The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis.

Susannah Fleming,Caroline Jones,Matthew Thompson,Carl Heneghan,Ann Van Den Bruel,Nia Roberts,James A Taylor,Peter Gill,Nguyen Tien Huy

doi:10.1371/journal.pone.0138155

Abstract

ImportanceCapillary refill time (CRT) is widely recommended as part of the routine assessment of unwell children.ObjectiveTo determine the diagnostic value of capillary refill time for a range of serious outcomes in children.MethodsWe searched Medline, Embase and CINAHL from inception to June 2014. We included studies that measured both capillary refill time and a relevant clinical outcome such as mortality, dehydration, meningitis, or other serious illnesses in children aged up to 18 years of age. We screened 1,265 references, of which 24 papers were included in this review. Where sufficient studies were available, we conducted meta-analysis and constructed hierarchical summary ROC curves.ResultsMeta-analysis on the relationship between capillary refill time and mortality resulted in sensitivity of 34.6% (95% CI 23.9 to 47.1%), specificity 92.3% (88.6 to 94.8%), positive likelihood ratio 4.49 (3.06 to 6.57), and negative likelihood ratio 0.71 (0.60 to 0.84). Studies of children attending Emergency Departments with vomiting and diarrhea showed that capillary refill time had specificity of 89 to 94% for identifying 5% dehydration, but sensitivity ranged from 0 to 94%. This level of heterogeneity precluded formal meta-analysis of this outcome. Meta-analysis was not possible for other outcomes due to insufficient data, but we found consistently high specificity for a range of outcomes including meningitis, sepsis, admission to hospital, hypoxia, severity of illness and dengue.ConclusionsOur results show that capillary refill time is a specific sign, indicating that it can be used as a “red-flag”: children with prolonged capillary refill time have a four-fold risk of dying compared to children with normal capillary refill time. The low sensitivity means that a normal capillary refill time should not reassure clinicians.

Highlights

Identifying children who may have hemodynamic compromise or shock is a routine part of clinical assessment and a core component of Pediatric Advanced Life Support.[1,2,3] In most settings, this includes assessment of peripheral perfusion such as capillary refill time (CRT) as well as measurement of blood pressure to assess cardiovascular status
Meta-analysis on the relationship between capillary refill time and mortality resulted in sensitivity of 34.6%, specificity 92.3% (88.6 to 94.8%), positive likelihood ratio 4.49 (3.06 to 6.57), and negative likelihood ratio 0.71 (0.60 to 0.84)
Our results show that capillary refill time is a specific sign, indicating that it can be used as a “red-flag”: children with prolonged capillary refill time have a four-fold risk of dying compared to children with normal capillary refill time

Summary

Methods

We searched Medline, Embase and CINAHL from inception to June 2014. We included studies that measured both capillary refill time and a relevant clinical outcome such as mortality, dehydration, meningitis, or other serious illnesses in children aged up to 18 years of age. We screened 1,265 references, of which 24 papers were included in this review. Where sufficient studies were available, we conducted meta-analysis and constructed hierarchical summary ROC curves

Results

Conclusions

Introduction

Discussion