COMMENTARY

Clinical monitoring of peripheral perfusion: thereis more to learnAlexandre Lima* and Jan Bakker

See related research by He et al., http://ccforum.com/content/17/3/R116

Abstract

Irrespective of initiating factors, the peripheral circulationshows two general phases during the development andtreatment of shock. Most published reports supportearlier knowledge that the peripheral circulation isamong the first to deteriorate and the last to berestored. With the advent of new and old techniquesthat allow us to continuously monitor peripheralperfusion, we may further shift our focus from pressure-based to flow-based resuscitation. The persisting chal-lenge is the validation (effect on outcome parameters)of peripheral perfusion monitoring tools that can besimple and readily available worldwide.

Despite enthusiasm raised by new hemodynamic moni-toring systems, a large gap still exists between what wecan measure and what we would really like to measure.The report in a previous issue of Critical Care by Heand colleagues on two techniques for peripheral perfu-sion monitoring adds new insights into this topic [1]. Inpatients with septic shock, they studied the use of con-tinuous transcutaneous oxygen, carbon dioxide tensionand peripheral perfusion index (PI) derived from thepulse oximetry signal. Although these are not new tech-nologies, their study highlights the importance of thestatus of nonvital organ perfusion in the resuscitation ofpatients with circulatory shock.Earlier observations on the behavior of nonvital organ

perfusion have shown two phases during the shock state,irrespective of initiating factors [2]. During the initialphase, compensatory mechanisms predominate to preservethe perfusion of vital organs at expense of the peripheraltissues (nonvital organs). As blood flow variations in thisphase follow a similar response pattern in the skin,

* Correspondence: a.pintolima@erasmusmc.nlDepartment of Adult Intensive Care, Erasmus MC University Medical Centre,PO Box 2040 – Room H625, 3000CA, Rotterdam, the Netherlands

subcutaneous tissue, muscle and gastrointestinal vascularbeds, these tissues are highly sensitive for detecting occulttissue hypoperfusion during compensated circulatoryshock. Although these are functionally and metabolicallydifferent organs, at a functional circulatory level they areremarkably similar. Blood flow in these organs is moder-ately to strongly influenced by sympathetic vasoconstrictormechanisms. In this regard, coronary, cerebral, and renalcirculations show a high degree of autoregulation withpoor sympathetic control, whereas skeletal muscle, gastro-intestinal and cutaneous circulations show a predominantsympathetic control with a poor degree of autoregulation.With the progression of circulatory shock and followinginitiation of therapy and normalization of systemichemodynamic parameters, the association between globalflow and peripheral circulation becomes less striking andultimately disappears. Some patients enter a phase wherethe physiological gap between macrocirculation and micro-circulation becomes more evident and intricate(Figure 1).To what extent each peripheral vascular bed expresses hy-poperfusion in these stages of shock remains to be investi-gated. Nevertheless, most published reports support ourearlier knowledge that the vascular bed of peripheral circu-lation is among the first to deteriorate and the last to be re-stored after resuscitation and, therefore, through this beinga window of perfusion [3].Poeze and colleagues observed that global hemodynamic

variables and gastric tonometry variables were both differ-ent between survivors and nonsurvivors, and no superiorpredictor of outcome was identified at admission beforeICU resuscitation was initiated [4]. However, afterstabilization and normalization of global hemodynamics,gastric tonometry variables were the best predictor of out-come. Other studies have reported similar time courses indifferent peripheral vascular beds, such as skin, muscle andsublingual microcirculation. These studies showed thatpersistence of abnormal peripheral perfusion following res-toration of global hemodynamics was related to an un-favorable outcome [5-9]. Our group evaluated changes in

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Lima and Bakker Critical Care

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2014, 18:113http://ccforum.com/content/18/1/113

parameters of skin and muscle perfusion during early re-suscitation of circulatory shock [8,9]. We found that pa-tients who failed to normalize their capillary refill time, PIand peripheral tissue oxygenation during early treatmenthad a worse outcome. These findings could have implica-tions for the treatment of critically ill patients with persist-ent abnormal peripheral perfusion, requiring additionaldiagnostic or therapeutic interventions.He and colleagues explored the relationship between

global and peripheral perfusion variables following initialresuscitation in septic patients [1]. The authors used twodistinct but complementary methods to evaluate periph-eral perfusion (PI and transcutaneous oxygen/carbon di-oxide tension). The PI calculates the ratio between thearterial compartment and the nonpulsatile componentand because the size of the pulsatile portion increaseswith vasodilation and decreases with vasoconstriction,changes in the PI reflect changes in peripheral bloodflow. Transcutaneous oxygen/carbon dioxide tension, onthe other hand, is a measure of oxygenation, and is re-lated to variations in local perfusion [10]. The authorsdemonstrated that nonsurviving septic patients had poorperipheral perfusion characterized by lower PI and ablunted response to the oxygen challenge test (OCT; thechange in transcutaneous oxygen tension relative to thechange in arterial partial pressure of oxygen after 10 mi-nutes on fraction of inspired oxygen of 1.0). The authorsalso showed that the PI and OCT could predict mortalitywith similar accuracy to arterial lactate levels, althoughnot corrected for confounding factors.Interestingly, the study showed that both survivors and

nonsurvivors had abnormal peripheral blood flow, as

reflected by the lower PI values, when compared withhealthy controls. Even more interestingly, nonsurvivors hadsignificantly lower OCT values associated with higher arter-ial lactate levels. Assuming that global hemodynamic vari-ables were optimized in all patients, the low OCT in thenonsurvivors could be explained either by a high rate ofoxygen consumption or by decreased oxygen delivery, ashypothesized by the authors. Since oxygen requirements ofthe skin are quite low relative to other organs, we canspeculate variations in peripheral blood flow as the mainreason of low OCT in nonsurvivors, supported also by thelow PI values. These results underscore the context of theperipheral circulation in septic shock, and provide evidenceof a heterogeneous distribution of blood flow in sepsis. Thisphenomenon was first described by Gilbert in 1960 as ‘dila-tion in one (vascular) bed might be accompanied by con-striction elsewhere’ [11]. This statement is supported by thefindings of He and colleagues showing that peripheral vaso-constriction can be a hallmark of early septic shock [1].While these abnormalities in peripheral perfusion predictan unfavorable outcome, it still needs to be proven that cor-recting these abnormalities results in improved outcome.As clinicians we start shifting our focus from monitor-

ing global pressures to monitoring flow and its determi-nants in order to assess adequacy of resuscitation[12,13]. With the advent of techniques that allow us tocontinuously monitor peripheral perfusion, we couldfurther shift our focus to maintaining normal perfusionin nonvital organs, such as skin, subcutaneous tissue andmuscle. The fundamental challenge is the validation oflow-cost peripheral perfusion monitoring tools that canbe readily available worldwide. The measurement of

Figure 1 Clinical pattern of alterations in global and peripheral blood flow during circulatory shock. After initial treatment, restoration ofglobal flow (A) is usually followed by peripheral perfusion trends towards normalization in survivors (B), and remained altered in nonsurvivors (C).

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transcutaneous and sublingual microcirculation at thebedside is still mostly used in larger research centers.Reliance on simple methods such as the capillary refilltime, skin temperature, and PI must be emphasized andexploited. However, the true clinical implications ofthese tools should be better defined in clinical trials tar-geting peripheral perfusion.

AbbreviationsPI: Perfusion index; OCT: Oxygen challenge test.

Competing interestsThe authors declare that they have no competing interests.

Published:

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Cite this article as: Lima and Bakker: Clinical monitoring of peripheralperfusion: there is more to learn. Critical Care

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21 Feb 2014

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2014, 18:113

2014, 18:113http://ccforum.com/content/18/1/113