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Blood lactate is a marker of tissue hypoxia while capillary refill time (CRT) is a surrogate of tissue perfusion. Measuring these parameters is recommended for assessing circulatory status and guiding resuscitation. However, blood lactate is not widely available in African emergency departments. Additionally, CRT assessment faces challenges related to its precision and reproducibility. This study aims to evaluate the accuracy of visual CRT(V-CRT) compared to plethysmographic CRT (P-CRT) in predicting lactate levels among septic patients. This prospective observational study enrolled consecutive patients with sepsis or septic shock over a 6-month period from a tertiary hospital in Marrakech, Morroco. V-CRT and P-CRT were evaluated upon admission, and simultaneous measurements of arterial lactate levels were obtained. The precision of V-CRT and P-CRT in predicting arterial lactate was assessed using ROC curve analysis. Forty-three patients aged of 64±15 years, of whom 70 % were male, were included in the study. Of these, 23 patients (53 %) had sepsis, and 20 patients (47 %) experienced septic shock. Both V-CRT and P-CRT demonstrated statistically significant correlations with arterial lactate, with correlation coefficients of 0.529 (p < 0.0001) and 0.517 (p = 0.001), respectively. ROC curve analysis revealed that V-CRT exhibited satisfactory accuracy in predicting arterial lactate levels >2 mmol/l, with an area under the curve (AUC) of 0.8 (95 % CI=0.65 – 0.93; p < 0.0001). The prediction ability of P-CRT was lower than V-CRT with an AUC of 0.73 (95 % CI: 0.57–0.89; p = 0.043). The optimal thresholds were determined as 3.4 s for V-CRT (sensitivity = 90 %, specificity = 58 %) and 4.1 s for P-CRT (sensitivity = 85 %, specificity = 62 %). These findings suggest that the plethysmographic evaluation did not improve the accuracy of CRT for predicting lactate level. However, V-CRT may still serve as a viable surrogate for lactate in septic patients in low-income settings. [ABSTRACT FROM AUTHOR]

Introduction: Blood lactate is a marker of tissue hypoxia while capillary refill time (CRT) is a surrogate of tissue perfusion. Measuring these parameters is recommended for assessing circulatory status and guiding resuscitation. However, blood lactate is not widely available in African emergency departments. Additionally, CRT assessment faces challenges related to its precision and reproducibility. This study aims to evaluate the accuracy of visual CRT(V-CRT) compared to plethysmographic CRT (P-CRT) in predicting lactate levels among septic patients. Methods: This prospective observational study enrolled consecutive patients with sepsis or septic shock over a 6-month period from a tertiary hospital in Marrakech, Morroco. V-CRT and P-CRT were evaluated upon admission, and simultaneous measurements of arterial lactate levels were obtained. The precision of V-CRT and P-CRT in predicting arterial lactate was assessed using ROC curve analysis. Results: Forty-three patients aged of 64±15 years, of whom 70 % were male, were included in the study. Of these, 23 patients (53 %) had sepsis, and 20 patients (47 %) experienced septic shock. Both V-CRT and P-CRT demonstrated statistically significant correlations with arterial lactate, with correlation coefficients of 0.529 (p < 0.0001) and 0.517 (p = 0.001), respectively. ROC curve analysis revealed that V-CRT exhibited satisfactory accuracy in predicting arterial lactate levels >2 mmol/l, with an area under the curve (AUC) of 0.8 (95 % CI=0.65 – 0.93; p < 0.0001). The prediction ability of P-CRT was lower than V-CRT with an AUC of 0.73 (95 % CI: 0.57–0.89; p = 0.043). The optimal thresholds were determined as 3.4 s for V-CRT (sensitivity = 90 %, specificity = 58 %) and 4.1 s for P-CRT (sensitivity = 85 %, specificity = 62 %). Conclusion: These findings suggest that the plethysmographic evaluation did not improve the accuracy of CRT for predicting lactate level. However, V-CRT may still serve as a viable surrogate for lactate in septic patients in low-income settings.

Prolonged capillary refill time (CRT) is an indicator of poor peripheral perfusion. The aim of the systematic review and meta-analysis was to evaluate the association of prolonged CRT and mortality of critically ill patients. To achieve the objective of this meta-analysis, we conducted a thorough search of PubMed, Embase, Cochrane Library, and the Web of Science to identify relevant observational studies with longitudinal follow-up. The Cochrane Q test was utilized to assess between-study heterogeneity, and the I2 statistic was calculated to estimate the degree of heterogeneity. We employed random-effects models to combine the outcomes, considering the potential influence of heterogeneity. Eleven studies, encompassing 11,659 critically ill patients were included. During follow-up durations within hospitalization to 3 months, 1247 (10.7%) patients died. The pooled results indicated that a prolonged CRT at early phase of admission was significantly associated with an increased risk of all-cause mortality (risk ratio [RR]: 1.73, 95% confidence interval [CI]: 1.39 to 2.16, p < 0.001; I2 = 60%). Subgroup analyses showed that the association was not significantly modified by study design (prospective or retrospective), etiology of diseases (infection, non-infection, or mixed), or cutoff of CRT (>3 s, 3.5 s, or 4 s). The association between CRT and mortality was weaker in studies with multivariate analysis (RR: 1.43, 95% CI: 1.27 to 1.60, p < 0.001; I2 = 0%) as compared to that derived from studies of univariate analysis (RR: 6.27, 95% CI: 3.29 to 11.97, p < 0.001; I2 = 0%). Prolonged CRT at admission may be a predictor of increased short-term mortality of critically ill patients. [ABSTRACT FROM AUTHOR]

Capillary refill time (CRT) is an internationally accepted indicator of peripheral circulation. The CRT is measured by applying compression to the fingernail for a few seconds, releasing it, and observing the process of refilling of blood at the fingertip. The international guidelines for the management of sepsis and septic shock 2021 contains an additional new recommendation for CRT measurement to determine the peripheral circulation statuses of adult patients with septic shock. However, the current CRT measurement method lacks objectivity. Previous studies have reported the development of measurement devices and video analysis systems, which involve complex measurement environment construction and assume only in-hospital measurements. In addition, since medical workers are limited in the number of carrying medical devices, devices that can be used to obtain multiple biometric indicators in a single measurement are needed. Hence, a prototype wearable CRT measurement device was developed in this study, and its feasibility was evaluated by comparing the agreement, intra-class correlation coefficient, and coefficient of variation with those of a CRT measurement device developed in the past. The results indicated that mean CRTs between measurement methods were agreement, with moderate or better intra-rater reliability and no difference in coefficient of variation. Therefore, the results indicate the feasibility of the proposed wearable CRT device. [ABSTRACT FROM AUTHOR]

Purpose: Capillary Refill Time (CRT) measurement has gained increasing attention in the field of sepsis and septic shock. Recognizing pressure as a fundamental determinant in CRT measurement is crucial for establishing a standardized CRT measurement procedure. In this preliminary study, we elucidated the optimal pressing strength for CRT measurement by analyzing the CRTs measured under varying pressures. Method: Seventeen healthy individuals were enlisted to undergo CRT tests on their fingertips at various pressure levels. The applied force was initiated at 0.5N and incrementally increased by 0.5N until it reached 10.5N. An integrated Photoplethysmography (PPG) device was employed to capture fluctuations in light intensity. The CRT was automatically derived from the PPG signals via a specialized algorithm. The study included correlation assessment and reliability evaluation. Box plot and Bland-Altman plot were used to visualize the impact of pressure levels on CRTs. Results: A dataset of 1414 CRTs across 21 pressures showed significant differences (Kruskal-Wallis test, p

Abstract Background Skin mottling is a common manifestation of peripheral tissue hypoperfusion, and its severity can be described using the skin mottling score (SMS). This study aims to evaluate the value of the SMS in detecting peripheral tissue hypoperfusion in critically ill patients following cardiac surgery. Methods Critically ill patients following cardiac surgery with risk factors for tissue hypoperfusion were enrolled (n = 373). Among these overall patients, we further defined a hypotension population (n = 178) and a shock population (n = 51). Hemodynamic and perfusion parameters were recorded. The primary outcome was peripheral hypoperfusion, defined as significant prolonged capillary refill time (CRT, > 3.0 s). The characteristics and hospital mortality of patients with and without skin mottling were compared. The area under receiver operating characteristic curves (AUROC) were used to assess the accuracy of SMS in detecting peripheral hypoperfusion. Besides, the relationships between SMS and conventional hemodynamic and perfusion parameters were investigated, and the factors most associated with the presence of skin mottling were identified. Results Of the 373-case overall population, 13 (3.5%) patients exhibited skin mottling, with SMS ranging from 1 to 5 (5, 1, 2, 2, and 3 cases, respectively). Patients with mottling had lower mean arterial pressure, higher vasopressor dose, less urine output (UO), higher CRT, lactate levels and hospital mortality (84.6% vs. 12.2%, p

Abstract Background Several studies have validated capillary refill time (CRT) as a marker of tissue hypoperfusion, and recent guidelines recommend CRT monitoring during septic shock resuscitation. Therefore, it is relevant to further explore its kinetics of response to short-term hemodynamic interventions with fluids or vasopressors. A couple of previous studies explored the impact of a fluid bolus on CRT, but little is known about the impact of norepinephrine on CRT when aiming at a higher mean arterial pressure (MAP) target in septic shock. We designed this observational study to further evaluate the effect of a fluid challenge (FC) and a vasopressor test (VPT) on CRT in septic shock patients with abnormal CRT after initial resuscitation. Our purpose was to determine the effects of a FC in fluid-responsive patients, and of a VPT aimed at a higher MAP target in chronically hypertensive fluid-unresponsive patients on the direction and magnitude of CRT response. Methods Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80–85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions). Results CRT decreased significantly with both tests (from 5 [3.5–7.6] to 4 [2.4–5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3–5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin. Conclusions Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research.

Abstract Introduction This study aimed to compare the predictive abilities of macrocirculation markers (mean arterial pressure, heart rate, and central venous pressure), microcirculation markers (capillary refill time and peripheral perfusion index), as well as fluid balance, lactate level, and lactate clearance on the outcomes of patients with septic shock during initial resuscitation. Methods In this prospective, single-center observational study, adult patients with septic shock admitted to the intensive care unit (ICU) at Shohada Hospital in Tabriz, Iran, between December 2020 and September 2021, were included. Receiver operating characteristic (ROC) curve analysis and multivariate logistic regression were used to assess the associations between macrocirculation markers (heart rate, mean arterial pressure, central venous pressure, and fluid balance) and microcirculation markers (capillary refill time, peripheral perfusion index, mottling score, lactate level, and lactate clearance level) with outcomes such as ICU length of stay, need for renal replacement therapy (RRT), vasopressor requirements, duration of mechanical ventilation (MV), and mortality rate. Assessments were performed at baseline, 6 h, and 24 h after fluid resuscitation. Results A total of 100 patients with septic shock (55 men and 45 women) were enrolled in the study. The area under the curve (AUC) values for the macrocirculation and microcirculation markers in predicting mortality ranged from 0.517 to 0.770 and 0.695 to 0.993, respectively. Among the macrocirculation markers, central venous pressure and mean arterial pressure at baseline showed the best predictive values for mortality, with AUCs of 0.770 and 0.753, respectively. Conclusion In patients with septic shock, microcirculation markers, particularly the peripheral perfusion index (PPI), demonstrated better predictive accuracy for mortality compared to macrocirculation markers. Furthermore, the combination of markers had a higher AUC, sensitivity, and specificity for predicting outcomes compared to individual markers alone.

Abstract Background In this study, we aimed to evaluate the ability of central-to-peripheral temperature gradients using thermal imaging to predict in-hospital mortality in surgical patients with septic shock. Methods This prospective observational study included adult patients with septic shock admitted to the intensive care unit postoperatively. Serum lactate (in mmol/L), capillary refill time (CRT) (in seconds), toe (peripheral) and canthal (central) temperature by infrared thermography and the corresponding room temperature in (Celsius [°C]) were assessed at the time of admission, 6- and 12 h after admission. The canthal-toe and room-toe temperature gradients were calculated. According to their final outcomes, patients were divided into survivors and non-survivors. The ability of canthal-toe temperature gradient (primary outcome), room-toe temperature gradient, toe temperature, serum lactate and CRT, measured at the prespecified timepoints to predict in-hospital mortality was analyzed using the area under receiver operating characteristic curve (AUC). Results Fifty-six patients were included and were available for the final analysis and 41/56 (73%) patients died. The canthal-toe and room-toe temperature gradients did not show significant accuracy in predicting mortality at any timepoint. Only the toe temperature measurement at 12 h showed good ability in predicting in-hospital mortality with AUC (95% confidence interval) of 0.72 (0.58–0.84) and a negative predictive value of 70% at toe temperature of ≤ 25.5 °C. Both serum lactate and CRT showed good ability to predict in-hospital mortality at all timepoints with high positive predictive values (> 90%) at cut-off value of > 2.5–4.3 mmol/L for the serum lactate and > 3-4.2 s for the CRT. Conclusion In post-operative emergency surgical patients with septic shock, high serum lactate and CRT can accurately predict in-hospital mortality and were superior to thermal imaging, especially in the positive predictive values. Toe temperature > 25.5 °C, measured using infrared thermal imaging can exclude in-hospital mortality with a negative predictive value of 70%.

IntroductionRecent studies have shown the prognostic value of capillary refill time (CRT) and suggested that resuscitation management guided by CRT may reduce morbidity and mortality in patients with septic shock. However, little is known about the current use of CRT in routine clinical practice. This study aimed to assess the modalities of CRT use among French adult and pediatric intensivists.MethodsA cross-sectional survey exploring CRT practices in acute circulatory failure was performed. The targeted population was French adult and pediatric intensivists (SFAR and GFRUP networks). An individual invitation letter including a survey of 32 questions was emailed twice. Descriptive and analytical statistics were performed.ResultsAmong the 6071 physicians who received the letter, 418 (7%) completed the survey. Among all respondents, 82% reported using CRT in routine clinical practice, mainly to diagnose acute circulatory failure, but 45% did not think CRT had any prognostic value. Perfusion goal-directed therapy based on CRT was viewed as likely to improve patient outcome by 37% of respondents. The measurement of CRT was not standardized as the use of a chronometer was rare (3%) and the average of multiple measurements rarely performed (46%). Compared to adult intensivists, pediatric intensivists used CRT more frequently (99% versus 76%) and were more confident in its diagnostic value and its ability to guide treatment.ConclusionCRT measurement is widely used by intensivists in patients with acute circulatory failure but most often in a non-standardized way. This may lead to a misunderstanding of CRT reliability and clinical usefulness.

Background: Skin mottling is a common manifestation of peripheral tissue hypoperfusion, and its severity can be described using the skin mottling score (SMS). This study aims to evaluate the value of the SMS in detecting peripheral tissue hypoperfusion in critically ill patients following cardiac surgery. Methods: Critically ill patients following cardiac surgery with risk factors for tissue hypoperfusion were enrolled (n = 373). Among these overall patients, we further defined a hypotension population (n = 178) and a shock population (n = 51). Hemodynamic and perfusion parameters were recorded. The primary outcome was peripheral hypoperfusion, defined as significant prolonged capillary refill time (CRT, > 3.0 s). The characteristics and hospital mortality of patients with and without skin mottling were compared. The area under receiver operating characteristic curves (AUROC) were used to assess the accuracy of SMS in detecting peripheral hypoperfusion. Besides, the relationships between SMS and conventional hemodynamic and perfusion parameters were investigated, and the factors most associated with the presence of skin mottling were identified. Results: Of the 373-case overall population, 13 (3.5%) patients exhibited skin mottling, with SMS ranging from 1 to 5 (5, 1, 2, 2, and 3 cases, respectively). Patients with mottling had lower mean arterial pressure, higher vasopressor dose, less urine output (UO), higher CRT, lactate levels and hospital mortality (84.6% vs. 12.2%, p < 0.001). The occurrences of skin mottling were higher in hypotension population and shock population, reaching 5.6% and 15.7%, respectively. The AUROC for SMS to identify peripheral hypoperfusion was 0.64, 0.68, and 0.81 in the overall, hypotension, and shock populations, respectively. The optimal SMS threshold was 1, which corresponded to specificities of 98, 97 and 91 and sensitivities of 29, 38 and 67 in the three populations (overall, hypotension and shock). The correlation of UO, lactate, CRT and vasopressor dose with SMS was significant, among them, UO and CRT were identified as two major factors associated with the presence of skin mottling. Conclusion: In critically ill patients following cardiac surgery, SMS is a very specific yet less sensitive parameter for detecting peripheral tissue hypoperfusion. [ABSTRACT FROM AUTHOR]

Background: Several studies have validated capillary refill time (CRT) as a marker of tissue hypoperfusion, and recent guidelines recommend CRT monitoring during septic shock resuscitation. Therefore, it is relevant to further explore its kinetics of response to short-term hemodynamic interventions with fluids or vasopressors. A couple of previous studies explored the impact of a fluid bolus on CRT, but little is known about the impact of norepinephrine on CRT when aiming at a higher mean arterial pressure (MAP) target in septic shock. We designed this observational study to further evaluate the effect of a fluid challenge (FC) and a vasopressor test (VPT) on CRT in septic shock patients with abnormal CRT after initial resuscitation. Our purpose was to determine the effects of a FC in fluid-responsive patients, and of a VPT aimed at a higher MAP target in chronically hypertensive fluid-unresponsive patients on the direction and magnitude of CRT response. Methods: Thirty-four septic shock patients were included. Fluid responsiveness was assessed at baseline, and a FC (500 ml/30 mins) was administered in 9 fluid-responsive patients. A VPT was performed in 25 patients by increasing norepinephrine dose to reach a MAP to 80–85 mmHg for 30 min. Patients shared a multimodal perfusion and hemodynamic monitoring protocol with assessments at at least two time-points (baseline, and at the end of interventions). Results: CRT decreased significantly with both tests (from 5 [3.5–7.6] to 4 [2.4–5.1] sec, p = 0.008 after the FC; and from 4.0 [3.3–5.6] to 3 [2.6 -5] sec, p = 0.03 after the VPT. A CRT-response was observed in 7/9 patients after the FC, and in 14/25 pts after the VPT, but CRT deteriorated in 4 patients on this latter group, all of them receiving a concomitant low-dose vasopressin. Conclusions: Our findings support that fluid boluses may improve CRT or produce neutral effects in fluid-responsive septic shock patients with persistent hypoperfusion. Conversely, raising NE doses to target a higher MAP in previously hypertensive patients elicits a more heterogeneous response, improving CRT in the majority, but deteriorating skin perfusion in some patients, a fact that deserves further research. [ABSTRACT FROM AUTHOR]

Background: In this study, we aimed to evaluate the ability of central-to-peripheral temperature gradients using thermal imaging to predict in-hospital mortality in surgical patients with septic shock. Methods: This prospective observational study included adult patients with septic shock admitted to the intensive care unit postoperatively. Serum lactate (in mmol/L), capillary refill time (CRT) (in seconds), toe (peripheral) and canthal (central) temperature by infrared thermography and the corresponding room temperature in (Celsius [°C]) were assessed at the time of admission, 6- and 12 h after admission. The canthal-toe and room-toe temperature gradients were calculated. According to their final outcomes, patients were divided into survivors and non-survivors. The ability of canthal-toe temperature gradient (primary outcome), room-toe temperature gradient, toe temperature, serum lactate and CRT, measured at the prespecified timepoints to predict in-hospital mortality was analyzed using the area under receiver operating characteristic curve (AUC). Results: Fifty-six patients were included and were available for the final analysis and 41/56 (73%) patients died. The canthal-toe and room-toe temperature gradients did not show significant accuracy in predicting mortality at any timepoint. Only the toe temperature measurement at 12 h showed good ability in predicting in-hospital mortality with AUC (95% confidence interval) of 0.72 (0.58–0.84) and a negative predictive value of 70% at toe temperature of ≤ 25.5 °C. Both serum lactate and CRT showed good ability to predict in-hospital mortality at all timepoints with high positive predictive values (> 90%) at cut-off value of > 2.5–4.3 mmol/L for the serum lactate and > 3-4.2 s for the CRT. Conclusion: In post-operative emergency surgical patients with septic shock, high serum lactate and CRT can accurately predict in-hospital mortality and were superior to thermal imaging, especially in the positive predictive values. Toe temperature > 25.5 °C, measured using infrared thermal imaging can exclude in-hospital mortality with a negative predictive value of 70%. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to compare the predictive abilities of macrocirculation markers (mean arterial pressure, heart rate, and central venous pressure), microcirculation markers (capillary refill time and peripheral perfusion index), as well as fluid balance, lactate level, and lactate clearance on the outcomes of patients with septic shock during initial resuscitation. Methods: In this prospective, single-center observational study, adult patients with septic shock admitted to the intensive care unit (ICU) at Shohada Hospital in Tabriz, Iran, between December 2020 and September 2021, were included. Receiver operating characteristic (ROC) curve analysis and multivariate logistic regression were used to assess the associations between macrocirculation markers (heart rate, mean arterial pressure, central venous pressure, and fluid balance) and microcirculation markers (capillary refill time, peripheral perfusion index, mottling score, lactate level, and lactate clearance level) with outcomes such as ICU length of stay, need for renal replacement therapy (RRT), vasopressor requirements, duration of mechanical ventilation (MV), and mortality rate. Assessments were performed at baseline, 6 h, and 24 h after fluid resuscitation. Results: A total of 100 patients with septic shock (55 men and 45 women) were enrolled in the study. The area under the curve (AUC) values for the macrocirculation and microcirculation markers in predicting mortality ranged from 0.517 to 0.770 and 0.695 to 0.993, respectively. Among the macrocirculation markers, central venous pressure and mean arterial pressure at baseline showed the best predictive values for mortality, with AUCs of 0.770 and 0.753, respectively. Conclusion: In patients with septic shock, microcirculation markers, particularly the peripheral perfusion index (PPI), demonstrated better predictive accuracy for mortality compared to macrocirculation markers. Furthermore, the combination of markers had a higher AUC, sensitivity, and specificity for predicting outcomes compared to individual markers alone. [ABSTRACT FROM AUTHOR]

Background: Albumin has potential endothelial protective effects through antioxidant and anti-inflammatory properties. However, the effect of albumin on peripheral tissue perfusion in human sepsis remains poorly known. Methods: Bi-centric prospective study included patients with sepsis with or without shock and prolonged CRT > 3 s despite initial resuscitation. Clinicians in charge of the patients were free to infuse either saline 500 mL or human serum albumin 20% 100 mL over 15 min. Global hemodynamic parameters as well as peripheral tissue perfusion were analyzed after 1 (H1) and 4 h (H4). The primary endpoint was CRT normalization (< 3 s) at H1. Results: 62 patients were screened, and 50 patients (13 sepsis and 37 septic shock) were included, 21 in the saline group and 29 in the albumin group. SOFA score was 8 [5–11], and SAPS II was 53 [45–70]. Median age was 68 [60–76] years with a higher proportion of men (74%). The primary sources of infection were respiratory (54%) and abdominal (24%). At baseline, comorbidities, clinical and biological characteristics were similar between groups. At H1, CRT normalization (< 3 s) was more frequent in patients receiving albumin as compared to patients treated by saline (63 vs 29%, P = 0.02). The decrease in fingertip CRT was more important in the albumin group when compared to saline group (− 1.0 [− 0.3; − 1.5] vs − 0.2 [− 0.1; − 1.1] seconds, P = 0.04) as well as decrease in mottling score. At H4, beneficial effects of albumin on peripheral tissue perfusion were maintained and urinary output trended to be higher in the albumin group (1.1 [0.5–1.8] vs 0.7 [0.5–0.9] ml/kg/h, P = 0.08). Finally, arterial lactate level did not significantly change between H0 and H4 in the saline group but significantly decreased in the albumin group (P = 0.03). Conclusion: In patients with resuscitated sepsis, albumin infusion might lead to greater improvement of tissue hypoperfusion compared to saline. ClinicalTrials.gov Identifier: NCT05094856. [ABSTRACT FROM AUTHOR]

Microvascular dysfunction and inflammation caused by COVID-19 disrupt organ function. The study aimed to investigate the association between the severity of SARS-CoV-2 pneumonia and peripheral and organ perfusion as a consequence of altered microcirculation. A total of 116 patients hospitalized due to severe COVID-19 were enrolled in the study. On admission, the patients underwent a Capillary Refill Time (CRT) examination, finger oxygen saturation measurement, thermal imaging of the hand (FIT), and a kidney Doppler ultrasound. Medical data were collected from the medical history. From the evaluated perfusion parameters, only renal cortex perfusion (RCP) was substantially correlated with the CT score (p < 0.010). The peripheral perfusion parameters of Sat., FIT, CRT, and RCP correlated with the ARDS stages (p = 0.0021; p = 0.038; p < 0.0006; p < 0.0002, respectively). The Oxygenation Ratio value (p < 0.001) was significantly associated with all the perfusion parameters (saturation, CRT, FIT, and RCP) in the multivariable regression analysis model. According to the stepwise retrograde regression analysis, RCP was an independent parameter linked with the Oxygenation Ratio (p < 0.001). Severe COVID-19 can result in microvascular dysfunction influencing peripheral and organ perfusion, which can be measured with various methods. The staging of COVID-19 assessed by CT and the Oxygenation Ratio correlates with RCP, CRT, FIT, and oxygen saturation. [ABSTRACT FROM AUTHOR]

OBJECTIVE To assess intraobserver and interobserver reliability of capillary refill time (CRT) measurement in dogs using a standardized technique after training. ANIMALS 20 dogs presented to the emergency room. METHODS Dogs presented to the emergency room were prospectively recruited. Using a timing device and standardized technique, CRT was measured at the oral mucosa of the inner lip. Measurements were performed by 2 emergency and critical care residents (observer 1 [Obl] and observer 2 [Ob2]) and repeated 3 times by each observer for each dog. CRT values and signalment were recorded. Intraobserver and interobserver reliability were analyzed by calculation of the coefficient of variation (CV%), intraclass correlation coefficient (ICC), and minimal detectable difference. Reliability was considered high if CV% was lower than 10% and ICC was between 0.9 and 1. RESULTS Median CRT for Obl was 1.22 seconds and for Ob2 was 1.19 seconds. Intraobserver reliability was high, evidenced by a median CV% of 6.2% (range, 1.0% to 18.6%) and 9.5% (range, 1.3% to 22.6%) and an ICC of 0.97 (95% Cl, 0.94 to 0.99) and 0.95 (95% Cl, 0.90 to 0.98) for Obl and Ob2, respectively. Between observers, the CV% was 4.4% (range, 0.8% to 17.5%) and the ICC was 0.98 (95% Cl, 0.94 to 0.99), indicating high interobserver reliability. The minimal detectable differences for intraobserver and interobserver were 0.30 and 0.34 seconds, respectively. CLINICAL RELEVANCE The reported high reliability of CRT despite its subjective nature enhances its usefulness in daily practice. However, further research on the validity of CRT is warranted. [ABSTRACT FROM AUTHOR]

Purpose: Acute circulatory failure leads to tissue hypoperfusion. Capillary refill time (CRT) has been widely studied, but its predictive value remains debated. We conducted a meta-analysis to assess the ability of CRT to predict death or adverse events in a context at risk or confirmed acute circulatory failure in adults. Method: MEDLINE, EMBASE, and Google scholar databases were screened for relevant studies. The pooled area under the ROC curve (AUC ROC), sensitivity, specificity, threshold, and diagnostic odds ratio using a random-effects model were determined. The primary analysis was the ability of abnormal CRT to predict death in patients with acute circulatory failure. Secondary analysis included the ability of CRT to predict death or adverse events in patients at risk or with confirmed acute circulatory failure, the comparison with lactate, and the identification of explanatory factors associated with better accuracy. Results: A total of 60,656 patients in 23 studies were included. Concerning the primary analysis, the pooled AUC ROC of 13 studies was 0.66 (95%CI [0.59; 0.76]), and pooled sensitivity was 54% (95%CI [43; 64]). The pooled specificity was 72% (95%CI [55; 84]). The pooled diagnostic odds ratio was 3.4 (95%CI [1.4; 8.3]). Concerning the secondary analysis, the pooled AUC ROC of 23 studies was 0.69 (95%CI [0.65; 0.74]). The prognostic value of CRT compared to lactate was not significantly different. High-quality CRT was associated with a greater accuracy. Conclusion: CRT poorly predicted death and adverse events in patients at risk or established acute circulatory failure. Its accuracy is greater when high-quality CRT measurement is performed. [ABSTRACT FROM AUTHOR]

Background: Skin mottling as a clinical perfusion marker in septic shock is significantly associated with severity and outcome in white-skinned population and its validity as a clinical sign in dark-skinned population is not known. The objectives of this study were to evaluate mottling in septic shock in the Indian ethnic population who has different skin color as compared to the white-skinned population and to assess mottling as an outcome predictor with capillary refill time (CRT) and other biochemical parameters which are the established clinical markers of perfusion in septic shock. Materials and methods: We conducted a prospective observational study of patients with skin color categories 21-34 on the von Luschan scale or Fitzprick type IV-VI who had septic shock needing a high dose of norepinephrine ≥0.2 µg/kg/min after fluid optimization. The study was conducted in a mixed medical-surgical ICU over 12 months. Two blinded experts (a Dermatologist and a plastic surgeon) independently classified the skin type, validated the occurrence of mottling, and scored mottling in our patients. We recorded the demographics, hemodynamic variables, and mottling score and observed the incidence of mottling and its correlation with predictors of the severity of septic shock. We also compared CRT, arterial lactate, central venous oxygen saturation, and venoarterial PCO2 gap with occurrence of mottling in septic shock patients. Results: We included 108 patients with age 61 ± 16 years. Mean Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores at enrolment were 10.3-21.9, respectively. Incidence of mottling was 20.3% (22/108). CRT >3 seconds was observed in 50.9% (55/108). Development of mottling was significantly associated with 90-day mortality; 20/22 (90.9%) patients died in the mottling group versus 58/86 (65.1%) in the non-mottling group (p = 0.028). Capillary refill time >3 seconds did not corelate with mortality; 40/55 (72.7%) Patients with CRT >3 seconds died versus 32/53 (60.4%) patients died in CRT ≤3 seconds group. Occurrence of mottling could predict mortality; positive predictive value of 90.9% which was comparable to positive predictive value of lactate levels >4 mmol/L, i.e., 94.1%. Conclusion: The incidence of mottling in septic shock is much less in patients of Indian ethnicity with brown skin color than in white-skinned population. Occurrence of mottling and not delayed CRT, is a better predictor of outcome in this setting. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Capillary Refill Time (CRT) assesses peripheral perfusion in resource‐limited settings. However, the repeatability and reproducibility of CRT measurements are limited for individuals with darker skin. This paper presents quantitative CRT measurements demonstrating good performance and repeatability across all Fitzpatrick skin phototypes. The study involved 22 volunteers and utilized controlled compression at 7 kPa, an RGB video camera, and cocircular polarized white LED light. CRT was determined by calculating the time constant of an exponential regression applied to the mean pixel intensity of the green (G) channel. An adaptive algorithm identifies the optimal regression region for noise reduction, and flags inappropriate readings. The results indicate that 80% of the CRT readings fell within a 20% range of the expected CRT value. The repetition standard deviation was 17%. These findings suggest the potential for developing reliable and reproducible quantitative CRT methods for robust measurements in patient triage, monitoring, and telehealth applications. [ABSTRACT FROM AUTHOR]

Capillary refill time (CRT) is an important indicator of peripheral perfusion with a strong prognostic value, but it is sensitive to environmental factors and numerous measurement methods are reported in the litterature. DiCARTECH has developed a device that assesses CRT. We sought to investigate the robustness of the device and the reproducibility of the algorithm in a bench and in-silico study. We used the video acquired from a previous clinical study on healthy volunteers. For the bench study, the measurement process was performed by a robotic system piloted by a computer that analyzed 250 times nine previously acquired videos. For the in-silico study, we used 222 videos to test the algorithm's robustness. We created 30 videos from each video with a large blind spot and used the "color jitter" function to create a hundred videos from each video. In the bench study, the coefficient of variation was 11% (95%CI: 9–13). The correlation with human-measured CRT was good (R2 = 0.91, P < 0.001). In the in-silico study, for the blind spotted video, the coefficient of variation was 13% (95%CI: 10–17). For the color-jitter modified video the coefficient of variation was 62% (95%CI: 55–70). We confirmed the ability of the DiCART™ II device to perform multiple measurements without mechanical or electronic dysfunction. The precision and reproducibility of the algorithm are compatible with the assessment of clinical small changes in CRT. [ABSTRACT FROM AUTHOR]

Background: The initial hemodynamic goal during septic shock resuscitation is to achieve a mean arterial pressure (MAP) above 65 mm Hg, although this does not assure a normal tissue perfusion. Capillary refill time (CRT), a marker of skin blood flow, has been validated as a marker of the reperfusion process. The aim of the study was to explore the relationship between MAP and CRT in patients in septic shock. Methods: We systematically reviewed studies which reported CRT and MAP in septic shock patients. Authors of eligible studies were asked to provide necessary data for performing a meta-correlation of Spearman's rank correlation coefficients. Subgroup analyses were performed, including studies of good quality and studies with higher/lower norepinephrine doses. Results: We identified 10 studies, comprising 917 patients. There were 5 studies considered to be of good quality. A meta-correlation showed a statistically significant but poor negative correlation between MAP and CRT (R = −0.158, range −0.221 to −0.093, P <.001, I2 = 0.0%). Subgroup analysis of best-quality studies gave similar results (R = −0.201, range −0.282 to −0.116, P <.001, I2 = 0.0%). In subanalysis concerning norepinephrine doses, no significant correlations were found. Conclusions: In patients with septic shock, there is poor inverse correlation between MAP and CRT. MAP > 65 mm Hg does not guarantee normalization of CRT. Registration code: PROSPERO: CRD42022355996. Registered on 5 September 2022. [ABSTRACT FROM AUTHOR]

To evaluate the association between capillary refill time (CRT) measured by a medical device and sepsis among patients presenting to the Emergency Department (ED). This prospective observational study enrolled adult and pediatric patients during ED triage when sepsis was considered a potential diagnosis by the triage nurse. Patients were enrolled at an academic medical center between December 2020 and June 2022. CRT was measured by a research assistant using an investigational medical device. The outcomes included sepsis and septic shock defined using sep-3 criteria, septic shock defined as IV antibiotics and a vasopressor requirement, ICU admission, and hospital mortality. Other measures included patient demographics and vital signs at ED triage. We evaluated univariate associations between CRT and sepsis outcomes. We enrolled 563 patients in the study, 48 met Sep-3 criteria, 5 met Sep-3 shock criteria, and 11 met prior septic shock criteria (IV antibiotics and vasopressors to maintain mean arterial pressure of 65). Sixteen patients were admitted to the ICU. The mean age was 49.1 years, and 51% of the cohort was female. The device measured CRT was significantly associated with the diagnosis of sepsis by sep-3 criteria (OR 1.23, 95% CI 1.06–1-43), septic shock by sep-3 criteria (OR 1.57, 95% CI 1.02–2.40), and septic shock defined as receipt of IV antibiotics and a vasopressor requirement (OR 1.37, 95% CI 1.03–1.82). Patients with CRT >3.5 s measured by the DCR device had an odds ratio of 4.67 (95%CI 1.31–16.1) of septic shock (prior definition), and an odds ratio of 3.97 (95% CI 1.99–7.92) of ICU admission, supporting the potential for the 3.5-s cutoff of the DCR measurement. CRT measured by a medical device at ED triage was associated with the diagnosis of sepsis. Objective CRT measurement using a medical device may be a relatively simple way to improve sepsis diagnosis during ED triage. [ABSTRACT FROM AUTHOR]

BackgroundSeptic 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.MethodsThe 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.DiscussionThe trial aims to provide evidence on the efficacy and safety of Ilomedin in patients with septic shock and persistent microcirculatory disorders.Trial registrationNCT NCT03788837 . Registered on 28 December 2018.

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. [ABSTRACT FROM AUTHOR]

Capillary refill time (CRT), a costless and widely available tool, has emerged as a promising target to guide septic shock resuscitation. However, it has yet to gain universal acceptance due to its potential inter-observer variability. Standardization of CRT assessment may minimize this problem, but few studies have compared this approach with techniques that directly assess skin blood flow (SBF). Our objective was to determine if an abnormal CRT is associated with impaired SBF and microvascular reactivity in early septic shock patients. Twelve septic shock patients were subjected to multimodal perfusion and hemodynamic monitoring for 24 h. Three time-points (0, 1, and 24 h) were registered for each patient. SBF was measured by laser doppler. We performed a baseline SBF measurement and two microvascular reactivity tests: one with a thermal challenge at 44 °C and other with a vascular occlusion test. Ten healthy volunteers were evaluated to obtain reference values. The patients (median age 70 years) exhibited a 28-day mortality of 50%. Baseline CRT was 3.3 [2.7–7.3] seconds. In pooled data analysis, abnormal CRT presented a significantly lower SBF when compared to normal CRT [44 (13.3–80.3) vs 193.2 (99.4–285) APU, p = 0.0001]. CRT was strongly associated with SBF (R2 0.76, p < 0.0001). An abnormal CRT also was associated with impaired thermal challenge and vascular occlusion tests. Abnormal CRT values observed during early septic shock resuscitation are associated with impaired skin blood flow, and abnormal skin microvascular reactivity. Future studies should confirm these results. [ABSTRACT FROM AUTHOR]

Introduction: Capillary refill time (CRT) is an indicator of peripheral circulation and is recommended in the 2021 guidelines for treating and managing sepsis. Study Objective: This study developed a portable device to realize objective CRT measurement. Assuming that peripheral blood flow obstruction by the artery occlusion test (AOT) or venous occlusion test (VOT) increases the CRT, the cut-off value for peripheral circulatory failure was studied by performing a comparative analysis with CRT with no occlusion test (No OT). Methods: Fourteen (14) healthy adults (age: 20–26 years) participated in the study. For the vascular occlusion test, a sphygmomanometer was placed on the left upper arm of the participant in the supine position, and a pressure of 30mmHg higher than the systolic pressure was applied for AOT, a pressure of 60mmHg was applied for VOT, respectively, and no pressure was applied for No OT. The CRT was measured from the index finger of the participant's left hand. Results: Experimental results revealed that CRT was significantly longer in the AOT and did not differ significantly in the VOT. The cut-off value for peripheral circulatory failure was found to be 2.88 seconds based on Youden's index by using receiver operating characteristic (ROC) analysis with AOT as positive and No OT as negative. Conclusion: Significant results were obtained in a previous study on the evaluation of septic shock patients when CRT > three seconds was considered abnormal, and the cut-off value for peripheral circulatory failure in the current study validated this. [ABSTRACT FROM AUTHOR]

Multiple tissue perfusion markers are described to guide therapy in critically ill pediatric patients undergoing congenital heart surgery. Given the advantages of capillary refill time, our goal is to determine its predictive capacity for mortality and postoperative extracorporeal oxygenation requirements in congenital heart surgery and compare it to serum lactate. We conducted a prospective cohort observational study in a single high-complexity university hospital. Serum lactate and capillary refill time were measured at five predetermined time points: preoperative, immediate postoperative, 6, 12, and 24 h after the surgery. Prolonged immediate postoperative, 6 h, and 12 h capillary refill time measurements turned out to be independent risk factors for both outcomes. The capillary refill time area under the curve ranged between 0.70 and 0.80, while the serum lactate resulted between 0.79 and 0.92 for both outcomes. Both tissue perfusion markers resulted in mortality and extracorporeal oxygenation requirement predictors. Given the advantages of capillary refill time over serum lactate, a monitoring strategy including these two perfusion markers should be considered for congenital heart surgeries. [ABSTRACT FROM AUTHOR]

Ahmed Shaker,1 Ahmed Hasanin,1 Mostafa Nagy,1 Maha Mostafa,1 Ahmed Z Fouad,1 Hassan Mohamed,1 Ahmed S Abdallah,2 Mohamed Elsayad1 1Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt; 2Department of General Surgery, Cairo University, Cairo, EgyptCorrespondence: Ahmed Hasanin, Department of anesthesia and critical care medicine, Faculty of Medicine, 01 elsarayah Street, Elmanyal, Cairo, Egypt, Tel +201000365115, Fax +20224168736, Email ahmedmohamedhasanin@gmail.com

OBJECTIVE: Currently, there are limited data on the effect of macrocirculatory hemodynamic changes on human microcirculation, especially during the induction of general anesthesia (GA). METHODS: We performed a non-randomized observational trial on patients receiving GA for elective surgery. In the control group (CG), for GA induction sufentanil, propofol, and rocuronium was administered. Patients assigned to the esketamine group (EG) received additional esketamine for GA induction. Invasive blood pressure (IBP) and pulse contour cardiac output (CO) measurement were performed continuously. Microcirculation was assessed using cutaneous Laser Doppler Flowmetry (forehead and sternum LDF), peripheral and central Capillary Refill Time (pCRT, cCRT), as well as brachial temperature gradient (Tskin-diff) at baseline, 5, 10 and 15 minutes after induction of GA. RESULTS: 42 patients were included in the analysis (CG n = 22, EG n = 20). pCRT, cCRT, Tskin-diff, forehead and sternum LDF decreased following GA induction in both groups. IBP and CO were significantly more stable in esketamine group. However, the changes in the microcirculatory parameters were not significantly different between the groups. CONCLUSIONS: The addition of esketamine for GA induction warranted better hemodynamic stability for the first five minutes, but had no significant effect on any of the cutaneous microcirculatory parameters measured. [ABSTRACT FROM AUTHOR]

The capillary refill time (CRT) is the time that elapses before the fingernail color returns to red from white after releasing a load applied to the nail. We aimed to estimate hypovolemic status using the CRT. However, the precision of CRT is low. The first step toward improving precision was estimation of the coefficient of variance (CV) via repeated measurements. The best and next-best indices of the CRT change rates in the hypovolemic state were 0.19 and 0.48 respectively, and the corresponding target CVs were ≤ 0.10 and 0.24. The CRTs of subjects were measured by imaging nails during loading and unloading and fitting of an exponential function to the curve of intensity changes. The CRT was 0.77 ± 0.35 s (n = 108), which is comparable to previous studies. However, the CV was 0.37 ± 0.13, which is higher than even the second-best index. Thus, we used only the green color channels of nail images to generate algorithms to define the optimal start time of the CRT calculations; this provided a lower CV (0.31 ± 0.12). Finally, we investigated the effects of fingertip temperature and load release timing on CRT during a cardiac cycle. Correction of the temperature effect with a care on a phase during the cardiac cycle to trigger data collection reduced CV to 0.15 ± 0.11, which cleared the second-best index. Thus, our protocol improves CRT precision; it may be possible to estimate hypovolemic status using the CRT.

Abstract Introduction Recent studies have shown the prognostic value of capillary refill time (CRT) and suggested that resuscitation management guided by CRT may reduce morbidity and mortality in patients with septic shock. However, little is known about the current use of CRT in routine clinical practice. This study aimed to assess the modalities of CRT use among French adult and pediatric intensivists. Methods A cross-sectional survey exploring CRT practices in acute circulatory failure was performed. The targeted population was French adult and pediatric intensivists (SFAR and GFRUP networks). An individual invitation letter including a survey of 32 questions was emailed twice. Descriptive and analytical statistics were performed. Results Among the 6071 physicians who received the letter, 418 (7%) completed the survey. Among all respondents, 82% reported using CRT in routine clinical practice, mainly to diagnose acute circulatory failure, but 45% did not think CRT had any prognostic value. Perfusion goal-directed therapy based on CRT was viewed as likely to improve patient outcome by 37% of respondents. The measurement of CRT was not standardized as the use of a chronometer was rare (3%) and the average of multiple measurements rarely performed (46%). Compared to adult intensivists, pediatric intensivists used CRT more frequently (99% versus 76%) and were more confident in its diagnostic value and its ability to guide treatment. Conclusion CRT measurement is widely used by intensivists in patients with acute circulatory failure but most often in a non-standardized way. This may lead to a misunderstanding of CRT reliability and clinical usefulness.

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&lowbar;e/ctr&lowbar;view.cgi7recptno = R000049905). [ABSTRACT FROM AUTHOR]

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. To give physicians a concise overview of CRT and explore recent evidence on its reliability and value in the management of sepsis. A narrative review. 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. 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. 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. [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 (ScvO2), venous-to-arterial CO2 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.

Validity and reproducibility of clinical capillary refill time (CRT) measurement depend on many factors in daily routine practice. We conducted a prospective validation study of an automatized handheld prototype device providing standardized CRT assessment (DiCART™) in 20 healthy volunteers. Three different methods of CRT measurement were compared before and during dynamic circulatory changes induced by venous and arterial occlusion tests at both upper and lower limb levels: CRTCLIN corresponding to basic clinical assessment and considered as the reference method; CRTVIDEO corresponding to off-line videos reviewed by investigators recorded by DiCART™; and CRTDiCART corresponding to on-line videos analysed by a built-in proprietary mathematical algorithm included in DiCART™. Five subjects were excluded because of a DiCART™ dysfunction. ROCAUC to detect arterial occlusion test changes at the upper limb level were 1.00 (95%CI 1.00; 1.00), 0.96 (95%CI 0.88; 1.00), and 0.92 (95%CI 0.79; 1.00) for CRTCLIN, CRTVIDEO, and CRTDiCART, respectively. Precision of CRTCLIN and CRTVIDEO were significantly better than CRTDiCART (0.18 and 0.20 vs. 0.28; P < 0.05). Percentages of error were 76% and 87% for CRTVIDEO and CRTDiCART, respectively. DiCART™ had an excellent discrimination to detect major changes in CRT induced by arterial ischemia. However, the perfectible precision, the poor agreement with clinical assessment and numerous device dysfunctions give leads to the development of a further version of the prototype before promoting its use in clinical practice.Trial registration clinicaltrial.gov. Identifier: NCT04538612. [ABSTRACT FROM AUTHOR]

Purpose: Capillary Refill Time (CRT) measurement has gained increasing attention in the field of sepsis and septic shock. Recognizing pressure as a fundamental determinant in CRT measurement is crucial for establishing a standardized CRT measurement procedure. In this preliminary study, we elucidated the optimal pressing strength for CRT measurement by analyzing the CRTs measured under varying pressures., Method: Seventeen healthy individuals were enlisted to undergo CRT tests on their fingertips at various pressure levels. The applied force was initiated at 0.5N and incrementally increased by 0.5N until it reached 10.5N. An integrated Photoplethysmography (PPG) device was employed to capture fluctuations in light intensity. The CRT was automatically derived from the PPG signals via a specialized algorithm. The study included correlation assessment and reliability evaluation. Box plot and Bland-Altman plot were used to visualize the impact of pressure levels on CRTs., Results: A dataset of 1414 CRTs across 21 pressures showed significant differences (Kruskal-Wallis test, p < 0.0001), highlighting the impact of pressure on CRT. CRT values between 4.5N and 10.5N pressures varied less, with an Intraclass Correlation Coefficient (ICC) of 0.499 indicating moderate consistency. Notably, CRTs at 10N and 10.5N pressures revealed a high ICC of 0.790, suggesting strong agreement., Conclusion: A pressure range of 4.5N-10.5N is recommended for stable CRT measurements, with 10.0N-10.5N providing optimal consistency and reliability., Competing Interests: None to declare., (© 2024 The Authors.)

Background: Monitoring fluid therapy is challenging in patients assisted with Veno-arterial ECMO. The aim of our study was to evaluate the usefulness of capillary refill time to assess the response to fluid challenge in patients assisted with VA-ECMO., Methods: Retrospective monocentric study in a cardiac surgery ICU. We assess fluid responsiveness after a fluid challenge in patients on VA-ECMO. We recorded capillary refill time before and after fluid challenge and the evolution of global hemodynamic parameters., Results: A total of 27 patients were included. The main indications for VA-ECMO were post-cardiotomy cardiogenic shock (44%). Thirteen patients (42%) were responders and 14 non-responders (58%). In the responder group, the index CRT decreased significantly (1.7 [1.5; 2.1] vs. 1.2 [1; 1.3] s; p = 0.01), whereas it remained stable in the non-responder group (1.4 [1.1; 2.5] vs. 1.6 [0.9; 1.9] s; p = 0.22). Diagnosis performance of CRT variation to assess response after fluid challenge shows an AUC of 0.68 (p = 0.10) with a sensitivity of 79% [95% CI, 52-92] and a specificity of 69% [95% CI, 42-87], with a threshold at 23%., Conclusion: In patients treated with VA-ECMO index capillary refill time is a reliable tool to assesses fluid responsiveness., Specialty: Critical care, Cardiac surgery, ECMO., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier Inc.)

Multiple tissue perfusion markers are described to guide therapy in critically ill pediatric patients undergoing congenital heart surgery. Given the advantages of capillary refill time, our goal is to determine its predictive capacity for mortality and postoperative extracorporeal oxygenation requirements in congenital heart surgery and compare it to serum lactate. We conducted a prospective cohort observational study in a single high-complexity university hospital. Serum lactate and capillary refill time were measured at five predetermined time points: preoperative, immediate postoperative, 6, 12, and 24 h after the surgery. Prolonged immediate postoperative, 6 h, and 12 h capillary refill time measurements turned out to be independent risk factors for both outcomes. The capillary refill time area under the curve ranged between 0.70 and 0.80, while the serum lactate resulted between 0.79 and 0.92 for both outcomes. Both tissue perfusion markers resulted in mortality and extracorporeal oxygenation requirement predictors. Given the advantages of capillary refill time over serum lactate, a monitoring strategy including these two perfusion markers should be considered for congenital heart surgeries.

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• Capillary refill time (CRT) is used as an indicator of the pathophysiology. • While the measurement of CRT is easy to perform, its evaluation is highly subjective. • This study proposes a method to aid quantified CRT measurement using an RGB camera. • Also, we estimate compression force by a finger from the nail color. Skin color observation provides a simple and non-invasive method to estimate the health status of patients. Capillary Refill Time (CRT) is widely used as an indicator of pathophysiological conditions, especially in emergency patients. While the measurement of CRT is easy to perform, its evaluation is highly subjective. This study proposes a method to aid quantified CRT measurement using an RGB camera. The procedure consists in applying finger compression to the forearm, and the CRT is calculated based on the skin color change after the pressure release. We estimate compression applied by a finger from its fingernail color change during compression. Our study shows a step towards camera-based quantitative CRT for untrained individuals. [ABSTRACT FROM AUTHOR]

Purpose: No standardized execution or evidence demonstrates the area of the digit giving the most accurate capillary refill time (CRT). This study investigated the reliability and validity of CRT, and the relative merits of areas where the test could be performed. Methods: In all, 127 healthy volunteers were assessed for normal CRT at the fingernail, lateral paronychia, and proximal and distal pulps of the index finger. The predictive validity of the CRT for the diagnosis of compromised vascular perfusion was also investigated on 24 subjects, using an inflated tourniquet. Three raters assessed interobserver reliability. Results: The mean fingernail, lateral paronychia, proximal pulp, and distal pulp CRTs were 1.93, 1.78, 1.70, and 1.57 s, respectively. The tourniquet and non-tourniquet results demonstrated significant mean differences; however, the fingernail showed a subtle difference (1.22 s) compared with the proximal pulp (4.46 s). The CRT interobserver reliability was fair at the fingernail (intraclass correlation coefficient [ICC] = 0.51), but very poor in occluded limbs (ICC = 0.13). At the lateral paronychia and finger pulp, the interobserver reliability was reasonable (ICC = 0.75–0.81 [non-tourniquet] vs 0.62–0.68 [tourniquet]). In a receiver-operating characteristic curve analysis, the proximal pulp demonstrated better discrimination (area under the curve = 0.93, 95% CI 0.89–0.97, p < 0.0001); the best cutoff point was calculated to be 3 s at the proximal pulp. Conclusions: CRT use at appropriate areas is reliable. The most dependable site is the finger pulp, and the proposed cutoff is 3 s. [ABSTRACT FROM AUTHOR]

Objective: Systemic sclerosis (SSc) is a progressive connective tissue disorder that features vascular injury and persistent fibrosis with an autoimmune background. The hypoxic state at the capillary caused by SSc can be assessed with several methods. This study thus investigated the capillary refill time (CRT) effectivity in evaluating peripheral circulation in SSc patients. Methods: This prospective, case-control study was conducted with SSc patients and gender and age-matched healthy controls. The CRT measurements were performed by a rheumatologist unaware of patients' records with a smartphone camera in the optimized test ambiance. A video processing software was then applied for the captured videos. Results: 61 patients with SSc and 60 controls participated in this study. According to disease involvement, the patients were then divided into diffuse cutaneous SSc (dSSc) and limited cutaneous SSc. Mainly, CRT was prolonged in the patient group than in the control group. CRT was also prolonged in patients with pathological capillaroscopy patterns in the nail fold capillaroscopy (NFC), below 50 years old, or whose disease duration was over three years. Per disease involvement, patients in the dSSc group with pathologic NFC had prolonged CRT results and higher pulmonary artery pressure levels. The use of CRT for NFC positivity in patients with SSc was practicable (AUC: 0.717;95% CI 0.714-0.942; 83.95% accuracy; 67.9% sensitivity, 100% specificity, 100% positive predictive value, 21.7% negative predictive value, P=0.015). Conclusions: CRT is markedly prolonged in patients with SSc. Evaluating CRT with the NFC positivity may provide pulmonary progression predictable, notably in dSSc patients. [ABSTRACT FROM AUTHOR]

Abstract Background Persistent hyperlactatemia has been considered as a signal of tissue hypoperfusion in septic shock patients, but multiple non-hypoperfusion-related pathogenic mechanisms could be involved. Therefore, pursuing lactate normalization may lead to the risk of fluid overload. Peripheral perfusion, assessed by the capillary refill time (CRT), could be an effective alternative resuscitation target as recently demonstrated by the ANDROMEDA-SHOCK trial. We designed the present randomized controlled trial to address the impact of a CRT-targeted (CRT-T) vs. a lactate-targeted (LAC-T) fluid resuscitation strategy on fluid balances within 24 h of septic shock diagnosis. In addition, we compared the effects of both strategies on organ dysfunction, regional and microcirculatory flow, and tissue hypoxia surrogates. Results Forty-two fluid-responsive septic shock patients were randomized into CRT-T or LAC-T groups. Fluids were administered until target achievement during the 6 h intervention period, or until safety criteria were met. CRT-T was aimed at CRT normalization (≤ 3 s), whereas in LAC-T the goal was lactate normalization (≤ 2 mmol/L) or a 20% decrease every 2 h. Multimodal perfusion monitoring included sublingual microcirculatory assessment; plasma-disappearance rate of indocyanine green; muscle oxygen saturation; central venous-arterial pCO2 gradient/ arterial-venous O2 content difference ratio; and lactate/pyruvate ratio. There was no difference between CRT-T vs. LAC-T in 6 h-fluid boluses (875 [375–2625] vs. 1500 [1000–2000], p = 0.3), or balances (982[249–2833] vs. 15,800 [740–6587, p = 0.2]). CRT-T was associated with a higher achievement of the predefined perfusion target (62 vs. 24, p = 0.03). No significant differences in perfusion-related variables or hypoxia surrogates were observed. Conclusions CRT-targeted fluid resuscitation was not superior to a lactate-targeted one on fluid administration or balances. However, it was associated with comparable effects on regional and microcirculatory flow parameters and hypoxia surrogates, and a faster achievement of the predefined resuscitation target. Our data suggest that stopping fluids in patients with CRT ≤ 3 s appears as safe in terms of tissue perfusion. Clinical Trials: ClinicalTrials.gov Identifier: NCT03762005 (Retrospectively registered on December 3rd 2018)