Capillary refill time variation induced by passive leg raising predicts capillary refill time response to volume expansion

Matthias Jacquet-Lagrèze, Nourredine Bouhamri, Philippe Portran, Rémi Schweizer, Florent Baudin, Marc Lilot, William Fornier, Jean-Luc Fellahi, Matthias Jacquet-Lagrèze, Nourredine Bouhamri, Philippe Portran, Rémi Schweizer, Florent Baudin, Marc Lilot, William Fornier, Jean-Luc Fellahi

Abstract

Background: A peripheral perfusion-targeted resuscitation during early septic shock has shown encouraging results. Capillary refill time, which has a prognostic value, was used. Adding accuracy and predictability on capillary refill time (CRT) measurement, if feasible, would benefit to peripheral perfusion-targeted resuscitation. We assessed whether a reduction of capillary refill time during passive leg raising (ΔCRT-PLR) predicted volume-induced peripheral perfusion improvement defined as a significant decrease of capillary refill time following volume expansion.

Methods: Thirty-four patients with acute circulatory failure were selected. Haemodynamic variables, metabolic variables (PCO2gap), and four capillary refill time measurements were recorded before and during a passive leg raising test and after a 500-mL volume expansion over 20 min. Receiver operating characteristic curves were built, and areas under the curves were calculated (ROCAUC). Confidence intervals (CI) were performed using a bootstrap analysis. We recorded mortality at day 90.

Results: The least significant change in the capillary refill time was 25% [95% CI, 18-30]. We defined CRT responders as patients showing a reduction of at least 25% of capillary refill time after volume expansion. A decrease of 27% in ΔCRT-PLR predicted peripheral perfusion improvement with a sensitivity of 87% [95% CI, 73-100] and a specificity of 100% [95% CI, 74-100]. The ROCAUC of ΔCRT-PLR was 0.94 [95% CI, 0.87-1.0]. The ROCAUC of baseline capillary refill time was 0.73 [95% CI, 0.54-0.90] and of baseline PCO2gap was 0.79 [0.61-0.93]. Capillary refill time was significantly longer in non-survivors than in survivors at day 90.

Conclusion: ΔCRT-PLR predicted peripheral perfusion response following volume expansion. This simple low-cost and non-invasive diagnostic method could be used in peripheral perfusion-targeted resuscitation protocols.

Trial registration: CPP Lyon Sud-Est II ANSM: 2014-A01034-43 Clinicaltrial.gov, NCT02248025 , registered 13th of September 2014.

Keywords: Capillary refill time; Circulatory shock; Fluid responsiveness; Microcirculation; PCO2gap; Passive leg raising; Peripheral perfusion.

Conflict of interest statement

The corresponding author has created a medtech company called DICARTECH which is developing a device to assess capillary refill time. All other authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow chart of the study. CRT, capillary refill time; ∆CRT-PLR, capillary refill time variation induced by passive leg raising; ∆CRT-PLR > 27%, positive index test defined as a decrease of capillary refill time induced by passive leg raising of at least 27%; ∆CRT-VE > 25%, CRT response defined as a decrease of capillary refill time induced by volume expansion of at least 25%; PLR, passive leg raising; VE, volume expansion
Fig. 2
Fig. 2
Scatter plot of capillary refill time variation induced by passive leg raising vs. by volume expansion. CRT, capillary refill time; PLR, passive leg raising; VE, volume expansion
Fig. 3
Fig. 3
ROC curves of CRT and ∆CRT-PLR to predict CRT response to volume expansion. CRT, capillary refill time; CRT responders, response to volume expansion defined as patients showing a decrease in CRT after VE of at least 25%; PCO2gap, central venous-to-arterial carbon dioxide difference; PLR, passive leg raising; VE, volume expansion

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