Capillary Refill Research Articles

Laparoscopic versus open lumbar sympathectomy in critical limb threatening ischemia patients in Egypt

PurposeThe treatment of critical limb-threatening ischemia (CLTI) is revascularization. Lumbar sympathectomy (LS) could be attempted when this is not amenable. Using laparoscopic techniques to perform LS adds the advantages of minimally invasive surgery.MethodsTwenty-four patients, presenting with non-reconstructable CLTI and rest pain, were randomly divided into group I (14 patients) who underwent retroperitoneoscopic lumbar sympathectomy (RPLS) and group II (10 patients) who had conventional open lumber sympathectomy (COLS).ResultsRPLS patients had shorter hospital stays, fewer intraoperative complications, and less postoperative pain. However, the mean operative time was significantly longer (86.4 ± 9.1 min, p-value: 0.02) in the RPLS group but decreased with each subsequent case after that. The differences in post-operative capillary refill time, ABI, TBI, and TcPO2 were not statistically significant between both groups (p-values: 0.97, 0.13, 0.32, 0.10, respectively). However, the difference in the quality-of-life score was statistically significant; the mean (± SD) SF-36 score increased from 48 ± 6.8 to 81 ± 4.4 (p-value < 0.001) in RPLS group compared to 52 ± 8.8 to 59 ± 1.2 (p-value: 0.52) in COLS group.ConclusionRPLS is feasible, safe, and has the advantages of minimally invasive surgery: minimal blood loss, less intraoperative complications, shorter hospital stay, and less postoperative pain. However, the operative time in RPLS cases is longer than in the COLS; training on the procedure is recommended to improve the learning curve.

An Unusual Case of Alarming Lactic Acidosis: Brain Metabolic Cross-Talk

AbstractA 39-year-old male with a BMI of 30.8 kg/m2 and a normal medical history underwent excision of a left orbito-cavernal hemangioma (4 × 2 × 2 cm) under general anesthesia. Balanced anesthesia and fluid management guided by pulse pressure variation (kept below 12%) were employed. Despite stable hemodynamics and normal blood sugar levels, arterial blood gas (ABG) analysis revealed a progressive rise in lactate levels, reaching 10.6 mmol/L, accompanied by acidemia. Systemic hypoperfusion was ruled out by maintaining mean arterial pressure between 70-80 mm Hg, ensuring a capillary refill time of less than 3 seconds, and confirming a central venous oxygen saturation of 72%. With a total blood loss of 800 mL, one unit of packed red blood cells was transfused due to concerns about decreased microcirculation and tissue hypoxia. After 10 hours of surgery, sodium bicarbonate (NaHCO3) was administered to mitigate metabolic acidosis and its potential impact on intracranial pressure. Postoperatively, lactate levels remained elevated (8-9 mmol/L), but with continued NaHCO3 infusion, lactate reduced to 6.4 mmol/L, allowing extubation. The patient's lactate normalized by the evening, and recovery was uneventful. This case highlights the significant metabolic disturbances, particularly lactic acidosis, that can arise during brain tumor surgery due to prolonged operative times, large tumor size, higher BMI, and stress-induced metabolic derangements. Awareness and prompt management of these disturbances are crucial for successful patient outcomes.

Point of care lactate for differentiating septic shock from hypovolemic shock in non-ICU settings: a prospective observational study

BackgroundSeptic shock and hypovolemic shock are life-threatening illnesses that necessitate immediate recognition and intervention, as they can result in deadly consequences. While the underlying processes may vary, both entities can exhibit hypotension and organ dysfunction. No studies have been conducted on bedside testing to differentiate between these illnesses. Lactate measurement has been established as a viable option for early detection of septic shock. However, its role in diagnosing hypovolemic shock has yet to be evaluated. The aim of the study was to investigate alterations in lactate levels among diarrheal patients with septic shock and hypovolemic shock following the administration of first fluid resuscitation. MethodsWe conducted a prospective observational study in critically ill diarrheal adults aged ≥18 years in the emergency ward in Dhaka Hospital of icddr,b from 21st October 2021 to 31st May 2023 (total 19 months). The enrollment process was operational between 8:30 AM and 5:00 PM. Diarrheal adults with a diagnosis of sepsis with shock featured with poor peripheral perfusion (characterized by cold periphery and weak or absent pulse and capillary refill time >3 sec) or hypotension (characterized by mean arterial pressure <65 mm-Hg) were enrolled as cases and consecutive diarrheal patients without any obvious features of sepsis with hypovolemic shock (due to severe dehydration) comprised the comparison group.POC lactate test was done at hours 0, 1st and 6th by StatStrip Lactate meters (Nova Biomedical, US) to all enrolled patients. For comparison of POC lactate levels, we used paired t-test for comparing the lactate samples drawn at hour 0, hour 1 and 6 with the septic shock and hypovolemic shock group. Odds ratio (OR) and their 95% confidence intervals (CIs) were used to demonstrate the strength of association. The study was registered at Clinicaltrials.gov (NCT05108467) and received institutional ethical approval (PR-21097). FindingsOf 435 patients, 135 had septic shock and 141 had hypovolemic shock, rest 41 patient responded with fluid bolus. 25% (34/135) of the people in the septic shock group died whereas there is no mortality in the hypovolemic shock group. The number of patients visiting from outside Dhaka city had more septic shock than from inside were higher in comparison with (55% vs. 28%; p <0.001). Statistically significant difference was observed between septic shock and hypovolemic shock group for a median POC lactate in 0, 1st and 6th hours with an OR of 1.07 (95% CI: 0.99, 1.17; p=0.039); 1.48, (95% CI: 1.28, 1.70; p<0.001) and 2.36 (95% CI: 1.85, 3.00; p<0.001), respectively. The gradient of 1st to 2nd sample between septic shock and hypovolemic shock was found to be significantly different (OR:0.74, 95% CI: 0.64, 0.85; p<0.001). InterpretationPOC lactate test can detect septic shock by differentiating hypovolemic shock in diarrheal patients. By providing quick, reliable and accurate result this test can help clinicians quickly diagnose and treat time-sensitive condition, like septic shock. FundingThe study was funded by Global Affairs of Canada (GR-01726). The donors had no role in the design, implementation, analysis, data interpretation or writing manuscript, or decision to publish. The corresponding author had access to all data and takes responsibility for the final approval and submission of the manuscript.

Changes in portal pulsatility index induced by a fluid challenge in patients with haemodynamic instability and systemic venous congestion: a prospective cohort study

BackgroundIt is uncertain whether fluid administration can improve patients with systemic venous congestion and haemodynamic instability. This study aimed to describe the changes in systemic venous congestion and peripheral perfusion parameters induced by a fluid challenge in these patients, and to analyse the influence of the fluid responsiveness status on these changes.MethodsThe study is a single-centre prospective cohort study of 36 critically ill ICU patients with haemodynamic instability and a maximum vena cava diameter ≥ 20 mm. Changes in cardiac index during a fluid challenge (4 mL/kg of lactated Ringer’s solution during 5 min) assessed by pulse contour analysis, central venous pressure, ultrasound systemic congestion parameters (portal venous flow pulsatility index, supra hepatic and intrarenal venous Doppler), and peripheral perfusion parameters (capillary refill time and peripheral perfusion index) were assessed in the overall population. All these data were compared between patients presenting a cardiac index increase > 10% during the fluid challenge (fluid responders) and the others (fluid non-responders).ResultsTwenty-eight (78%) patients were admitted for postoperative care following cardiac surgery; their mean ± SD left ventricular ejection fraction was 42 ± 9% and right ventricular dysfunction was found in at least 61% of the patients. The mean ± SD SOFA score was 9 ± 3. Thirteen (36%) patients were fluid responders. The fluid challenge administration induced a significant increase in portal pulsatility index, VExUS score, and central venous pressure without significant difference of these changes between fluid responders and non-responders. No significant change in perfusion parameters was observed.ConclusionFluid administration in patients with haemodynamic instability and systemic venous congestion worsens venous congestion regardless of the fluid responsiveness status, without improving perfusion parameters.

Evaluation of Automated Finger Compression for Capillary Refill Time Measurement in Pediatrics.

Evaluation of Automated Finger Compression for Capillary Refill Time Measurement in Pediatrics.

A survey on management practices of hypotension in preterm neonates: an Indian perspective.

Hypotension is a common entity in the neonatal intensive care unit (NICU) and is reported in 24%-50% of preterm infants with birth weight less than 1,500 g. Rapid diagnosis and aggressive management is crucial to reduce its detrimental effects on end-organs especially the brain. Physicians often rely on blood pressure alone as a reliable indicator of tissue perfusion, but variations exist in the definition of this crucial parameter. There are also practice variations in the use of diagnostic tools and management modalities among physicians. A physician-based cross-sectional survey of management practices of hypotension in preterm neonates in Indian NICUs was conducted using an online survey tool. The questionnaire addressed diagnostic criteria used, utility of echocardiography for the assessment of hypotension, and management strategies used, such as volume expansion, inotropes and steroids. Three hundred and twenty physicians, working predominantly in Level III NICUs, responded to the survey. The practice of delayed cord clamping was followed in the units of 78% respondents. Only 44% respondents had an institutional written protocol for the management of hypotension. The criteria for the diagnosis of hypotension varied, with 52% using mean blood pressure (BP) less than gestational age as the criteria. Capillary refill time, blood pressure and heart rate were the most common clinical criteria used. 85% respondents used echocardiography in the NICU, but only 73% utilised it for assessment of a hypotensive neonate. Physicians preferred a 'volume-inotrope-echo-steroid' strategy, with 85% respondents using volume expansion. Dopamine was the preferred first line inotrope, followed by norepinephrine and low-dose epinephrine. This survey reflects significant variations in practice amongst neonatal physicians in India. Bedside targeted echocardiography needs to be better utilised as a vital tool to determine the pathophysiology of disease and hemodynamic monitoring in the management of hypotension in neonates. While further research is needed on outcome-oriented objectives, awareness and dissemination of already existing guidelines would be useful to standardize clinical practice.

Quantitative Evaluation of Microcirculatory Alterations in Patients with COVID-19 and Bacterial Septic Shock through Remote Photoplethysmography and Automated Capillary Refill Time Analysis.

Background and Objectives: Sepsis, a leading global health challenge, accounts for around 20% of deaths worldwide. The complexity of sepsis, especially the difference between bacterial and viral etiologies, requires an effective assessment of microcirculation during resuscitation. This study aimed to evaluate the impact of infusion therapy on microcirculation in patients with sepsis, focusing on bacterial- and COVID-19-associated sepsis using remote photoplethysmography (rPPG) and the automated capillary refill time (aCRT). Materials and Methods: This single-center prospective study was conducted in the ICU of Pauls Stradins Clinical University Hospital, including 20 patients with sepsis/septic shock. The patients were selected based on hemodynamic instability and divided into COVID-19 and Bacterial Septic Shock groups. Fluid responsiveness was assessed using the Passive Leg Raising Test (PLRT). Systemic hemodynamics and microcirculation were monitored through MAP CRT, rPPG, and serum lactate levels. Statistical analyses compared responses within and between the groups across different stages of the protocol. Results: The Bacterial group exhibited higher initial serum lactate levels and more pronounced microcirculatory dysfunction than the COVID-19 group. rPPG was more sensitive in detecting perfusion changes, showing significant differences between the groups. The automated CRT demonstrated greater sensitivity compared to the manual CRT, revealing significant differences during PLRT stages between bacterial- and COVID-19-associated sepsis. Both groups had a transient hemodynamic response to PLRT, with subsequent stabilization upon fluid infusion. Conclusions: When managing patients with sepsis in intensive care, monitoring microcirculation is of paramount importance in infusion therapy. Our study highlights the potential of rPPG and aCRT as tools for this purpose. These techniques can be used in conjunction with routine parameters, such as lactate levels and systemic hemodynamic parameters, to provide a comprehensive assessment of a patient's condition.

Capillary Refill Time After Induction of General Anesthesia: A Pilot Study

Capillary Refill Time After Induction of General Anesthesia: A Pilot Study

8227 Complex Case of Myxedema Coma Complicated by Cardiac Arrest in a Geriatric Patient with Multiple Comorbidities

Abstract Disclosure: M. Parvez: None. L. Makahleh: None. S. Nagpal: None. A. Kavarthapu: None. V. Vedantam: None. Introduction: This case report details a rare instance of cardiac arrest in a patient with myxedema coma, a severe form of hypothyroidism. It highlights the diagnostic and therapeutic challenges in managing such complex endocrine emergencies. Case Presentation: A 70-year-old female with a history of hypothyroidism, type 2 diabetes, atrial fibrillation, pacemaker implantation, and COPD presented with a 3 day history of progressive lethargy and weakness. EMS found her with critically low blood glucose level of 20. History and Examination revealed non-compliance with thyroid medication and myxedematous features including moon-like facies, periorbital edema, generalized edema, elevated JVP, and cold extremities with sluggish capillary refill. In the ER, she was hypotensive, labs showed a significantly elevated TSH level of 30.55 (0.45-4.5), free T3 level of 1.2 (2.3-4.2), free T4 level of 1.12 (0.93-1.70), high lactate, metabolic acidosis, renal impairment, and liver enzyme elevation. These findings, coupled with the clinical presentation, led to the diagnosis of myxedema coma. The patient's critical state was further complicated by distributive shock, shock liver and oliguric AKI. Management included sodium bicarbonate infusion for severe acidosis, IV hydrocortisone, IV levothyroxine, and broad-spectrum antibiotics. Amiodarone was discontinued due to its potential contribution to acute liver injury and hypothyroidism. Despite interventions, she developed acute respiratory failure, requiring intubation and norepinephrine for low mean arterial pressure. Her renal function improved with pressor support, and her lactic acidosis resolved. She recovered quickly and was subsequently extubated. After stabilization, she was switched to oral levothyroxine and discharged. Shortly after discharge, she returned again with generalized weakness, confusion, and dysuria. ER evaluation revealed lethargy, hypotension, hypoglycemia, severe metabolic acidosis, and a UTI. She tested positive for Influenza. While in the ER, she had cardiac arrest, presenting with agonal breathing and PEA. CPR was initiated, achieving ROSC after two rounds and one dose of epinephrine. She was treated again with IV levothyroxine, and IV antibiotics. She recovered well and was discharged to rehab facility with re-education on compliance. Conclusion: This case exemplifies the complexity and challenges in managing a geriatric patient with multiple comorbidities, particularly in the context of myxedema coma. The intricate interplay of endocrine, cardiovascular, respiratory, and infectious complications necessitated a multifaceted and dynamic therapeutic approach. This case underscores the importance of compliance, vigilant monitoring, prompt recognition of complicating factors, and the need for a coordinated multidisciplinary approach in managing similar cases. Presentation: 6/2/2024

Utilizing the '5 in 1 Magic Touch' CCRTV method for early detection of severe dengue warning signs in pediatric patients: A case study from a Type C Hospital in Indonesia

Background: Dengue fever, prevalent in tropical and subtropical regions, is recognized by WHO as a significant global health threat. Early detection of severe dengue symptoms, especially in resource-limited settings, is critical for patient outcomes. The "5 in 1 Magic Touch - CCRTV" method, which evaluates Color, Capillary Refill Time, Temperature, Pulse Rate, and Pulse Volume, provides a simple yet effective approach to monitor hemodynamics and identify early warning signs of severe dengue. Case Description: In a case study, a 3-year-old boy was admitted with fever, shortness of breath, weakness, nausea, vomiting, and epigastric pain. On the third day, he entered a critical phase with symptoms of pale extremities, delayed capillary refill time, high fever, and a weak, rapid pulse. Thorax examination revealed severe plasma leakage, pulmonary edema, and right pleural effusion, indicating a pre-shock state. The patient required close clinical monitoring, regular fluid balance management, and frequent blood tests to guide treatment. Conclusion:The CCRTV assessment method allowed for the early identification of the pre-shock condition, facilitating timely and appropriate intervention. This case highlights the potential of the CCRTV method for improving prognosis in severe dengue cases. The effectiveness of this method warrants further research, particularly in its ability to predict outcomes and improve recovery rates in children with severe dengue.

Capillary Refill Time as a Part of Routine Physical Examination in Critically Ill Patients Undergoing Vasoactive Therapy: A Prospective Study.

Background/Objectives: In critically ill patients, achieving a mean arterial pressure (MAP) of 65 mmHg is a recommended resuscitation goal to ensure proper tissue oxygenation. Unfortunately, some patients do not benefit from providing such a value, suggesting that other indices are needed for better hemodynamic assessment. Capillary refill time (CRT) has emerged as an established marker for peripheral perfusion and a therapeutic target in critical illness, but its relationship with other exponents of hypoperfusion during vasopressor support after resuscitation period still warrants further research. This study aimed to investigate whether in critically ill patients after initial resuscitation, CRT would provide information independent of other, readily accessible hemodynamic variables. Methods: Critically ill patients who were mechanically ventilated after the resuscitation period and receiving vasopressors were prospectively studied between December 2022 and June 2023. Vasopressor support was measured using norepinephrine equivalent doses (NEDs). CRT, MAP and NED were assessed simultaneously and analyzed using Spearman's rank correlation. Results: A total of 92 patients were included and 210 combined MAP-CRT-NED-Lactate records were obtained. There was no correlation between CRT and MAP (R = -0.1, p = 0.14) or lactate (R = 0.11, p = 0.13), but there was a positive weak correlation between CRT and NED (R = 0.25, p = 0.0005). In patients with hypotension, in 83% of cases (15/18), CRT was within normal range, despite different doses of catecholamines. When assessing patients with high catecholamine doses, in 58% cases (11/19), CRT was normal and MAP was usually above 65 mmHg. Conclusions: Capillary refill time provides additional hemodynamic information that is not highly related with the values of mean arterial pressure, lactate level and vasopressor doses. It could be incorporated into routine physical examination in critically ill patients who are beyond initial resuscitation.

Peripheral Perfusion Index in Ugandan Children With Plasmodium falciparum Severe Malaria: Secondary Analysis of Outcomes in a 2014-2017 Cohort Study.

Continuous, noninvasive tools to monitor peripheral perfusion, such as perfusion index (PI), can detect hemodynamic abnormalities and assist in the management of critically ill children hospitalized with severe malaria. In this study of hospitalized children with severe malaria, we aimed to assess whether PI correlates with clinical markers of perfusion and to determine whether combining PI with these clinical measures improves identification of children with greater odds of mortality. Post hoc analysis of a prospective, multicenter, cohort study conducted between 2014 and 2017. Two referral hospitals in Central and Eastern Uganda. Six hundred children younger than 5 years old with severe malaria and 120 asymptomatic community children. None. PI was measured at 6-hour intervals for the first 24 hours of hospitalization. We compared PI to standard clinical perfusion measures such as capillary refill time, presence of cold peripheral limbs, or temperature gradient. Admission PI was highly correlated with clinical measures of perfusion. Admission PI was lower in children with severe malaria compared with asymptomatic community children; and, among the children with severe malaria, PI was lower in those with clinical features of poor perfusion or complications of severe malaria, such as shock and hyperlactatemia (all p < 0.02). Among children with severe malaria, lower admission PI was associated with greater odds of mortality after adjustment for age, sex, and severe malaria criteria (adjusted odds ratio, 2.4 for each log decrease in PI [95% CI, 1.0-5.9]; p = 0.045). Diagnostically, the presence of two consecutive low PI measures (< 1%) predicted mortality, with a sensitivity of 50% and a specificity of 76%. In severe malaria, PI correlates with clinical complications (including shock and elevated serum lactate) and may be useful as an objective, continuous explanatory variable associated with greater odds of later in-hospital mortality.

Role of arterial blood glucose and interstitial fluid glucose difference in evaluating microcirculation and clinical prognosis of patients with septic shock: a prospective observational study

BackgroundMicrocirculation abnormality in septic shock is closely associated with organ dysfunction and mortality rate. It was hypothesized that the arterial blood glucose and interstitial fluid (ISF) glucose difference (GA−I) as a marker for assessing the microcirculation status can effectively evaluate the severity of microcirculation disturbance in patients with septic shock.MethodsThe present observational study enrolled patients with septic shock admitted to and treated in the intensive care unit (ICU) of a tertiary teaching hospital. The parameters reflecting organ and tissue perfusion, including lactic acid (Lac), skin mottling score, capillary refill time (CRT), venous-to-arterial carbon dioxide difference (Pv-aCO2), urine volume, central venous oxygen saturation (ScvO2) and GA−I of each enrolled patient were recorded at the time of enrollment (H0), H2, H4, H6, and H8. With ICU mortality as the primary outcome measure, the ICU mortality rate at any GA−I interval was analyzed.ResultsA total of 43 septic shock patients were included, with median sequential organ failure assessment (SOFA) scores of 10.5 (6–16), and median Acute Physiology and Chronic Health Evaluation (APACHAE) II scores of 25.7 (9–40), of whom 18 died during ICU stay. The GA−I levels were negative correlation with CRT (r = 0.369, P < 0.001), Lac (r = -0.269, P < 0.001), skin mottling score (r=-0.223, P < 0.001), and were positively associated with urine volume (r = 0.135, P < 0.05). The ICU mortality rate of patients with septic shock presenting GA−I ≤ 0.30 mmol/L and ≥ 2.14 mmol/L was significantly higher than that of patients with GA−I at 0.30–2.14 mmol/L [65.2% vs. 15.0%, odds ratio (OR) = 10.625, 95% confidence interval (CI): 2.355–47.503].ConclusionGA−I was correlated with microcirculation parameters, and with differences in survival. Future studies are needed to further explore the potential impact of GA−I on microcirculation and clinical prognosis of septic shock, and the bedside monitoring of GA−I may be beneficial for clinicians to identify high-risk patients.

The Effect of Repeated Capillary Refill Tests on the Cutaneous Microcirculation.

The capillary refill test (CR test) is often used in emergency care, and the capillary refill time (CR time) is used to assess a patient's circulatory condition. The objective of this study was to investigate if repeated CR tests affect CR time. Thirteen healthy volunteers had repeated CR tests performed on the sternum, forehead, and fingers. The tests were filmed using polarized reflectance spectroscopy and dedicated software for objective quantification of the CR time. There were no statistical differences between the first CR test in a series and the following. However, there were statistically significant differences in CR time between the different anatomical sites. Repeated CR tests, separated by a minimum of 2 min, do not affect CR time in healthy volunteers. The site where the test is performed is of importance for CR time.

Nitroglycerin challenge identifies microcirculatory target for improved resuscitation in patients with circulatory shock

BackgroundCirculatory shock and multi-organ failure remain major contributors to morbidity and mortality in critically ill patients and are associated with insufficient oxygen availability in the tissue. Intrinsic mechanisms to improve tissue perfusion, such as up-regulation of functional capillary density (FCD) and red blood cell velocity (RBCv), have been identified as maneuvers to improve oxygen extraction by the tissues; however, their role in circulatory shock and potential use as resuscitation targets remains unknown. To fill this gap, we examined the baseline and maximum recruitable FCD and RBCv in response to a topical nitroglycerin stimulus (FCDNG, RBCvNG) in patients with and without circulatory shock to test whether this may be a method to identify the presence and magnitude of a microcirculatory reserve capacity important for identifying a resuscitation target.MethodsSublingual handheld vital microscopy was performed after initial resuscitation in mechanically ventilated patients consecutively admitted to a tertiary medical ICU. FCD and RBCv were quantified using an automated computer vision algorithm (MicroTools). Patients with circulatory shock were retrospectively identified via standardized hemodynamic and clinical criteria and compared to patients without circulatory shock.Results54 patients (57 ± 14y, BMI 26.3 ± 4.9 kg/m2, SAPS 56 ± 19, 65% male) were included, 13 of whom presented with circulatory shock. Both groups had similar cardiac index, mean arterial pressure, RBCv, and RBCvNG. Heart rate (p < 0.001), central venous pressure (p = 0.02), lactate (p < 0.001), capillary refill time (p < 0.01), and Mottling score (p < 0.001) were higher in circulatory shock after initial resuscitation, while FCD and FCDNG were 10% lower (16.9 ± 4.2 and 18.9 ± 3.2, p < 0.01; 19.3 ± 3.1 and 21.3 ± 2.9, p = 0.03). Nitroglycerin response was similar in both groups, and circulatory shock patients reached FCDNG similar to baseline FCD found in patients without shock.ConclusionCritically ill patients suffering from circulatory shock were found to present with a lower sublingual FCD. The preserved nitroglycerin response suggests a dysfunction of intrinsic regulation mechanisms to increase the microcirculatory oxygen extraction capacity associated with circulatory shock and identifies a potential resuscitation target. These differences in microcirculatory hemodynamic function between patients with and without circulatory shock were not reflected in blood pressure or cardiac index.

Application of microcirculatory indicators in predicting the prognosis of patients with septic shock

ObjectiveThe aim of this study is to investigate the predictive value of indicators associated with microcirculation, capillary refill time (CRT), perfusion index (PI), and mottling score, on the prognosis of patients with septic shock. MethodA retrospective clinical study was conducted encompassing 78 patients diagnosed with septic shock and admitted to the Department of Critical Care Medicine at our hospital from January 2019 to January 2022. The study collated the clinical data of these patients, focusing on macrocirculatory hemodynamic parameters and microcirculatory indices. The parameters of interest were recorded at 0, 6, 24, and 48 hours post-admission, including heart rate, mean arterial pressure (MAP), venous-to-arterial carbon dioxide partial pressure difference, superior vena cava oxygen saturation, lactic acid (LAC), CRT, PI, and mottling score. The enrolled patients were stratified into two cohorts based on the 28-day mortality rate: a survival group and a mortality group. A non-parametric statistical test was employed to compare the CRT, PI, and mottling score between the two groups. Furthermore, the predictive value of these microcirculatory indicators for mortality in septic shock patients was assessed using receiver operating characteristic (ROC) curve analysis. This methodology allowed for the evaluation of the prognostic accuracy of CRT, PI, and mottling score as indicators for mortality in the context of septic shock. ResultsThe vasoactive drug dose, PI, LAC, mottling score, and CRT upon admission in the survival group were significantly better than those in the mortality group at hour 6 of treatment, hour 24 of treatment, and hour 48 of treatment (P < 0.05). The predictive value of the three microcirculatory indicators at various time points was highest for the Perfusion Index (PI) at 48 hours of treatment, the mottling score at 24 hours of treatment, and the Capillary Refill Time (CRT) upon admission. The Area Under the Curve (AUC) for PI at 48 hours of treatment was 0.941 (0.885 to 0.996), with a sensitivity of 90.9% and a specificity of 94.1%. For the mottling score at 24 hours of treatment, the AUC was 0.889 (0.805 to 0.972), with a sensitivity of 82.4% and a specificity of 88.6%. The AUC for CRT upon admission was 0.872 (0.788 to 0.956), with a sensitivity of 91.2% and a specificity of 77.3%. Among the three indicators: PI, mottling score, and CRT, PI at hour 48 of treatment had the highest predictive value for the prognosis of patients with septic shock. ConclusionMicrocirculatory indicators have specific predictive value for the prognosis of patients with septic shock.

Elevation and distraction of the Tibial periosteum in the management of chronic ischemic lower limb diseases.

This study investigates the effectiveness of tibia periosteum distraction (TPD) applied to the tibial periosteum, an innovative approach grounded in Ilizarov's tension-stress theory, for the treatment of ischemic diabetic foot and vasculitic foot conditions. A retrospective analysis was conducted on 33 patients (36 limbs) who underwent TPD between June 2019 and May 2022. The study comprised 21 males (23 limbs) and 12 females (13 limbs), aged 41 to 80 years (mean age: 63.4 years). Diabetic foot accounted for 27 cases, thromboangiitis obliterans for 2 cases, and arterial occlusive disease for 4 cases. The distribution of affected limbs included 15 left feet and 21 right feet. Periosteum traction commenced on the third postoperative day at a rate of approximately 0.75mm/day, adjusted biweekly. The traction device was removed after two weeks. Evaluation included capillary refill and wound healing assessment, along with pre- and postoperative analysis of foot skin temperature, ankle-brachial index (ABI), visual analogue scale (VAS) pain scores, and peripheral blood oxygen saturation. CT angiography (CTA) was utilized to assess vascular conditions in both lower limbs. All 33 patients were successfully followed up for a duration ranging from 4 to 24 weeks (mean: 11.03 weeks). VAS pain scores significantly decreased from preoperative (5.09 ± 1.70, range: 2-8) to postoperative two weeks (2.24 ± 0.90, range: 1-4) (t = 9.44, p < .001). Oxygen saturation levels increased from 83.88% ± 11.82% (range: 58%-97%) preoperatively to 91.36% ± 5.69% (range: 76%-98%) at two weeks postoperatively (t = -4.21, p < .001). Foot skin temperature also showed a significant increase (t = -3.98, p < .001). Capillary refill test at two weeks postoperatively demonstrated notable improvement. CTA revealed evident neovascularization in the operated limbs compared to preoperative conditions. Wound improvement was significant in all 33 patients within two months postoperatively. TPD emerges as a promising technique for chronic ischemic lower limb diseases, demonstrating favorable preliminary outcomes in wound healing promotion and amputation rate reduction. Nevertheless, large-scale randomized controlled trials are essential to further validate its efficacy.

Hemodynamic Instability during Intermittent Hemodialysis in ICU Patients with Abnormal Capillary Refill Time

Intradialytic Hemodynamic Instability (IHI) may cause delay in renal recovery and also increases risk of mortality. Capillary Refill Time (CRT) was a stress free method used for peripheral perfusion that becomes worse during circulatory failure. Objective: To determine Hemodynamic Instability during Intermittent Hemodialysis in ICU Patients with Abnormal Capillary Refill Time at a tertiary care hospital, Karachi, Pakistan. Methods: This was the 06 months’ data collection, 1-year prospective observational study. Overall 137 patients were evaluated via sampling technique of non-probability consecutive sampling technique. For each intermittent hemodialysis session, index CRT was recorded. IHI was noted down 30 minutes before the beginning of intermittent hemodialysis and then 60 minutes, 120 minutes and 180 minutes. Entire data were recorded as a predesigned proforma. The natural distribution of patients into subgroups was done using Chi Square test considering p-value ≤0.05 as significant Results: The total population was 98 men (71.5%) and 39 women (28.5%) Average age was 61.51 ± 15.37 years. 45(17.5%) patients observed abnormal Capillary refill time. 20(14.6%) patients experienced intradialytic hemodynamic instability. Among patients diagnosed with intradialytic hemodynamic instability, 9(45%) had abnormal CRT. Compared to patients with normal CRT, individuals with aberrant CRT had a higher risk of hemodynamic instability (OR = 5.564, p &lt; 0.001). Conclusion: IHI was most at risk when it comes to initiating intermittent hemodialysis, especially in the first hour of the first session. The increase in index capillary refill time was linked to IHI.

The Vitruvian exploration: systematic review of capillary refill time in adult critically ill patients

The Vitruvian exploration: systematic review of capillary refill time in adult critically ill patients

Pilot study on optimizing pressure for standardized capillary refill time measurement

PurposeCapillary Refill Time (CRT) measurement has gained increasing attention in the field of sepsis and septic shock. Recognizing pressure as a fundamental determinant in CRT measurement is crucial for establishing a standardized CRT measurement procedure. In this preliminary study, we elucidated the optimal pressing strength for CRT measurement by analyzing the CRTs measured under varying pressures. MethodSeventeen healthy individuals were enlisted to undergo CRT tests on their fingertips at various pressure levels. The applied force was initiated at 0.5N and incrementally increased by 0.5N until it reached 10.5N. An integrated Photoplethysmography (PPG) device was employed to capture fluctuations in light intensity. The CRT was automatically derived from the PPG signals via a specialized algorithm. The study included correlation assessment and reliability evaluation. Box plot and Bland-Altman plot were used to visualize the impact of pressure levels on CRTs. ResultsA dataset of 1414 CRTs across 21 pressures showed significant differences (Kruskal-Wallis test, p < 0.0001), highlighting the impact of pressure on CRT. CRT values between 4.5N and 10.5N pressures varied less, with an Intraclass Correlation Coefficient (ICC) of 0.499 indicating moderate consistency. Notably, CRTs at 10N and 10.5N pressures revealed a high ICC of 0.790, suggesting strong agreement. ConclusionA pressure range of 4.5N–10.5N is recommended for stable CRT measurements, with 10.0N–10.5N providing optimal consistency and reliability.