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Jan Bakker - One of the best experts on this subject based on the ideXlab platform.
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Narrative review: clinical assessment of peripheral tissue perfusion in septic shock.
Annals of Intensive Care, 2019Co-Authors: Geoffroy Hariri, Jérémie Joffre, Guillaume Leblanc, Michael Bonsey, Jean-rémi Lavillegrand, Tomas Urbina, Bertrand Guidet, Eric Maury, Jan Bakker, Hafid Ait-oufellaAbstract:Sepsis is one of the main reasons for intensive care unit admission and is responsible for high morbidity and mortality. The usual hemodynamic targets for resuscitation of patients with septic shock use macro-hemodynamic parameters (hearth rate, mean arterial pressure, central venous pressure). However, persistent alterations of microcirculatory blood flow despite restoration of macro-hemodynamic parameters can lead to organ failure. This dissociation between macro- and microcirculatory compartments brings a need to assess end organs tissue perfusion in patients with septic shock. Traditional markers of tissue perfusion may not be readily available (lactate) or may take time to assess (urine output). The skin, an easily accessible organ, allows clinicians to quickly evaluate the peripheral tissue perfusion with noninvasive bedside parameters such as the skin temperatures gradient, the Capillary Refill time, the extent of mottling and the peripheral perfusion index.
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Capillary Refill time during fluid resuscitation in patients with sepsis related hyperlactatemia at the emergency department is related to mortality
PLOS ONE, 2017Co-Authors: Barbara Lara, Jan Bakker, Ricardo Castro, Eduardo Kattan, Luis Enberg, Marcos Ortega, Paula Leon, Cristobal Kripper, Pablo Aguilera, Glenn HernandezAbstract:Introduction Acute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary Refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome. Methods We performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered. Results Ninety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7–7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9–16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality. Conclusions Hyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.
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changes in peripheral perfusion relate to visceral organ perfusion in early septic shock a pilot study
Journal of Critical Care, 2016Co-Authors: Andreas Brunauer, Jan Bakker, Ilse Gradwohlmatis, Daniel Dankl, Andreas Kokofer, Otgon Bataar, Martin W DunserAbstract:Abstract Purpose To correlate clinical indicators of peripheral perfusion with visceral organ vascular tone in 30 septic shock patients. Materials and Methods In a prospective pilot study, Capillary Refill time, the Mottling score, and peripheral temperature were determined within 24, 48, and 72 hours after intensive care unit admission. Simultaneously, pulsatility indices in the liver, spleen, kidneys, and intestines were measured by Doppler ultrasonography. Correlation analyses were calculated, applying an adjusted significance level ( P Results Significant relationships were observed between the pulsatility index of selected organs and the Capillary Refill time (intestines: r = 0.325, P = .007), and the Mottling score (kidneys: r = 0.396, P = .006), but not peripheral temperature (all r P > .05). An association over time was observed for the Capillary Refill time and pulsatility index of the liver ( P = .04) and intestines ( P = .03) as well as for the Mottling score and the kidneys' pulsatility index ( P = .03), but not for peripheral temperature and any visceral organs' pulsatility index. Conclusions Capillary Refill time and skin mottling may be correlated with the pulsatility index, a sonographic surrogate of vascular tone, of visceral organs in early septic shock.
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the relation of near infrared spectroscopy with changes in peripheral circulation in critically ill patients
Critical Care Medicine, 2011Co-Authors: Alexandre Lima, Elko Klijn, Karolina Sikorska, Michel E. Van Genderen, Can Ince, Jasper Van Bommel, Emmanuel Lesaffre, Jan BakkerAbstract:We conducted this observational study to investigate tissue oxygen saturation during a vascular occlusion test in relationship with the condition of peripheral circulation and outcome in critically ill patients. Prospective observational study. Multidisciplinary intensive care unit in a university hospital. Seventy-three critically ill adult patients admitted to the intensive care unit. None. Patients were followed every 24 hrs until day 3 after intensive care admission. Near-infrared spectroscopy was used to measure thenar tissue oxygen saturation, tissue oxygen saturation deoxygenation rate, and tissue oxygen saturation recovery rate after the vascular occlusion test. Measurements included heart rate, mean arterial pressure, forearm-to-fingertip skin-temperature gradient, and physical examination of peripheral perfusion with Capillary Refill time. Patients were stratified according to the condition of peripheral circulation (abnormal: forearm-to-fingertip skin-temperature gradient ≥4 and Capillary Refill time >4.5 secs). The outcome was defined based on the daily Sequential Organ Failure Assessment score and blood lactate levels. Upon intensive care unit admission, 35 (47.9%) patients had abnormal peripheral perfusion (forearm-to-fingertip skin-temperature gradient >4 or Capillary Refill time >4.5 secs). With the exception of the tissue oxygen saturation deoxygenation rate, tissue oxygen saturation baseline and tissue oxygen saturation recovery rate were statistically lower in patients who exhibited abnormal peripheral perfusion than in those with normal peripheral perfusion: 72 ± 9 vs. 81 ± 9; p = .001 and 1.9 ± 0.7 vs. 3.2 ± 0.9; p = .001, respectively. When a mixed-model analysis was performed over time for estimate (s) calculation, adjusted to the condition of disease, we did not find a significant clinical effect between vascular occlusion test-derived tissue oxygen saturation measurements (as response variables) and mean systemic hemodynamic variables (as independent variables): tissue oxygen saturation vs. heart rate: s (95% confidence interval) = 0.007 (-0.08; 0.09); tissue oxygen saturation vs. mean arterial pressure: s (95% confidence interval) = -0.02 (-0.12; 0.08); tissue oxygen saturation deoxygenation rate vs. heart rate: s (95% confidence interval) = 0.002 (-0.0004; 0.006); tissue oxygen saturation deoxygenation rate vs. mean arterial pressure: s (95% confidence interval) - 0.0007 (-0.003; 0.004); tissue oxygen saturation recovery rate vs. heart rate: s (95% confidence interval) = -0.009 (-0.02; -0.0015); tissue oxygen saturation recovery rate vs. mean arterial pressure: s (95% confidence interval) = 0.01 (0.002; 0.018). However, there was a strong association between tissue oxygen saturation baseline and tissue oxygen saturation recovery rate with abnormal peripheral perfusion: tissue oxygen saturation vs. abnormal peripheral perfusion: s (95% confidence interval) = -10.1 (-13.9; -6.2); tissue oxygen saturation recovery rate vs. abnormal peripheral perfusion: s (95% confidence interval) =-10.1 (-13.9; -6.2); tissue oxygen saturation recovery rate vs. abnormal peripheral perfusion: s (95% confidence interval) = -1.1 (-1.4; -0.81). Poor outcome was more closely related to abnormalities in peripheral perfusion than to tissue oxygen saturation-derived parameters. We found that the condition of peripheral circulation in critically ill patients strongly influences tissue oxygen saturation resting values and the tissue oxygen saturation reoxygenation rate but not the tissue oxygen saturation deoxygenation rate. In addition, changes in near-infrared spectroscopy-derived variables were independent of condition of disease and were not accompanied by any major differences in systemic hemodynamic variables
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the prognostic value of the subjective assessment of peripheral perfusion in critically ill patients
Critical Care Medicine, 2009Co-Authors: Alexandre Lima, Can Ince, Tim C Jansen, Jasper Van Bommel, Jan BakkerAbstract:Objective: The physical examination of peripheral perfusion based on touching the skin or measuring Capillary Refill time has been related to the prognosis of patients with circulatory shock. It is unclear, however, whether monitoring peripheral perfusion after initial resuscitation still provides information on morbidity in critically ill patients. Therefore, we investigated whether subjective assessment of peripheral perfusion could help identify critically ill patients with a more severe organ or metabolic dysfunction using the Sequential Organ Failure Assessment (SOFA) score and lactate levels. Design: Prospective observational study. Setting: Multidisciplinary intensive care unit in a university hospital. Patients: Fifty consecutive adult patients admitted to the intensive care unit. Interventions: None. Measurements and Main Results: Patients were considered to have abnormal peripheral perfusion if the examined extremity had an increase in Capillary Refill time (>4.5 seconds) or it was cool to the examiner hands. To address reliability of subjective inspection and palpation of peripheral perfusion, we also measured forearm-to-fingertip skin-temperature gradient (Tskin-diff), centralto-toe temperature difference (Tc-toe), and peripheral flow index. The measurements were taken within 24 hours of admission to the intensive care after hemodynamic stability was obtained (mean arterial pressure >65 mm Hg). Changes in SOFA score during the first 48 hours were analyzed (-SOFA). Individual SOFA score was significantly higher in patients with abnormal peripheral perfusion than in those with normal peripheral perfusion (9 3 vs. 7 2, p 0 was significantly higher in patients with abnormal peripheral perfusion (77% vs. 23%, p < 0.05). The logistic regression analysis showed that the odds of unfavorable evolution are 7.4 (95% confidence interval 2‐19; p < 0.05) times higher for a patient with abnormal peripheral perfusion. The proportion of hyperlactatemia was significantly different between patients with abnormal and normal peripheral perfusion (67% vs. 33%, p < 0.05). The odds of hyperlactatemia by logistic regression analysis are 4.6 (95% confidence interval 1.4‐15; p < 0.05) times higher for a patient with abnormal peripheral perfusion. Conclusions: Subjective assessment of peripheral perfusion with physical examination following initial hemodynamic resuscitation in the first 24 hours of admission could identify hemodynamically stable patients with a more severe organ dysfunction and higher lactate levels. Patients with abnormal peripheral perfusion had significantly higher odds of worsening organ failure than did patients with normal peripheral perfusion following initial resuscitation. (Crit Care Med 2009; 37:934‐938)
Glenn Hernandez - One of the best experts on this subject based on the ideXlab platform.
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Capillary Refill time during fluid resuscitation in patients with sepsis related hyperlactatemia at the emergency department is related to mortality
PLOS ONE, 2017Co-Authors: Barbara Lara, Jan Bakker, Ricardo Castro, Eduardo Kattan, Luis Enberg, Marcos Ortega, Paula Leon, Cristobal Kripper, Pablo Aguilera, Glenn HernandezAbstract:Introduction Acute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary Refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome. Methods We performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered. Results Ninety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7–7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9–16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality. Conclusions Hyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.
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evolution of peripheral vs metabolic perfusion parameters during septic shock resuscitation a clinical physiologic study
Journal of Critical Care, 2012Co-Authors: Glenn Hernandez, Ricardo Castro, Cesar Pedreros, Enrique Veas, Alejandro Bruhn, Carlos Romero, Maximiliano Rovegno, Rodolfo Neira, Sebastian Bravo, Eduardo KattanAbstract:Abstract Purpose Perfusion assessment during septic shock resuscitation is difficult and usually complex determinations. Capillary Refill time (CRT) and central-to-toe temperature difference (Tc-toe) have been proposed as objective reproducible parameters to evaluate peripheral perfusion. The comparative evolution of peripheral vs metabolic perfusion parameters in septic shock resuscitation has not been studied. We conducted a prospective observational clinical-physiologic study to address this subject. Methods Patients with sepsis-related circulatory dysfunction were resuscitated according to a standard local algorithm. Perfusion assessment included serial determinations of metabolic (central venous O 2 saturation [Scvo 2 ] and central venous to arterial Pco 2 gradient [P(cv-a)co 2 ]) and peripheral perfusion parameters (CRT and Tc-toe, among others). Successful resuscitation was defined as a normal plasma lactate at 24 hours. Results Forty-one patients were included. The presence of normal values for both CRT and Tc-toe considered together at 6 hours was independently associated with a successful resuscitation ( P = .02), as compared with the behavior of metabolic parameters. Capillary Refill time was the first parameter to be significantly normalized. Conclusion Early recovery of peripheral perfusion anticipates a successful resuscitation compared with traditional metabolic parameters in septic shock patients. Our findings support the inclusion of serial peripheral perfusion assessment in multimodal monitoring strategies for septic shock resuscitation.
Ricardo Castro - One of the best experts on this subject based on the ideXlab platform.
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effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28 day mortality among patients with septic shock the andromeda shock randomized clinical trial
JAMA, 2019Co-Authors: Gle Hernandez, Ricardo Castro, Gustavo A Ospinatasco, Lucas Petri Damiani, Elisa Estenssoro, Arnaldo Dubi, Javie Hurtado, Gilberto Friedma, Leyla Alegria, Jeanlouis TeboulAbstract:Importance Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. Objective To determine if a peripheral perfusion–targeted resuscitation during early septic shock in adults is more effective than a lactate level–targeted resuscitation for reducing mortality. Design, Setting, and Participants Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. Interventions Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing Capillary Refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. Main Outcomes and Measures The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation–, renal replacement therapy–, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. Results Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02];P = .06; risk difference, −8.5% [95% CI, −18.2% to 1.2%]). Peripheral perfusion–targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, −1.00 [95% CI, −1.97 to −0.02];P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. Conclusions and Relevance Among patients with septic shock, a resuscitation strategy targeting normalization of Capillary Refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. Trial Registration ClinicalTrials.gov Identifier:NCT03078712
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Capillary Refill time during fluid resuscitation in patients with sepsis related hyperlactatemia at the emergency department is related to mortality
PLOS ONE, 2017Co-Authors: Barbara Lara, Jan Bakker, Ricardo Castro, Eduardo Kattan, Luis Enberg, Marcos Ortega, Paula Leon, Cristobal Kripper, Pablo Aguilera, Glenn HernandezAbstract:Introduction Acute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary Refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome. Methods We performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered. Results Ninety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7–7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9–16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality. Conclusions Hyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.
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evolution of peripheral vs metabolic perfusion parameters during septic shock resuscitation a clinical physiologic study
Journal of Critical Care, 2012Co-Authors: Glenn Hernandez, Ricardo Castro, Cesar Pedreros, Enrique Veas, Alejandro Bruhn, Carlos Romero, Maximiliano Rovegno, Rodolfo Neira, Sebastian Bravo, Eduardo KattanAbstract:Abstract Purpose Perfusion assessment during septic shock resuscitation is difficult and usually complex determinations. Capillary Refill time (CRT) and central-to-toe temperature difference (Tc-toe) have been proposed as objective reproducible parameters to evaluate peripheral perfusion. The comparative evolution of peripheral vs metabolic perfusion parameters in septic shock resuscitation has not been studied. We conducted a prospective observational clinical-physiologic study to address this subject. Methods Patients with sepsis-related circulatory dysfunction were resuscitated according to a standard local algorithm. Perfusion assessment included serial determinations of metabolic (central venous O 2 saturation [Scvo 2 ] and central venous to arterial Pco 2 gradient [P(cv-a)co 2 ]) and peripheral perfusion parameters (CRT and Tc-toe, among others). Successful resuscitation was defined as a normal plasma lactate at 24 hours. Results Forty-one patients were included. The presence of normal values for both CRT and Tc-toe considered together at 6 hours was independently associated with a successful resuscitation ( P = .02), as compared with the behavior of metabolic parameters. Capillary Refill time was the first parameter to be significantly normalized. Conclusion Early recovery of peripheral perfusion anticipates a successful resuscitation compared with traditional metabolic parameters in septic shock patients. Our findings support the inclusion of serial peripheral perfusion assessment in multimodal monitoring strategies for septic shock resuscitation.
Eduardo Kattan - One of the best experts on this subject based on the ideXlab platform.
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Capillary Refill time during fluid resuscitation in patients with sepsis related hyperlactatemia at the emergency department is related to mortality
PLOS ONE, 2017Co-Authors: Barbara Lara, Jan Bakker, Ricardo Castro, Eduardo Kattan, Luis Enberg, Marcos Ortega, Paula Leon, Cristobal Kripper, Pablo Aguilera, Glenn HernandezAbstract:Introduction Acute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary Refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome. Methods We performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered. Results Ninety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7–7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9–16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality. Conclusions Hyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.
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evolution of peripheral vs metabolic perfusion parameters during septic shock resuscitation a clinical physiologic study
Journal of Critical Care, 2012Co-Authors: Glenn Hernandez, Ricardo Castro, Cesar Pedreros, Enrique Veas, Alejandro Bruhn, Carlos Romero, Maximiliano Rovegno, Rodolfo Neira, Sebastian Bravo, Eduardo KattanAbstract:Abstract Purpose Perfusion assessment during septic shock resuscitation is difficult and usually complex determinations. Capillary Refill time (CRT) and central-to-toe temperature difference (Tc-toe) have been proposed as objective reproducible parameters to evaluate peripheral perfusion. The comparative evolution of peripheral vs metabolic perfusion parameters in septic shock resuscitation has not been studied. We conducted a prospective observational clinical-physiologic study to address this subject. Methods Patients with sepsis-related circulatory dysfunction were resuscitated according to a standard local algorithm. Perfusion assessment included serial determinations of metabolic (central venous O 2 saturation [Scvo 2 ] and central venous to arterial Pco 2 gradient [P(cv-a)co 2 ]) and peripheral perfusion parameters (CRT and Tc-toe, among others). Successful resuscitation was defined as a normal plasma lactate at 24 hours. Results Forty-one patients were included. The presence of normal values for both CRT and Tc-toe considered together at 6 hours was independently associated with a successful resuscitation ( P = .02), as compared with the behavior of metabolic parameters. Capillary Refill time was the first parameter to be significantly normalized. Conclusion Early recovery of peripheral perfusion anticipates a successful resuscitation compared with traditional metabolic parameters in septic shock patients. Our findings support the inclusion of serial peripheral perfusion assessment in multimodal monitoring strategies for septic shock resuscitation.
Patricia M Stassen - One of the best experts on this subject based on the ideXlab platform.
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the power of flash mob research conducting a nationwide observational clinical study on Capillary Refill time in a single day
Chest, 2017Co-Authors: Jelmer Alsma, Jan L C M Van Saase, Prabath W B Nanayakkara, W Ineke E M Schouten, Anique Baten, Martijn P Bauer, Frits Holleman, Jack J M Ligtenberg, Patricia M StassenAbstract:Background Capillary Refill time (CRT) is a clinical test used to evaluate the circulatory status of patients; various methods are available to assess CRT. Conventional clinical research often demands large numbers of patients, making it costly, labor-intensive, and time-consuming. We studied the interobserver agreement on CRT in a nationwide study by using a novel method of research called flash mob research (FMR). Methods Physicians in the Netherlands were recruited by using word-of-mouth referrals, conventional media, and social media to participate in a nationwide, single-day, "nine-to-five," multicenter, cross-sectional, observational study to evaluate CRT. Patients aged ≥ 18 years presenting to the ED or who were hospitalized were eligible for inclusion. CRT was measured independently (by two investigators) at the patient's sternum and distal phalanx after application of pressure for 5 s (5s) and 15 s (15s). Results On October 29, 2014, a total of 458 investigators in 38 Dutch hospitals enrolled 1,734 patients. The mean CRT measured at the distal phalanx were 2.3 s (5s, SD 1.1) and 2.4 s (15s, SD 1.3). The mean CRT measured at the sternum was 2.6 s (5s, SD 1.1) and 2.7 s (15s, SD 1.1). Interobserver agreement was higher for the distal phalanx (κ value, 0.40) than for the sternum (κ value, 0.30). Conclusions Interobserver agreement on CRT is, at best, moderate. CRT measured at the distal phalanx yielded higher interobserver agreement compared with sternal CRT measurements. FMR proved a valuable instrument to investigate a relatively simple clinical question in an inexpensive, quick, and reliable manner.
