Capillary Refill: Is It a Useful Clinical Sign? LARRY J.

BARAFF Pediatrics 1993;92;723

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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COMMENTARIES
op inions Academy expressed in these commentaries of Pediatrics or Committees. its are those of the authors and not necessarily
those of the

American

are disease-free who are labeled negative) is 31%. Because the Trauma Score is designed for field hiage to determine which patients are to receive treatment priority, a test with this degree specificity of than a coin toss) is of no value in circumCapifiary refill is a clinical sign popularized in the(worse past 15 years. Intuitively it is a measure of peripheral stances in which ambient temperatures are likely to perfusion which is likely to be a function of cardiac be cool, ie, outside at night or in temperate or cold output and peripheral vascular resistance. It is climates. a The Trauma Score was revised 1990, and in semiquantitative test, with a value of <2 seconds capifiary refill was eliminated.6 generally considered to be normal. What is known about the sensitivity of this clinical In 1980, Champion et a!1 proposed capfflary refill sign, ie, what proportion of those who are diseased as one of five elements of the Trauma Score. Two are labeled positive by the test. Two studies address seconds was defined as the upper limit normal. of this issue. My colleagues and I evaluated capillary After the publication of the Trauma Score and therefill as a predictor of hypovolemic states in adult inclusion of capillary refill as a formal means of patients immediately following blood donation, or evaluation of not only trauma patients but of many with dehydration or hypovolemic shock.7 The sensiother classes of patients, including children,2 my tivity of capifiary refill was 11% for a 450-mL blood colleagues and I made the bedside observation that donation, 47% for hypovolemia with orthostatic hycapifiary refill was not a reliable clinical sign. Many potension, and 77% for frank hypotension. In a study trauma patients with minimal or no injury had ab- of children with dehydration, Saavedra et al8 found normal capillary refill, and many patients with ob- that 1 of 8 children with 5% dehydration, 6 of 12 vious hypovolemia had normal capifiary refill. We children with 5 to 10% dehydration, and 10 of 11 then searched the medical literature for the refer- children with >10% dehydration had capifiary refill ence which defined 2 seconds as the upper limit of times >2 seconds (values derived from Figure 2 in normal. There was none. We called Dr Champion toreference 8). It is apparent from these two studies determine how he had arrived at this value, and he that capifiary refill is not much better than a coin toss informed us that one of nurses his had derived this in predicting moderate degrees of hypovolemia; in value. When we called her (she was then a medical fact, 23% of patients with frank hypotension have student), she informed us that she had performed normal capillary refill. no formal measurements but had arbitrarily chosen All the results that I have quoted come from mea2 seconds as the upper limit f normal. o Subsesurement of capillary refill using either the fingernail quently, we set out to determine the normal values bed or the pulp of the finger. When other sites are of capifiary refill in healthy children and adults.4 We used, the results are even less reliable. Capillaryrefill demonstrated that for most healthy children and times are generally longer when measured at the young adults, 2 seconds was in fact a reasonable heel.5 value, but that the lowest capifiary refill time that How did atest that is neither sensitive nor specific included 95% of the study population was substangain such acceptance? (It is still widespread in use tially higher in healthy women (2.9 seconds) and today.) Before the introduction of capillary refill, the elderly (4.5 seconds). We noted that patients there were no studies to determine normal values. who felt subjectively cold often had abnormal valOnly after its widespread use were there any studies ues and then demonstrated the effect on capillary of its clinical utility. Thisprobably occurred for two refill of immersing the hand in cool water (14#{176}C) for reasons: (1) the advocates of its use were opinion 1 minute. As expected, this resulted in prolongation leaders, Dr Champion and the American College of of capifiary refill. The work by Gorelick et al5 in this Surgeons2 and the American Heart Association3 and issue of Pediatrics is an splendid extension of these (2) the test has implicit a priori validity. It is obvifindings. Sixty-nine percent of children without volously a test of perfusion, the skin is red because of ume depletion or serious ifiness had capifiary refill blood flow, and delayed returnof the normal color times longer than 2 seconds after only 15 minutes in after emptying the capifiary bed by compression is a room with an ambient temperature of 19.4#{176}C due to decreased peripheral perfusion. However, the (67#{176}F). mbient A temperature clearly has a profound limited studies of this clinical sign that I referred to effect on capillary refill. In this setting, the specificabove demonstrate that it is neither sensitive nor ity of this clinical sign (the proportion of those who

Capillary Clinical

Refill: Sign?

Is It a Useful

Received for publication May 11, 1993; accepted May 11, 1993. PEDIATRICS (ISSN 0031 4005). Copyright 1993 the American by

specific. impression, use

It

not only adds it frequently

nothing misclassifies

to

ones clinical normals as

Acad-

emy of

Pediatrics.

abnormal and vise versa. Certainly a laboratory test (eg, a pregnancy

one test)

would not if 70 per-

PEDIATRICS Vol. 92 No. 5 2012 Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 15, November

1993

723

cent of normals were classified as positive and the Parent Dissatisfaction With test missed 50% of the positives. Neonatal Intensive Care Unit Care I believe there are two important lessons to be learned from this experience. (1) As physicians, we and Suggestions for Improvements are scientists and as such must remain skified observers and open-minded about the scientifictruths The article, The Principles for Family-Centered that we are taught or that we ourselves observe. (2) Neonatal Care, in this issue is unique. I believe it is Most clinical signs and symptoms have not been subthe first article weve published that is authored by a jected to analysis to determine their clinical utility. group of parents. This needs to be done. For example, Baker recently This special group of parents whose infants were investigated the utility of the symptom of ear pulling cared for in intensive care nurseries was selected
as a predictor of acute otitis media.9 Of 20 children because of their previous attempts in the lay literawith ear pulling, none had only otitis media; only ture to communicate 4 with the medical establishment of 18 children with fever and ear pulling had acute through newspapers, association newsletters, books, otitis media. As the environment of health care prac- or television interviews. They are unhappy with the tice changes, we will be expected to limit unnecespresent situation, and they want to see change. sary or low-yield diagnostic testing and rely more Ross Laboratories sponsored a 2-day meeting of upon our clinical acumen. In thisenvironment, in the some of these parents with a small group of neonasame manner that we have carefully defined the actologists, pediatricians, social workers, and intensive curacy of laboratory and other diagnostic tests, we care nursery nurses. Members this of medical group had read many of the previous publications of should determine more specifically the utility of parents. The parents were asked to make up a clinical signs and symptoms. The work by Gorelick etthese for improving the care infants of al regarding capillary refill and Baker regarding ear list of suggestions and the communication with parents for discussion puffing are examples of how this can done be quite with members of the medical group. The meeting easily if one is able to clearly define the question of was held in Burlington, VT, in June 1992. 6 No atinterest. tempt was made to arrive any concensus. at The J. Bi, MD discussion was open and frank, and there were 5evUCLA Emergency Medicine Center eral disagreements without resolution. think I both UCLA School of Medicine groups learned from this encounter. The parents Los Angeles, CA 90024-1744 were asked to rewrite their suggestions, and I agreed to publish these in Pediatrics. The article was not to be REFERENCES reviewed or revised by Pediatrics. I wanted the parents article to truly represent their viewpoints. Mrs 1. Champion HR. Sacco WI, Hannan DS, et a!. Assessment of injury severity: the Triage Index. Crit Care Med. 1980;8:201-208 Harrison spent a year revising the article and wid2. Committee on Trauma. Advanced Trauma Life Support Manual. Chicago: ening the input by soliciting views from other parAmerican College of Surgeons; 1989:60-61 ents and groups. 3. Chameides L, ed. Textbook of Pediatric Advanced Life Support.Dallas: I anticipate that this willbe a controversial article. American Heart Assodation and American Academy of Pediatrics; It should be recognized for what it is, a sincere at1988:7 tempt to communicate with physicians in a construc4. Schriger DL, Baraff U. Defining normal capillary refill:variation with age, sex and temperature. Ann Emerg Med. 1988;17:932-935 tive fashion. 5. Gorelick MI-I, Shaw KN, Baker MD. Effect ambient of temperature on In the brave new world we are facing, patients are capillary refill in normal children. Pediatrics. 199392:699-702 often referred to as customers. We are care pro6. Champion Fifi, Sacco WJ, Copes WS, Gann Genarrelli DS, TA, flanagan viders. It is obviously wise to listen to customer ME. Revision of the trauma score. J Trauma. 1989;29:623-629 viewpoints. I hope that this will be the beginning of 7. Schriger DL, Baraff U. Capillary refill: is it useful a predictor of hypovolemic states? Ann Emerg Med. 199120:601-605 a continuing dialogue with concerned parents. In the 8. Saavedra JM, Harris GD, Li S. Finberg L. Capillary reffiling (skin turgor) future we might be able to form a group working in the assessment of dehydration. AJDC. 1991;145:296-298 together to implement some of the parents sugges9. Baker RB. Is ear pulling associated with ear infection? Pediatrics. tions. 199290:1006-1007
JEROLD

F.

LUCEY,

MD
Hospital of Vermont

Medical

Center

Burlington,
PEDIATRICh (ISSN emy of Pediatrics. 0031 4005). Copyright

VT 05401
1993 by the American Acad-

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Capillary Refill: Is It a Useful Clinical Sign? LARRY J. BARAFF Pediatrics 1993;92;723

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on April 15, 2012