Skin mottling score as a predictor of 28-day mortality in patients with septic shock

Moura, Edmilson Bastos de; Amorim, Fábio Ferreira; Santana, Alfredo Nicodemos Cruz; Kanhouche, Gabriel; Godoy, Lucas Garcia de Souza; Almeida, Lucila de Jesus; Rodrigues, Thais Almeida; Silveira, Carlos Darwin Gomes da; Maia, Marcelo de Oliveira

doi:10.1007/s00134-015-4184-4

Cited by 32 publications

(21 citation statements)

References 5 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%

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%

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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“…Based on instrumental investigations with laser Doppler imaging and near-infrared spectroscopy it was shown that in mottled skin areas perfusion as well as tissue oxygenation are reduced (31). The use of the mottling score has been validated in several studies in patients with sepsis (32, 33) as well as liver cirrhosis (34).…”

Section: Clinical Assessment Of Micro-circulationmentioning

confidence: 99%

Assessment of Regional Perfusion and Organ Function: Less and Non-invasive Techniques

et al. 2019

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

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Skin mottling score as a predictor of 28-day mortality in patients with septic shock

Cited by 32 publications

References 5 publications

Perfusion indices revisited

Perfusion indices revisited

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

Assessment of Regional Perfusion and Organ Function: Less and Non-invasive Techniques

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