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Noninvasive monitoring of peripheral perfusion

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Abstract

Background

Early hemodynamic assessment of global parameters in critically ill patients fails to provide adequate information on tissue perfusion. It requires invasive monitoring and may represent a late intervention initiated mainly in the intensive care unit. Noninvasive monitoring of peripheral perfusion can be a complementary approach that allows very early application throughout the hospital. In addition, as peripheral tissues are sensitive to alterations in perfusion, monitoring of the periphery could be an early marker of tissue hypoperfusion. This review discusses noninvasive methods for monitoring perfusion in peripheral tissues based on clinical signs, body temperature gradient, optical monitoring, transcutaneous oximetry, and sublingual capnometry.

Discussion

Clinical signs of poor peripheral perfusion consist of a cold, pale, clammy, and mottled skin, associated with an increase in capillary refill time. The temperature gradients peripheral-to-ambient, central-to-peripheral and forearm-to-fingertip skin are validated methods to estimate dynamic variations in skin blood flow. Commonly used optical methods for peripheral monitoring are perfusion index, near-infrared spectroscopy, laser Doppler flowmetry and orthogonal polarization spectroscopy. Continuous noninvasive transcutaneous measurement of oxygen and carbon dioxide tensions can be used to estimate cutaneous blood flow. Sublingual capnometry is a noninvasive alternative for gastric tonometry.

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References

  1. Bakker J, Coffernils M, Leon M, Gris P, Vincent J-L (1991) Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock. Chest 99:956–962

    PubMed  Google Scholar 

  2. De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL (2002) Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 166:98–104

    Article  PubMed  Google Scholar 

  3. Rady MY, Rivers EP, Nowak RM (1996) Resuscitation of the critically ill in the ED: responses of blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J Emerg Med 14:218–225

    Article  PubMed  Google Scholar 

  4. Shoemaker WC, Appel PL, Kram HB, Nathan RC, Thompson JL (1988) Multicomponent noninvasive physiologic monitoring of circulatory function. Crit Care Med 16:482–490

    PubMed  Google Scholar 

  5. Siegemund M, van Bommel J, Ince C (1999) Assessment of regional tissue oxygenation. Intensive Care Med 25:1044–1060

    Article  PubMed  Google Scholar 

  6. Tibby SM, Hatherill M, Murdoch IA (1999) Capillary refill and core-peripheral temperature gap as indicators of haemodynamic status in paediatric intensive care patients. Arch Dis Child 80:163–166

    PubMed  Google Scholar 

  7. Bailey JM, Levy JH, Kopel MA, Tobia V, Grabenkort WR (1990) Relationship between clinical evaluation of peripheral perfusion and global hemodynamics in adults after cardiac surgery. Crit Care Med 18:1353–1356

    PubMed  Google Scholar 

  8. Schriger DL, Baraff L (1988) Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med 17:932–935

    Article  PubMed  Google Scholar 

  9. Kaplan LJ, McPartland K, Santora TA, Trooskin SZ (2001) Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients. J Trauma 50:620–627

    PubMed  Google Scholar 

  10. Schriger DL, Baraff L (1991) Capillary refill: is it a useful predictor of hypovolemic states? Ann Emerg Med 20:601–605

    Article  PubMed  Google Scholar 

  11. Steiner MJ, DeWalt DA, Byerley JS (2004) Is this child dehydrated? JAMA 291:2746–2754

    PubMed  Google Scholar 

  12. Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ (1981) Trauma score. Crit Care Med 9:672–676

    PubMed  Google Scholar 

  13. Hasdai D, Holmes DR Jr, Califf RM, Thompson TD, Hochman JS, Pfisterer M, Topol EJ (1999) Cardiogenic shock complicating acute myocardial infarction: predictors of death. GUSTO Investigators. Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries. Am Heart J 138:21–31

    PubMed  Google Scholar 

  14. McGee S, Abernethy WB, III, Simel DL (1999) Is this patient hypovolemic? JAMA 281:1022–1029

    Article  PubMed  Google Scholar 

  15. Joly HR, Weil MH (1969) Temperature of the great toe as an indication of the severity of shock. Circulation 39:131–138

    PubMed  Google Scholar 

  16. Ibsen B (1967) Treatment of shock with vasodilators measuring temperature of the great toe: ten years experience in 150 cases. Dis Chest 52:425

    PubMed  Google Scholar 

  17. Guyton AC (1996) Body temperature, temperature regulation, and fever. In: Guyton AC, Hall JE (eds) Textbook of medical physiology. Saunders, Philadelphia, pp 911–922

  18. Ross BA, Brock L, Aynsley-Green A (1969) Observations on central and peripheral temperatures in the understanding and management of shock. Br J Surg 56:877–882

    PubMed  Google Scholar 

  19. Curley FJ, Smyrnios NA (2003) Routine monitoring of critically ill patients. In: Irwin RS, Cerra FB, Rippe JM (eds) Intensive care medicine. Lippincott Williams & Wilkins, New York, pp 250–270

  20. Ibsen B (1966) Further observations in the use of air-conditioned rooms in the treatment of hyperthermia and shock. Acta Anaesthesiol Scand Suppl 23:565–570

    PubMed  Google Scholar 

  21. Rubinstein EH, Sessler DI (1990) Skin-surface temperature gradients correlate with fingertip blood flow in humans. Anesthesiology 73:541–545

    PubMed  Google Scholar 

  22. Sessler DI (2003) Skin-temperature gradients are a validated measure of fingertip perfusion. Eur J Appl Physiol 89:401–402

    PubMed  Google Scholar 

  23. House JR, Tipton MJ (2002) Using skin temperature gradients or skin heat flux measurements to determine thresholds of vasoconstriction and vasodilatation. Eur J Appl Physiol 88:141–145

    Article  PubMed  Google Scholar 

  24. Brock L, Skinner JM, Manders JT (1975) Observations on peripheral and central temperatures with particular reference to the occurrence of vasoconstriction. Br J Surg 62:589–595

    PubMed  Google Scholar 

  25. Ruiz CE, Weil MH, Carlson RW (1979) Treatment of circulatory shock with dopamine. Studies on survival. JAMA 242:165–168

    Article  PubMed  Google Scholar 

  26. Ryan CA, Soder CM (1989) Relationship between core/peripheral temperature gradient and central hemodynamics in children after open heart surgery. Crit Care Med 17:638–640

    PubMed  Google Scholar 

  27. Vincent JL, Moraine JJ, van der LP (1988) Toe temperature versus transcutaneous oxygen tension monitoring during acute circulatory failure. Intensive Care Med 14:64–68

    PubMed  Google Scholar 

  28. Henning RJ, Wiener F, Valdes S, Weil MH (1979) Measurement of toe temperature for assessing the severity of acute circulatory failure. Surg Gynecol Obstet 149:1–7

    PubMed  Google Scholar 

  29. Murdoch IA, Qureshi SA, Mitchell A, Huggon IC (1993) Core-peripheral temperature gradient in children: does it reflect clinically important changes in circulatory haemodynamics? Acta Paediatr 82:773–776

    PubMed  Google Scholar 

  30. Butt W, Shann F (1991) Core-peripheral temperature gradient does not predict cardiac output or systemic vascular resistance in children. Anaesth Intensive Care 19:84–87

    PubMed  Google Scholar 

  31. Woods I, Wilkins RG, Edwards JD, Martin PD, Faragher EB (1987) Danger of using core/peripheral temperature gradient as a guide to therapy in shock. Crit Care Med 15:850–852

    PubMed  Google Scholar 

  32. Sessler DI (2000) Perioperative heat balance. Anesthesiology 92:578–596

    Google Scholar 

  33. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377

    Article  PubMed  Google Scholar 

  34. Vincent JL (1996) End-points of resuscitation: arterial blood pressure, oxygen delivery, blood lactate, or..? Intensive Care Med 22:3–5

    Article  PubMed  Google Scholar 

  35. Flewelling R (2000) Noninvasive optical monitoring. In: Bronzino JD (ed) The biomedical engineering handbook. Springer, Berlin Heidelberg New York, pp 1–10

  36. Lima AP, Beelen P, Bakker J (2002) Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med 30:1210–1213

    PubMed  Google Scholar 

  37. Kurz A, Xiong J, Sessler DI, Dechert M, Noyes K, Belani K (1995) Desflurane reduces the gain of thermoregulatory arteriovenous shunt vasoconstriction in humans. Anesthesiology 83:1212–1219

    Article  PubMed  Google Scholar 

  38. Lima A, Bakker J (2004) The peripheral perfusion index in reactive hyperemia in critically ill patients. Crit Care 8:S27–P53

    Article  PubMed  Google Scholar 

  39. De Felice C, Latini G, Vacca P, Kopotic RJ (2002) The pulse oximeter perfusion index as a predictor for high illness severity in neonates. Eur J Pediatr 161:561–562

    Article  PubMed  Google Scholar 

  40. Van Beekvelt MC, Colier WN, Wevers RA, Van Engelen BG (2001) Performance of near-infrared spectroscopy in measuring local O (2) consumption and blood flow in skeletal muscle. J Appl Physiol 90:511–519

    PubMed  Google Scholar 

  41. De Blasi RA, Ferrari M, Natali A, Conti G, Mega A, Gasparetto A (1994) Noninvasive measurement of forearm blood flow and oxygen consumption by near-infrared spectroscopy. J Appl Physiol 76:1388–1393

    PubMed  Google Scholar 

  42. Edwards AD, Richardson C, van der ZP, Elwell C, Wyatt JS, Cope M, Delpy DT, Reynolds EO (1993) Measurement of hemoglobin flow and blood flow by near-infrared spectroscopy. J Appl Physiol 75:1884–1889

    PubMed  Google Scholar 

  43. Taylor DE, Simonson SG (1996) Use of near-infrared spectroscopy to monitor tissue oxygenation. New Horiz 4:420–425

    Google Scholar 

  44. Rhee P, Langdale L, Mock C, Gentilello LM (1997) Near-infrared spectroscopy: continuous measurement of cytochrome oxidation during hemorrhagic shock. Crit Care Med 25:166–170

    Article  PubMed  Google Scholar 

  45. Puyana JC, Soller BR, Zhang S, Heard SO (1999) Continuous measurement of gut pH with near-infrared spectroscopy during hemorrhagic shock. J Trauma 46:9–15

    PubMed  Google Scholar 

  46. Beilman GJ, Myers D, Cerra FB, Lazaron V, Dahms RA, Conroy MJ, Hammer BE (2001) Near-infrared and nuclear magnetic resonance spectroscopic assessment of tissue energetics in an isolated, perfused canine hind limb model of dysoxia. Shock 15:392–397

    PubMed  Google Scholar 

  47. Crookes BA, Cohn SM, Burton EA, Nelson J, Proctor KG (2004) Noninvasive muscle oxygenation to guide fluid resuscitation after traumatic shock. Surgery 135:662–670

    Article  PubMed  Google Scholar 

  48. McKinley BA, Marvin RG, Cocanour CS, Moore FA (2000) Tissue hemoglobin O2 saturation during resuscitation of traumatic shock monitored using near infrared spectrometry. J Trauma 48:637–642

    PubMed  Google Scholar 

  49. Cairns CB, Moore FA, Haenel JB, Gallea BL, Ortner JP, Rose SJ, Moore EE (1997) Evidence for early supply independent mitochondrial dysfunction in patients developing multiple organ failure after trauma. J Trauma 42:532–536

    PubMed  Google Scholar 

  50. Muellner T, Nikolic A, Schramm W, Vecsei V (1999) New instrument that uses near-infrared spectroscopy for the monitoring of human muscle oxygenation. J Trauma 46:1082–1084

    PubMed  Google Scholar 

  51. Arbabi S, Brundage SI, Gentilello LM (1999) Near-infrared spectroscopy: a potential method for continuous, transcutaneous monitoring for compartmental syndrome in critically injured patients. J Trauma 47:829–833

    PubMed  Google Scholar 

  52. Giannotti G, Cohn SM, Brown M, Varela JE, McKenney MG, Wiseberg JA (2000) Utility of near-infrared spectroscopy in the diagnosis of lower extremity compartment syndrome. J Trauma 48:396–399

    PubMed  Google Scholar 

  53. Girardis M, Rinaldi L, Busani S, Flore I, Mauro S, Pasetto A (2003) Muscle perfusion and oxygen consumption by near-infrared spectroscopy in septic-shock and non-septic-shock patients. Intensive Care Med 29:1173–1176

    Article  PubMed  Google Scholar 

  54. Groner W, Winkelman JW, Harris AG, Ince C, Bouma GJ, Messmer K, Nadeau RG (1999) Orthogonal polarization spectral imaging: a new method for study of the microcirculation. Nat Med 5:1209–1212

    Article  PubMed  Google Scholar 

  55. De Backer D, Dubois MJ, Creteur J, Vincent J-L (2001) Effects of dobutamine on microcirculatory alterations in patients with septic shock. Intensive Care Med 27:S237

    Google Scholar 

  56. Spronk PE, Ince C, Gardien MJ, Mathura KR, Oudemans-van Straaten HM, Zandstra DF (2002) Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet 360:1395–1396

    Article  PubMed  Google Scholar 

  57. De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL (2004) Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J 147:91–99

    Article  PubMed  Google Scholar 

  58. Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL (2004) Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 32:1825–1831

    Article  PubMed  Google Scholar 

  59. Jin X, Weil MH, Sun S, Tang W, Bisera J, Mason EJ (1998) Decreases in organ blood flows associated with increases in sublingual PCO2 during hemorrhagic shock. J Appl Physiol 85:2360–2364

    Google Scholar 

  60. Schabauer AM, Rooke TW (1994) Cutaneous laser Doppler flowmetry: applications and findings. Mayo Clin Proc 69:564–574

    PubMed  Google Scholar 

  61. Farkas K, Fabian E, Kolossvary E, Jarai Z, Farsang C (2003) Noninvasive assessment of endothelial dysfunction in essential hypertension: comparison of the forearm microvascular reactivity with flow-mediated dilatation of the brachial artery. Int J Angiol 12:224–228

    Article  Google Scholar 

  62. Koller A, Kaley G (1990) Role of endothelium in reactive dilation of skeletal muscle arterioles. Am J Physiol 259:H1313–H1316

    PubMed  Google Scholar 

  63. Morris SJ, Shore AC, Tooke JE (1995) Responses of the skin microcirculation to acetylcholine and sodium nitroprusside in patients with NIDDM. Diabetologia 38:1337–1344

    PubMed  Google Scholar 

  64. Warren JB (1994) Nitric oxide and human skin blood flow responses to acetylcholine and ultraviolet light. FASEB J 8:247–251

    PubMed  Google Scholar 

  65. Blaauw J, Graaff R, van Pampus MG, van Doormaal JJ, Smit AJ, Rakhorst G, Aarnoudse JG (2005) Abnormal endothelium-dependent microvascular reactivity in recently preeclamptic women. Obstet Gynecol 105:626–632

    PubMed  Google Scholar 

  66. Hartl WH, Gunther B, Inthorn D, Heberer G (1988) Reactive hyperemia in patients with septic conditions. Surgery 103:440–444

    PubMed  Google Scholar 

  67. Young JD, Cameron EM (1995) Dynamics of skin blood flow in human sepsis. Intensive Care Med 21:669–674

    Article  PubMed  Google Scholar 

  68. Sair M, Etherington PJ, Peter WC, Evans TW (2001) Tissue oxygenation and perfusion in patients with systemic sepsis. Crit Care Med 29:1343–1349

    Article  PubMed  Google Scholar 

  69. Hasibeder W, Haisjackl M, Sparr H, Klaunzer S, Horman C, Salak N, Germann R, Stronegger WJ, Hackl JM (1991) Factors influencing transcutaneous oxygen and carbon dioxide measurements in adult intensive care patients. Intensive Care Med 17:272–275

    Article  PubMed  Google Scholar 

  70. Carter B, Hochmann M, Osborne A, Nisbet A, Campbell N (1995) A comparison of two transcutaneous monitors for the measurement of arterial PO2 and PCO2 in neonates. Anaesth Intensive Care 23:708–714

    PubMed  Google Scholar 

  71. Phan CQ, Tremper KK, Lee SE, Barker SJ (1987) Noninvasive monitoring of carbon dioxide: a comparison of the partial pressure of transcutaneous and end-tidal carbon dioxide with the partial pressure of arterial carbon dioxide. J Clin Monit 3:149–154

    Article  PubMed  Google Scholar 

  72. Tremper KK, Shoemaker WC (1981) Transcutaneous oxygen monitoring of critically ill adults, with and without low flow shock. Crit Care Med 9:706–709

    PubMed  Google Scholar 

  73. Shoemaker WC, Wo CC, Bishop MH, Thangathurai D, Patil RS (1996) Noninvasive hemodynamic monitoring of critical patients in the emergency department. Acad Emerg Med 3:675–681

    PubMed  Google Scholar 

  74. Tremper KK, Barker SJ (1987) Transcutaneous oxygen measurement: experimental studies and adult applications. Int Anesthesiol Clin 25:67–96

    PubMed  Google Scholar 

  75. Reed RL, Maier RV, Landicho D, Kenny MA, Carrico CJ (1985) Correlation of hemodynamic variables with transcutaneous PO2 measurements in critically ill adult patients. J Trauma 25:1045–1053

    PubMed  Google Scholar 

  76. Tremper KK, Shoemaker WC, Shippy CR, Nolan LS (1981) Transcutaneous PCO2 monitoring on adult patients in the ICU and the operating room. Crit Care Med 9:752–755

    PubMed  Google Scholar 

  77. Waxman K, Sadler R, Eisner ME, Applebaum R, Tremper KK, Mason GR (1983) Transcutaneous oxygen monitoring of emergency department patients. Am J Surg 146:35–38

    Article  PubMed  Google Scholar 

  78. Tatevossian RG, Wo CC, Velmahos GC, Demetriades D, Shoemaker WC (2000) Transcutaneous oxygen and CO2 as early warning of tissue hypoxia and hemodynamic shock in critically ill emergency patients. Crit Care Med 28:2248–2253

    Article  PubMed  Google Scholar 

  79. Fiddian-Green RG, Baker S (1987) Predictive value of the stomach wall pH for complications after cardiac operations: comparison with other monitoring. Crit Care Med 15:153–156

    PubMed  Google Scholar 

  80. De Backer D, Creteur J (2003) Regional hypoxia and partial pressure of carbon dioxide gradients: what is the link? Intensive Care Med 29:2116–2118

    Article  PubMed  Google Scholar 

  81. Nakagawa Y, Weil MH, Tang W, Sun S, Yamaguchi H, Jin X, Bisera J (1998) Sublingual capnometry for diagnosis and quantitation of circulatory shock. Am J Respir Crit Care Med 157:1838–1843

    PubMed  Google Scholar 

  82. Povoas HP, Weil MH, Tang W, Moran B, Kamohara T, Bisera J (2000) Comparisons between sublingual and gastric tonometry during hemorrhagic shock. Chest 118:1127–1132

    Article  PubMed  Google Scholar 

  83. Rackow EC, O’Neil P, Astiz ME, Carpati CM (2001) Sublingual capnometry and indexes of tissue perfusion in patients with circulatory failure. Chest 120:1633–1638

    Article  PubMed  Google Scholar 

  84. Marik PE (2001) Sublingual capnography: a clinical validation study. Chest 120:923–927

    Article  PubMed  Google Scholar 

  85. Marik PE, Bankov A (2003) Sublingual capnometry versus traditional markers of tissue oxygenation in critically ill patients. Crit Care Med 31:818–822

    Article  PubMed  Google Scholar 

  86. Weil MH, Nakagawa Y, Tang W, Sato Y, Ercoli F, Finegan R, Grayman G, Bisera J (1999) Sublingual capnometry: a new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock. Crit Care Med 27:1225–1229

    Article  PubMed  Google Scholar 

  87. Pernat A, Weil MH, Tang W, Yamaguchi H, Pernat AM, Sun S, Bisera J (1999) Effects of hyper- and hypoventilation on gastric and sublingual PCO (2). J Appl Physiol 87:933–937

    Google Scholar 

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  1. Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands

    Alexandre Lima & Jan Bakker

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  1. Alexandre Lima
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  2. Jan Bakker
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Correspondence to Jan Bakker.

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This study was in part supported by materials provided by Hutchinson Technology and a grant from Philips USA. Both authors received a grant US $12,000 from Philips USA and $10,000 from Hutchinson Technology.

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Lima, A., Bakker, J. Noninvasive monitoring of peripheral perfusion. Intensive Care Med 31, 1316–1326 (2005). https://doi.org/10.1007/s00134-005-2790-2

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