Perspectives on peripheral perfusion assessment

Kattan, Eduardo; Ibarra‐Estrada, Miguel; Ospina-Tascón, Gustavo Adolfo; Hernández, Glenn

doi:10.1097/mcc.0000000000001038

Cited by 11 publications

(12 citation statements)

References 62 publications

(78 reference statements)

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“…Since assessment of sublingual microcirculation is only a research tool, CRT appears as a physiologically sound surrogate [ 13 ]. The ANDROMEDA-SHOCK trial introduced the concept of VPT, meaning a transient increase in MAP levels to 80–85 mmHg in chronically hypertensive fluid-unresponsive septic shock patients with persistent hypoperfusion, and evaluating response after a short period of time [ 15 ].…”

Section: Discussionmentioning

confidence: 99%

“…From an epidemiological perspective, a robust number of observational studies have demonstrated that achieving a normal peripheral perfusion after initial septic shock resuscitation is associated with a mortality risk of less than 20% as compared to more than 40% in patients with persistently abnormal CRT [ 1 , 3 , 5 , 13 , 14 ]. In addition, a recent randomized controlled trial (RCT) found that targeting CRT during early septic shock resuscitation resulted in less organ dysfunction and a trend to lower mortality when compared with lactate-guided resuscitation [ 15 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

“…A post-hoc analysis of the same trial found that patients that had normalized CRT at two hours (CRT-responders) exhibited a significant lower mortality than those with persistent abnormal CRT (non-responders) [ 2 ]. Thus, CRT normalization may signal a successful resuscitation in shock states, although the precise pathophysiological link is not yet fully understood [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

“…The previous considerations position CRT as a potential resuscitation target, and therefore, it appears as relevant to further explore its kinetics of response to common hemodynamic interventions such as fluids or vasopressors. Two recent small physiological studies found that CRT improves in minutes after a fluid bolus in most fluid-responsive patients, although not in all, a fact that may be attributed to the background status of macro-microcirculatory coupling, among other factors [ 6 , 13 , 17 ]. These studies included some patients with normal CRT at baseline and variable response criteria.…”

Section: Introductionmentioning

confidence: 99%

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Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study

Hernández,

Valenzuela,

Kattan

et al. 2024

Ann. Intensive Care

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study

Hernández,

Valenzuela,

Kattan

et al. 2024

Ann. Intensive Care

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“…The aim of resuscitation in patient with septic shock is to restore organ perfusion. Thus, monitoring changes in CRT over time may be used to follow the perfusion status [ 3 , 13 ]. However, the physiological determinants of CRT are not well defined.…”

Section: Introductionmentioning

confidence: 99%

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

Fage,

Moretto,

Rosalba

et al. 2023

Crit Care

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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.

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Monitoring capillary refill time in septic shock

Hernandez,

Carmona,

Ait-Oufella

2024

Intensive Care Med

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Capillary refill time (CRT) has been proposed as a marker of tissue hypoperfusion based on physiological and clinical-epidemiological data and is increasingly used as a monitor in shock states and other conditions [1][2][3][4]. Indeed, besides being costless and universally available, CRT is a dynamic parameter which changes rapidly in response to hemodynamic interventions, thus making it a suitable bedside tool to monitor and guide septic shock resuscitation [1]. Unfortunately, specific guidelines to standardize how to estimate CRT do not currently exist. This toolbox aims to provide a practical overview of the fundamentals of CRT assessment to facilitate and optimize its use at the bedside.

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Perspectives on peripheral perfusion assessment

Cited by 11 publications

References 62 publications

Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study

Capillary refill time response to a fluid challenge or a vasopressor test: an observational, proof-of-concept study

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock

Monitoring capillary refill time in septic shock

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