Lima Alexandre, Jansen Tim C, van Bommel Jasper, Ince Can, Bakker Jan
From the Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands.
Crit Care Med. 2009 Mar;37(3):934-8. doi: 10.1097/CCM.0b013e31819869db.
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.
: Prospective observational study.
Multidisciplinary intensive care unit in a university hospital.
Fifty consecutive adult patients admitted to the intensive care unit.
None.
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), central-to-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 (delta-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 < 0.05). Tskin-diff, Tc-toe, and peripheral flow index were congruent with the subjective assessment of peripheral perfusion. The proportion of patients with delta-SOFA score >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.
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.
基于触摸皮肤或测量毛细血管再充盈时间进行的外周灌注体格检查与循环性休克患者的预后相关。然而，初始复苏后监测外周灌注是否仍能为重症患者的发病率提供信息尚不清楚。因此，我们研究了外周灌注的主观评估是否有助于使用序贯器官衰竭评估（SOFA）评分和乳酸水平来识别器官或代谢功能障碍更严重的重症患者。
前瞻性观察性研究。
大学医院的多学科重症监护病房。
连续50例入住重症监护病房的成年患者。
无。
如果被检查肢体的毛细血管再充盈时间延长（>4.5秒）或检查者触摸时感觉发凉，则认为患者外周灌注异常。为了评估外周灌注主观检查和触诊的可靠性，我们还测量了前臂至指尖的皮肤温度梯度（Tskin-diff）、中心至脚趾的温差（Tc-toe）和外周血流指数。在血流动力学稳定（平均动脉压>65mmHg）后，于入住重症监护病房的24小时内进行测量。分析了最初48小时内SOFA评分的变化（delta-SOFA）。外周灌注异常的患者个体SOFA评分显著高于外周灌注正常的患者（9±3 vs. 7±2，p<0.05）。Tskin-diff、Tc-toe和外周血流指数与外周灌注的主观评估结果一致。外周灌注异常的患者中delta-SOFA评分>0的比例显著高于外周灌注正常的患者（77% vs. 23%，p<0.05）。逻辑回归分析显示，外周灌注异常的患者病情恶化的几率是外周灌注正常患者的7.4倍（95%置信区间2-19；p<0.05）。外周灌注异常和正常的患者中高乳酸血症的比例有显著差异（67% vs. 33%，p<0.05）。逻辑回归分析显示，外周灌注异常的患者发生高乳酸血症的几率是外周灌注正常患者的4.6倍（95%置信区间1.4-15；p<0.05）。
入院后24小时内首次血流动力学复苏后通过体格检查对外周灌注进行主观评估，可以识别出血流动力学稳定但器官功能障碍更严重且乳酸水平更高的患者。外周灌注异常的患者在初始复苏后器官功能恶化的几率显著高于外周灌注正常的患者。
