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      Does training level affect the accuracy of visual assessment of capillary refill time?


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          Capillary refill time (CRT) measured at the bedside is widely promulgated in critical care and intensive care medicine [1, 2]. However, traditional CRT measurements are relatively subjective [3], and the accuracy is questionable given that clinicians use the naked eye to perform these visual assessments [4, 5]. The purpose of our study was to evaluate the accuracy of visually assessed CRT among observers who have different training levels. Fingernail compression and release videos were recorded from patients in the emergency department (ED) at a suburban, quaternary care teaching hospital in New York. We used our image analysis software to analyze the corresponding fingernail video to calculate patient’s CRT (Fig. 1). Nine clinicians and two non-clinicians voluntarily participated as observers to review the videos. Videos from 20 patients were displayed on a screen three times in random order, for a total of 60 videos. The observers watched each fingernail video and pressed a time switch when they deemed the fingernail color had returned to its baseline state. The truth of visually assessed CRT was evaluated by using a correlation of the numbers between the image analysis and the visual assessment. We also sought to determine the intra-observer reliability to evaluate the precision of visual assessments. Fig. 1 Image analysis CRT. The recorded videos were used thereafter in a separate setting to calculate CRT via image software analysis (image analysis CRT). Averaged color of the fingernail area was extracted from the digital video file and the color change was represented as RGB waveforms. And then, the RGB waveforms were converted to a grayscale waveform. A curve fitting the returning phase of the grayscale waveform was modeled as an exponential decay using the least squares method. The time to achieve 90% return of fitting curve was reported as “image analysis CRT” Image analysis of CRT of 20 ED patients ranged from 0.47 to 7.98 s, with a mean of 2.44 ± 2.09 s. The highest intra-observer reliability among the three visual assessment times was displayed by one of the physician assistants (0.70 for single measure and 0.88 for average measures); however, it was also as low as 0.15 for a single measure and 0.34 for average measures by one of the non-clinicians. Intra-observer reliability was the highest in attending physicians and physician assistants, followed by residents, nurses, and non-clinicians. The mean intra-observer reliability of the clinicians was higher than the non-clinicians (0.46 vs. 0.25, p < 0.05). Figure 2 shows intra-observer reliability of the video assessment as a function of correlation coefficient of video CRT assessment with image CRT analysis. Observers, who showed a higher correlation with image CRT analysis, demonstrated higher intra-observer reliability, and there was a strong correlation between these coefficient values (r = 0.72, p < 0.05). Fig. 2 Scatter plot showing intra-rater (observer) reliability of video assessment CRT as a function of correlation coefficient of video assessment CRT with image analysis CRT. Attending physicians (22 and 28 years of ED work experience), residents (3 years of ED work experience), nurses (2 years of ED work experience), and physician assistants (1 and 2 years of ED work experience) participated in the study. Six clinicians were actively performing CRT assessments in their clinical work. Observers, who showed higher correlation with image analysis CRT, demonstrated higher intra-rater reliability, and there was a strong correlation between these coefficient values (r = 0.72, p < 0.05) Visual assessment of CRT is variable. Personal work experience may help improve both truth and precision of CRT assessments and increase the accuracy among individual observers. Therefore, training level appears to be an important factor that affects the reliability of visual CRT assessment.

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          Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults

          Introduction Altered peripheral perfusion is strongly associated with poor outcome in critically ill patients. We wanted to determine whether repeated assessments of peripheral perfusion during the days following surgery could help to early identify patients that are more likely to develop postoperative complications. Methods Haemodynamic measurements and peripheral perfusion parameters were collected one day prior to surgery, directly after surgery (D0) and on the first (D1), second (D2) and third (D3) postoperative days. Peripheral perfusion assessment consisted of capillary refill time (CRT), peripheral perfusion index (PPI) and forearm-to-fingertip skin temperature gradient (Tskin-diff). Generalized linear mixed models were used to predict severe complications within ten days after surgery based on Clavien-Dindo classification. Results We prospectively followed 137 consecutive patients, from among whom 111 were included in the analysis. Severe complications were observed in 19 patients (17.0%). Postoperatively, peripheral perfusion parameters were significantly altered in patients who subsequently developed severe complications compared to those who did not, and these parameters persisted over time. CRT was altered at D0, and PPI and Tskin-diff were altered on D1 and D2, respectively. Among the different peripheral perfusion parameters, the diagnostic accuracy in predicting severe postoperative complications was highest for CRT on D2 (area under the receiver operating characteristic curve = 0.91 (95% confidence interval (CI) = 0.83 to 0.92)) with a sensitivity of 0.79 (95% CI = 0.54 to 0.94) and a specificity of 0.93 (95% CI = 0.86 to 0.97). Generalized mixed-model analysis demonstrated that abnormal peripheral perfusion on D2 and D3 was an independent predictor of severe postoperative complications (D2 odds ratio (OR) = 8.4, 95% CI = 2.7 to 25.9; D2 OR = 6.4, 95% CI = 2.1 to 19.6). Conclusions In a group of patients assessed following major abdominal surgery, peripheral perfusion alterations were associated with the development of severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion–targeted resuscitation following major abdominal surgery.
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            Capillary refill time: is it still a useful clinical sign?

            Capillary refill time (CRT) is widely used by health care workers as part of the rapid, structured cardiopulmonary assessment of critically ill patients. Measurement involves the visual inspection of blood returning to distal capillaries after they have been emptied by pressure. It is hypothesized that CRT is a simple measure of alterations in peripheral perfusion. Evidence for the use of CRT in anesthesia is lacking and further research is required, but understanding may be gained from evidence in other fields. In this report, we examine this evidence and factors affecting CRT measurement. Novel approaches to the assessment of CRT are under investigation. In the future, CRT measurement may be achieved using new technologies such as digital videography or modified oxygen saturation probes; these new methods would remove the limitations associated with clinical CRT measurement and may even be able to provide an automated CRT measurement.
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              The Power of Flash Mob Research: Conducting a Nationwide Observational Clinical Study on Capillary Refill Time in a Single Day.

              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).

                Author and article information

                516-562-0309 , kshinozaki@northwell.edu , shino@gk9.so-net.ne.jp
                Crit Care
                Critical Care
                BioMed Central (London )
                6 May 2019
                6 May 2019
                : 23
                : 157
                [1 ]ISNI 0000 0001 2168 3646, GRID grid.416477.7, The Feinstein Institute for Medical Research, , Northwell Health System, ; 350 Community Dr., Manhasset, NY 11030 USA
                [2 ]ISNI 0000 0001 2168 3646, GRID grid.416477.7, Department of Emergency Medicine, North Shore University Hospital, , Northwell Health System, ; Manhasset, NY USA
                [3 ]Nihon Kohden Innovation Center, Cambridge, MA USA
                [4 ]ISNI 0000 0000 9708 882X, GRID grid.480283.5, Nihon Kohden Corporation, ; Tokyo, Japan
                [5 ]ISNI 0000 0004 0601 5481, GRID grid.455392.c, ZOLL Medical, ; Chelmsford, MA USA
                Author information
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 2 April 2019
                : 15 April 2019
                Funded by: Nihon Kohden Corporation
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                © The Author(s) 2019

                Emergency medicine & Trauma
                Emergency medicine & Trauma


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