Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

Abstract

IntroductionAltered peripheral perfusion is strongly associated with poor outcome in critically ill patients. We wanted to determine whether repeated assessments of peripheral perfusion during the days following surgery could help to early identify patients that are more likely to develop postoperative complications.MethodsHaemodynamic measurements and peripheral perfusion parameters were collected one day prior to surgery, directly after surgery (D0) and on the first (D1), second (D2) and third (D3) postoperative days. Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (Tskin-diff). Generalized linear mixed models were used to predict severe complications within ten days after surgery based on Clavien-Dindo classification.ResultsWe prospectively followed 137 consecutive patients, from among whom 111 were included in the analysis. Severe complications were observed in 19 patients (17.0%). Postoperatively, peripheral perfusion parameters were significantly altered in patients who subsequently developed severe complications compared to those who did not, and these parameters persisted over time. CRT was altered at D0, and PPI and Tskin-diff were altered on D1 and D2, respectively. Among the different peripheral perfusion parameters, the diagnostic accuracy in predicting severe postoperative complications was highest for CRT on D2 (area under the receiver operating characteristic curve = 0.91 (95% confidence interval (CI) = 0.83 to 0.92)) with a sensitivity of 0.79 (95% CI = 0.54 to 0.94) and a specificity of 0.93 (95% CI = 0.86 to 0.97). Generalized mixed-model analysis demonstrated that abnormal peripheral perfusion on D2 and D3 was an independent predictor of severe postoperative complications (D2 odds ratio (OR) = 8.4, 95% CI = 2.7 to 25.9; D2 OR = 6.4, 95% CI = 2.1 to 19.6).ConclusionsIn a group of patients assessed following major abdominal surgery, peripheral perfusion alterations were associated with the development of severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion–targeted resuscitation following major abdominal surgery.

Changes in peripheral perfusion relate to visceral organ perfusion in early septic shock: A pilot study

“…Similarly, improvement of capillary refill and skin mottling over time appears to parallel a decrease in visceral organ and renal vascular tone, respectively. This observation could for the first time provide an explanation for the published evidence on a strong relationship between clinical parameters of peripheral perfusion, arterial lactate, base deficit, organ function, and mortality [4][5][6][7][8][9][10][11][12][13].…”

“…Patients with abnormal peripheral perfusion, assessed by either skin temperature or color, had higher odds of hyperlactatemia and organ failure [7] and a high risk of death [8]. Even in postsurgery patients with a very low incidence of death, skin perfusion as assessed by the capillary refill time was related to increased morbidity [9]. In septic shock patients, Ait-Oufella et al [10] showed that the capillary refill time measured at 6 hours of resuscitation was related to lactate levels, organ dysfunction, and mortality.…”

Clinical assessment of peripheral circulation

“…Many studies already showed that a CRT >5.0 s following initial haemodynamic optimization discriminated haemodynamically stable patients with more severe organ dysfunction and higher odds for worsening organ failure [20][21][22][23].…”

Research in Review: Driving Critical Care Practice Change

“…In 60 patients with septic shock, the mottling score 6 hours after the initial resuscitation was strongly associated with 14-day mortality, and patients with a higher 6-hour mottling score had increased mortality on days 1 and 2. 55 The CRT was also found to be reproducible, 56,57 although the thresholds indicative of altered perfusion vary between studies (ranging from 2.4 to 5 seconds). In 59 patients with septic shock, the index finger and knee CRTs were predictive of 14-day mortality (index finger threshold 2.4 seconds, area under curve [AUC] 84%; knee threshold 4.9 seconds, AUC 90%).…”

“…Several recent studies provide examples of how to standardize and interpret the assessment for mottling [53][54][55] and CRT. 56,57 Using laser Doppler flow, Ait-Oufella et al 53,55 measured the microvascular flow on the lower extremity, and a standardized scoring system was created (Table 2). In 60 patients with septic shock, the mottling score 6 hours after the initial resuscitation was strongly associated with 14-day mortality, and patients with a higher 6-hour mottling score had increased mortality on days 1 and 2.…”