Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients

Coudroy, Rémi; Jamet, Angéline; Frat, Jean‐Pierre; Veinstein, Anne; Chatellier, Delphine; Goudet, Véronique; Cabasson, Séverin; Thille, Arnaud W.; Robert, René

doi:10.1007/s00134-014-3600-5

Cited by 76 publications

(49 citation statements)

References 55 publications

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“…SMS could be subjective estimate of the severity of peripheral hypoperfusion [39]. Higher SMS (scoring 4 to 5) was associated with poor patient outcome in general ICU population [40] and in patients with septic shock [41]. A good correlation was reported between changes in both mottling score and skin perfusion (assessed by laser Doppler) during resuscitation of septic shock patients [42].…”

Section: Markers Of Local Perfusionmentioning

confidence: 99%

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Perfusion indices revisited

2017

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Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs.The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock.Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.

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Section: Markers Of Local Perfusionmentioning

confidence: 99%

“…A good correlation was reported between changes in both mottling score and skin perfusion (assessed by laser Doppler) during resuscitation of septic shock patients [42]. Prolonged skin mottling more than 6 h was associated with ICU mortality independently from severity scoring systems [40]. …”

Section: Markers Of Local Perfusionmentioning

confidence: 99%

Perfusion indices revisited

2017

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“…Extensive mottling extension has been demonstrated to be predictive of mortality in patients with septic shock, independently of systemic haemodynamic parameters [3, 9, 10]. However, the mechanism responsible for the specific regional reduction of blood flow in the mottled skin area remains unknown.…”

Section: Introductionmentioning

confidence: 99%

Marked regional endothelial dysfunction in mottled skin area in patients with severe infections

et al. 2017

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BackgroundMottling around the knee, reflecting a reduced skin blood flow, is predictive of mortality in patients with septic shock. However, the causative pathophysiology of mottling remains unknown. We hypothesized that the cutaneous hypoperfusion observed in the mottled area is related to regional endothelial dysfunction.MethodsThis was a prospective, observational study in a medical ICU in a tertiary teaching hospital. Consecutive adult patients with sepsis admitted to ICU were included. After resuscitation, endothelium-dependent vasodilation in the skin circulation was measured before and after iontophoresis of acetylcholine (Ach) in the forearm and the knee area. We analyzed the patterns of induced vasodilatation according to the presence or absence of mottling and vital status at 14 days.ResultsWe evaluated 37 septic patients, including 11 without and 26 with septic shock. Overall 14-day mortality was 22%. Ten patients had mottling around the knee (10/37, 27%). In the knee area, the increased skin blood flow following iontophoresis of Ach was lower in patients with mottled skin as compared to patients without mottled skin (area under curve (AUC) 3280 (2643–6440) vs. 7980 (4233–19,707), both P < 0.05). In the forearm area, the increased skin blood flow following iontophoresis of Ach was similar in patients with and without mottled skin. Among patients with septic shock, the increased skin blood flow following iontophoresis of Ach in the knee area was significantly lower in non-survivors as compared to survivors at 14 days (AUC 3256 (2600–4426) vs. 7704 (4539–15,011), P < 0.01). In patients with septic shock, the increased skin blood flow in the forearm area following iontophoresis of Ach was similar in survivors and non-survivors at 14 days.ConclusionMottling is associated with regional endothelial dysfunction in patients with septic shock. Endothelial dysfunction in the knee skin area was more pronounced in non-survivors than in survivors.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1742-x) contains supplementary material, which is available to authorized users.

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“…Le principal défi auquel nous sommes aujourd'hui confrontés est de développer un outil facilement utilisable au lit du malade pour évaluer la perfusion microcirculatoire, un outil sensible qui permettrait d'identifier l'hypoperfusion tissulaire et de suivre son évolution au cours des différentes interventions thérapeutiques. Plusieurs travaux observationnels ont souligné la valeur pronostique de paramètres cliniques de perfusion tissulaire comme le score de marbrures [30,48], le temps de recoloration cutanée [29] ou encore la diurèse au cours des états de choc. Cependant, aucune étude n'a pour l'instant montré qu'une prise en charge s'appuyant sur ces paramètres pouvait améliorer le pronostic des patients.…”

Section: Hémodynamique Globale Et Microcirculationunclassified

Pourquoi ne fais-je pas de monitoring hémodynamique ?

2015

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Le monitoring hémodynamique a toujours été le sujet de nombreuses controverses en réanimation. Bien que les différents outils d'évaluation hémodynamique aient apporté de précieuses informations physiopathologiques au cours des états de choc, il est aujourd'hui pourtant difficile de les recommander dans notre pratique quotidienne. En dehors des critiques liées à la précision des mesures ou à leur reproductibilité, ces outils n'ont jamais apporté la preuve d'une amélioration pronostique des patients en réanimation. Les raisons de leur échec clinique sont multiples et incluent l'absence d'objectifs hémodynamiques précis à atteindre et l'absence d'intervention thérapeutique consensuelle qui en découle. Plus récemment, les discordances entre les paramètres hémodynamiques globaux comme le débit cardiaque ou la pression artérielle moyenne et la perfusion microcirculatoire ont augmenté le doute quant à leur utilité. Le monitoring de la perfusion tissulaire microcirculatoire au cours des états de choc doit à l'avenir occuper une place plus importante dans la gestion de l'insuffisance circulatoire aiguë. Mots clés Monitoring · Choc · Débit cardiaque · Pression artérielle moyenne · MicrocirculationAbstract Hemodynamic monitoring has been the subject of many controversies in intensive care unit. Although several monitoring devices have provided interesting pathophysiological information during acute circulatory failure, it is today difficult to recommend their use in daily practice. Outside criticisms related to measurement accuracy or reproducibility, no study has clearly shown that these monitoring tools improved the prognosis of critically ill patients. The reasons for their clinical failure are many and include a lack of clear hemodynamic goals to achieve and a lack of consensus resulting from therapeutic intervention. More recently, discrepancies between global hemodynamic parameters such as heart rate or mean arterial pressure and microcirculatory perfusion increased doubt on their usefulness. Monitoring of microcirculatory tissue perfusion during shock states must in the future have a more important place in the management of acute circulatory failure.

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Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients

Abstract: Skin mottling is frequent in the general population of patients admitted in ICU. Occurrence and persistence of skin mottling are independently associated with in-ICU mortality.

Cited by 76 publications

References 55 publications

Perfusion indices revisited

Perfusion indices revisited

Marked regional endothelial dysfunction in mottled skin area in patients with severe infections

Pourquoi ne fais-je pas de monitoring hémodynamique ?

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