (reflected light), or light transmitted through the inside of the fingertip (transmitted light). These new technologies may enable clinicians to monitor peripheral perfusion status more accurately and may increase the potential for ubiquitous hemodynamic monitoring across different clinical settings. This review will summarize the different methods available for peripheral perfusion monitoring and will discuss the advantages and disadvantages of each approach., Competing Interests: KSa is an employee of Nihon Kohden Corporation and Nihon Kohden Innovation Center, Inc. A pulse oximeter with the CRI function is marketed in Japan. This does not alter the authors' adherence to all the journal's policies on sharing data and materials. KSh and LB had a patent right of metabolic measurements in critically ill patients. KSh had a grant/research support from Nihon Kohden Corp. LB had a grant/research support from Philips Healthcare, the NIH, Nihon Kohden Corp., Zoll Medical Corp., PCORI, BrainCool, and United Therapeutics and owes patents including seven issued patents and several pending patents involving the use of medical slurries as human coolant devices to create slurries, reperfusion cocktails, and measurement of respiratory quotient. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Falotico, Shinozaki, Saeki and Becker.)

Background: Septic shock remains a significant cause of death in critically ill patients. During septic shock, some patients will retain microcirculatory disorders despite optimal hemodynamic support (i.e., fluid resuscitation, vasopressors, inotropes). Alterations in the microcirculation are a key pathophysiological factor of organ dysfunction and death in septic shock patients. Ilomedin is a prostacyclin analog with vasodilatory effect and anti-thrombotic properties (i.e., inhibition of platelet aggregation) preferentially at the microcirculatory level. We hypothesize that early utilization of intravenous Ilomedin in septic shock patients with clinical persistence of microperfusion disorders would improve the recovery of organ dysfunction., Methods: The I-MICRO trial is a multicenter, prospective, randomized, double-blinded, placebo-controlled study. We plan to recruit 236 adult patients with septic shock and persistent microcirculatory disorders (i.e., skin mottling or increased capillary refill time) despite hemodynamic support. Participants will be randomized to receive a 48-h intravenous infusion of either Ilomedin or placebo starting at the earliest 6 h and later 24 h after septic shock. The primary outcome will be the change (delta) of sequential organ failure assessment (SOFA) score between randomization and day 7. Secondary outcomes will include mean SOFA score during the first 7 days after randomization, mortality at day 28 post-randomization, number of ventilation-free survival days in the 28 days post-randomization, number of renal replacement therapy-free survival days in the 28 days post-randomization, number of vasopressor-free survival days in the 28 days post-randomization, and mottling score at day 1 after randomization., Discussion: The trial aims to provide evidence on the efficacy and safety of Ilomedin in patients with septic shock and persistent microcirculatory disorders., Trial Registration: NCT NCT03788837 . Registered on 28 December 2018.

Background: Assessment of tissue hypoxia at the bedside has yet to be translated into daily clinical practice in septic shock patients. Perfusion markers are surrogates of deeper physiological phenomena. Lactate-to-pyruvate ratio (LPR) and the ratio between veno-arterial PCO 2 difference and Ca-vO 2 (ΔPCO 2 /Ca-vO 2 ) have been proposed as markers of tissue hypoxia, but they have not been compared in the clinical scenario. We studied acute septic shock patients under resuscitation. We wanted to evaluate the relationship of these hypoxia markers with clinical and biochemical markers of hypoperfusion during septic shock resuscitation., Methods: Secondary analysis of a randomized controlled trial. Septic shock patients were randomized to fluid resuscitation directed to normalization of capillary refill time (CRT) versus normalization or significant lowering of lactate. Multimodal assessment of perfusion was performed at 0, 2, 6 and 24 hours, and included macrohemodynamic and metabolic perfusion variables, CRT, regional flow and hypoxia markers. Patients who attained their pre-specified endpoint at 2-hours were compared to those who did not., Results: Forty-two patients were recruited, median APACHE-II score was 23 [15-31] and 28-day mortality 23%. LPR and ΔPCO 2 /Ca-vO 2 ratio did not correlate during early resuscitation (0-2 h) and the whole study period (24-hours). ΔPCO 2 /Ca-vO 2 ratio derangements were more prevalent than LPR ones, either in the whole cohort (52% vs. 23%), and in association with other perfusion abnormalities. In patients who reached their resuscitation endpoints, the proportion of patients with altered ΔPCO 2 /Ca-vO 2 ratio decreased significantly (66% to 33%, P=0.045), while LPR did not (14% vs. 25%, P=0.34)., Conclusions: Hypoxia markers did not exhibit correlation during resuscitation in septic shock patients. They probably interrogate different pathophysiological processes and mechanisms of dysoxia during early septic shock. Future studies should better elucidate the interaction and clinical role of hypoxia markers during septic shock resuscitation., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-2048). The series “Hemodynamic monitoring in critically ill patients” was commissioned by the editorial office without any funding or sponsorship. GH served as the unpaid Guest Editor of the series. The other authors have no other conflicts of interest to declare., (2020 Annals of Translational Medicine. All rights reserved.)

Rationale: A recent randomized controlled trial showed that a peripheral perfusion-guided resuscitation strategy was associated with lower mortality and less organ dysfunction when compared with lactate-guided resuscitation strategy in patients with septic shock, but the difference in the primary outcome, 28-day mortality, did not reach the proposed statistical significance threshold (P = 0.06). We tested different analytic methods to aid in the interpretation of these results.Objectives: To reassess the results of the ANDROMEDA-SHOCK trial using both Bayesian and frequentist frameworks.Methods: All patients recruited in ANDROMEDA-SHOCK were included. Both a post hoc Bayesian analysis and a mixed logistic regression analysis were performed. The Bayesian analysis included four different priors (optimistic, neutral, null, and pessimistic) for mortality endpoints. The probability of having a Sequential Organ Failure Assessment in the lowest quartile at 72 hours was assessed using Bayesian networks.Measurements and Main Results: In the Bayesian analysis, the posterior probability that a peripheral perfusion-targeted resuscitation strategy is superior to lactate-targeted resuscitation at 28 days was above 90% for all priors; the probability of benefit at 90 days was above 90% for all but the pessimistic prior. Using an optimistic prior, posterior median odds ratios were 0.61 (95% credible interval, 0.41-0.90) and 0.68 (95% credible interval, 0.47-1.01) for 28-day and 90-day mortality, respectively. The comparable frequentist odds ratios for 28-day and 90-day mortality were 0.61 (95% confidence interval [CI], 0.38-0.92) and 0.70 (95% CI, 0.45-1.08), respectively. The odds that that patients in the peripheral perfusion-targeted resuscitation arm had Sequential Organ Failure Assessment scores in the lower quartile at 72 hours was 1.55 (95% CI, 1.02-2.37).Conclusions: Peripheral perfusion-targeted resuscitation may result in lower mortality and faster resolution of organ dysfunction when compared with a lactate-targeted resuscitation strategy. [ABSTRACT FROM AUTHOR]

Patients in shock present frequently to the emergency department. The emergency physician must be skilled in the resuscitation of both differentiated and undifferentiated shock. Early, aggressive resuscitation of patients in shock is essential, using macrocirculatory, microcirculatory, and clinical end points to guide interventions. Therapy should focus on the restoration of oxygen delivery to match tissue demand. This article reviews the evidence supporting common end points of resuscitation for common etiologies of shock and limitations to their use., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Sufficient organ perfusion essentially depends on preserved macro- and micro-circulation. The last two decades brought substantial progress in the development of less and non-invasive monitoring of macro-hemodynamics. However, several recent studies suggest a frequent incoherence of macro- and micro-circulation. Therefore, this review reports on interactions of macro- and micro-circulation as well as on specific regional and micro-circulation. Regarding global micro-circulation the last two decades brought advances in a more systematic approach of clinical examination including capillary refill time, a graded assessment of mottling of the skin and accurate measurement of body surface temperatures. As a kind of link between macro- and microcirculation, a number of biochemical markers can easily be obtained. Among those are central-venous oxygen saturation (S cv O 2 ), plasma lactate and the difference between central-venous and arterial CO 2 (cv-a-pCO 2 -gap). These inexpensive markers have become part of clinical routine and guideline recommendations. While their potential to replace parameters of macro-circulation such as cardiac output (CO) is limited, they facilitate the interpretation of the adequacy of CO and other macro-circulatory markers. Furthermore, they give additional hints on micro-circulatory impairment. In addition, a number of more sophisticated technical approaches to quantify and visualize micro-circulation including video-microscopy, laser flowmetry, near-infrared spectroscopy (NIRS), and partial oxygen pressure measurement have been introduced within the last 20 years. These technologies have been extensively used for scientific purposes. Moreover, they have been successfully used for educational purposes and to visualize micro-circulatory disturbances during sepsis and other causes of shock. Despite several studies demonstrating the association of these techniques and parameters with outcome, their practical application still is limited. However, future improvements in automated and "online" diagnosis will help to make these technologies more applicable in clinical routine. This approach is promising with regard to several studies which demonstrated the potential to guide therapy in different types of shock. Finally several organs have specific patterns of circulation related to their special anatomy (liver) or their auto-regulatory capacities (brain, kidney). Therefore, this review also discusses specific issues of monitoring liver, brain, and kidney circulation and function.