The physiological rationale for monitoring peripheral perfusion is based on the concept that the cutaneous circulation is deprived of autoregulation. Clinical parameters easily obtained at bedside can access compensatory mechanisms induced by shock in early stages, since hypoperfusion might occur despite normal macrohemodynamic parameters.
The capillary refill time (CRT) shows conflicting results in the literature. There is no well-established relationship between CRT and global hemodynamics; however the association with worse clinical outcomes should not be overlooked.
Peripheral temperature and temperature gradients are objective and cheap and available parameters obtained without discomfort to the patients. They are markers highly correlated with cardiac index and competent indicators of severity in shock.
Cold extremities are associated with changes in laboratory tissue perfusion markers such as blood PH, central venous oxygen saturation, and blood lactate levels. Furthermore, other parameters derived from physical examination, such as skin mottling score (SMS), are independent predictors of mortality and, therefore their use in combination with other tissue perfusion monitoring tools should be encouraged.
Microcirculation Physical examination Capillary refill Skin temperature Body temperature Critically ill Multiple organ failure Prognosis
This is a preview of subscription content, log in to check access.
Miyagatani Y, Yukioka T, Ohta S, et al. Vascular tone in patients with hemorrhagic shock. J Trauma. 1999;47:282–7.CrossRefPubMedGoogle Scholar
Ikossi DG, Knudson MM, Morabito DJ, et al. Continuous muscle tissue oxygenation in critically injured patients: a prospective observational study. J Trauma. 2006;61:780–8.CrossRefPubMedGoogle Scholar
Alexandre Lima; Tim C. Jansen; Jasper van Bommel, ; Can Ince, Bakker J. The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients. Crit Care Med 2009 Vol. 37, (3):934–938.CrossRefPubMedGoogle Scholar
Joly HR, Weil MH. Temperature of the great toe as an indication of the severity of shock. Circulation. 1969;39:131–8.CrossRefPubMedGoogle Scholar
Thompson MJ, Ninis N, Perera R, et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet. 2006;367:397–403.CrossRefPubMedGoogle Scholar
Kaplan LJ, McPartland K, Santora TA, et al. Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients. J Trauma. 2001;50:620–7.CrossRefPubMedGoogle Scholar
Hasdai D, Holmes DR Jr, Califf RM, et al. 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. 1999;138:21–31.CrossRefPubMedGoogle Scholar
Tibby SM, Hatherill M, Murdoch IA. Capillary refill and core-peripheral temperature gap as indicators of haemodynamic status in paediatric intensive care patients. Arch Dis Child. 1999;80:163–6.CrossRefPubMedPubMedCentralGoogle Scholar
Beecher HK, Simeone FA, Burnett CH. The internal state of the severely wounded man on entry to the most forward hospital. Surgery. 1947;22:672–81.PubMedGoogle Scholar
Schriger DL, Baraff L. Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med. 1988;17:932–5.CrossRefPubMedGoogle Scholar
Saavedra JM, Harris GD, Li S, Finberg L. Capillary refilling (skin turgor) in the assessment of dehydration. Am J Dis Child. 1991;145:296–8.PubMedGoogle Scholar
Advanced Life Support Group. Advanced paediatric life support: the practical approach. 1st ed. London: BMJ Publishing Group; 1993. p. 76.Google Scholar
Gorelick MH, Shaw KN, Baker MD. Effect of ambient temperature on capillary refill in healthy children. Pediatrics. 1993;92:699–702.PubMedGoogle Scholar
Bailey JM, Levy JH, Kopel MA, et al. Relationship between clinical evaluation of peripheral perfusion and global hemodynamics in adults after cardiac surgery. Crit Care Med. 1990;18:1353–6.CrossRefPubMedGoogle Scholar
Rubinstein EH, Sessler DI. Skinsurface temperature gradients correlate with fingertip blood flow in humans. Anesthesiology. 1990;73:541–5.CrossRefPubMedGoogle Scholar
Ibsen B. Treatment of shock with vasodilators measuring temperature of the great toe: ten years experience in 150 cases. Dis Chest. 1967;52:425–9.CrossRefPubMedGoogle Scholar
Ruiz CE, Weil MH, Carlson RW. Treatment of circulatory shock with dopamine. Studies on survival. JAMA. 1979;242:165–8.CrossRefPubMedGoogle Scholar
Guyton AC. Body temperature, temperature regulation, and fever. In: Guyton AC, Hall JE, editors. Textbook of medical physiology. Philadelphia: Saunders; 1996. p. 911–22.Google Scholar
Ross BA, Brock L, Aynsley-Green A. Observations on central and peripheral temperatures in the understanding and management of shock. Br J Surg. 1969;56:877–82.CrossRefPubMedGoogle Scholar
Curley FJ, Smyrnios NA. Routine monitoring of critically ill patients. In: Irwin RS, Cerra FB, Rippe JM, editors. Intensive care medicine. New York: Lippincott Williams & Wilkins; 2003. p. 250–70.Google Scholar
Sessler DI. Skin-temperature gradients are a validated measure of fingertip perfusion. Eur J Appl Physiol. 2003;89:401–2.CrossRefPubMedGoogle Scholar
House JR, Tipton MJ. Using skin temperature gradients or skin heat flux measurements to determine thresholds of vasoconstriction and vasodilatation. Eur J Appl Physiol. 2002;88:141–5.CrossRefPubMedGoogle Scholar
Henning RJ, Wiener F, Valdes S, Weil MH. Measurement of toe temperature for assessing the severity of acute circulatory failure. Surg Gynecol Obstet. 1979;149:1–7.PubMedGoogle Scholar
Vincent JL, Moraine JJ, van der LP. Toe temperature versus transcutaneous oxygen tension monitoring during acute circulatory failure. Intensive Care Med. 1988;14:64–8.CrossRefPubMedGoogle Scholar
Ait-Oufella H, Joffre J, Boelle PY, Galbois A, Bourcier S, Baudel JL, Margetis D, Alves M, Offenstadt G, Guidet B, Maury E. Knee area tissue oxygen saturation is predictive of 14-day mortality in septic shock. Intensive Care Med. 2012;38:976–83.CrossRefPubMedGoogle Scholar
de Moura EB, Amorim FF, da Cruz Santana NA, et al. Skin mottling score as a predictor of 28-day mortality in patients with septic shock. Intensive Care Med. 2016;42(3):479–80.CrossRefPubMedGoogle Scholar
Coudroy R, Jamet A, Frat JP, Veinstein A, Chatellier D, Goudet V, Cabasson S, Thille AW, Robert R. Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients. Intensive Care Med. 2015;41:452–9.CrossRefPubMedGoogle Scholar
De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL. Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J. 2004;147:91–9.CrossRefPubMedGoogle Scholar