SCH Journal Club

The Agreement of Fingertip and Sternum Capillary Refill Time in ChildrenThurs 6th June 2013

Lindsay Lewis St6

Image removed for copyright reasons

To determine the agreement of fingertip and sternum CRT in children

Aim

• Search literature relevant to question• Select useful paper to discuss• Determine validity and reliability of paper in answering

question• Assess whether clinical practice needs to change

Objectives

• CRT 1st used in battlefields in 1940s• Champion et al arbitrarily chose upper limit of 2 sec,

used as part of scoring system• Limited research in its use in children (particularly

sternal)• Research in neonates shown that length of pressure and

degree of pressure affect CRT

Background

• CRT used as part of assessment in all ill children• ALSG and NICE guidelines• Normal < 2 sec• Must press for 5 sec• Central (sternum) OR peripheral (finger tip)• Used interchangeably but should they?

Current Practice

Clinical Question

Population Paediatric (< 18yrs)

Intervention Performing central CRT

Comparison Performing peripheral CRT

Outcome Time / duration of CRT

Design Observational(Prospective, method-comparison study)

• CRT AND Central and / or peripheral• Limited to children (<16yrs)

• Searches; medline, embase, cochrane

Literature Search

The agreement of fingertip and sternum capillary refill time in children

Jodie Crook , Rachel M Taylor

Archives of Diseases in Childhood Online First Feb 9th 2013Doi:10.1136/archdichild-2012-303046

• Written consent & ethical approval• Single paediatric A+E dept in UK• March 2011• Well children• 1month – 12 years• Exclusion criteria; medication, distressed, D+V, poor

intake, cardiac / IEM

Methods 1

• One observer• Same room / lighting• Temperature controlled in waiting and triage room• CRT measured after 30min• Standard technique • Timed in milliseconds using digital SW

Methods 2

• Difference of 0.5s taken to be clinically significant • Data analysed using two-tailed t test• Pearson’s correlation coefficient used to measure

relationship• Bland Altman used to determine agreement

Methods 3 / Outcome measures

1524 children in A+E

1421 not approached 103 eligible approached

100 consented 3 refused

8 excluded 92 studied

Results:

• 48 female (52%)• 44 male (48%)• Mean age 6.3 years 3.7• Ethnic groups;

- white (n=37)

- asian (n=36%)

- mixed race (n=19)

- black (n=3)

Results

Reason for attendancen (%)

DiagnosisN (%)

Minor injury 53 (58) 46 (50)

Head injury 17 (18) 17 (18)

NAD 0 (0) 8 (9)

Foreign body 7 (8) 4 (4)

Rash 4 (4) 0 (0)

Viral illness 3 (3) 4 (4)

Burn/scald 2 (2) 2 (2)

Miscellaneous 6 (7) 11 (12)

Reason for attendance to A&E

Mean Range

Heart rate (beats per minute)

99±18.8 67–146

Respiratory rate (breaths per minute)

21.6±3.9 15–36

Temperature (°C) 36.9±0.3 36.2–37.5

Oxygen saturation (%)

99±0.97. 97–100

CRT—fingertip (s) 1.08±0.44 0.05–2.78

CRT—Sternum (s)

1.5±0.33 0.85–2.38

Clinical Observations

• Fingertip CRT on average 0.42s quicker than sternum CRT

• Statistically significant difference between fingertip and sternum CRT (p<0.001)

• Weak relationship between the two• Fingertip CRT showed greater variability

Results

Pearson's correlation coefficient test demonstrated a weak relationship between fingertip and sternum capillary refill time (CRT) (r=0.18, p>0.05).

Crook J , and Taylor R M Arch Dis Child 2013;98:265-268

Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.

The Bland Altman comparison showed the mean difference between fingertip and sternum capillary refill time (CRT) was −0.49±0.51 with an upper and lower limit of agreement ranging from −1.5 to 0.53, indicating sternum CRT ranged between 1.5 s slower to 0.53 s quicker than

fingertip CRT—upper and lower limits of agreement.

Crook J , and Taylor R M Arch Dis Child 2013;98:265-268

Copyright © BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.

Lets Critique

• Are the results of the study valid?

• What are the results? • Will the results help locally?

www.casp-uk.net/

1. Did the study address a clearly focused issue? Yes

2. Did the authors use an appropriate method to answer their question? Yes

3. Were the patients recruited in an acceptable way? No

4. Was the outcome accurately measured to minimize bias? Yes

5. Have the authors identified all important confounding factors? Yes

Critique - Validity

• What are the results of this study?

- Fingertip CRT on average 0.42 s quicker than sternum

- Weak association between measurements of CRT taken at the fingertip and sternum

- Fingertip CRT shows greater variability than sternum CRT

• How precise are the results?

- Precise

• Do you believe the results?

- Yes

Critique - Results

• Will the results help me locally? To some extent

• Do the results of this study fit with other available evidence? Yes

Critique - Usefulness

• Small number• One A&E setting • Well children• Difference statistically significant but not clinically • Excluded dark skin

Limitations

• Fingertip CRT on average 0.42 s quicker than sternum CRT

• Difference is statistically significant• However, not clinically significant

• Measurements of CRT taken at the fingertip and sternum are not comparable in ‘well’ children

• More research needed!

Summary and Conclusion

Box 1 Five point recommendation for carrying out the capillary refill time test • Consider any factors that are likely to alter capillary refill time (CRT)

(eg, consider not doing CRT if coldness of poor lighting has the potential to effect the result).

• Choose either the sternum or the fingertip pulp site (consider skin colour and size of child's finger).

• Using your index finger apply enough pressure to cause the skin to blanche (turn pale).

• Apply pressure for 5 s.• Remove pressure and immediately count aloud how long it takes for

skin to return from blanched back to pretest colour.CRT Should be 2–3 s• One person should carry out CRT and it should not be repeated or

sites compared.• When recording CRT in the patients notes the letter F or S should

be written next to the number to indicate whether the CRT was taken at the fingertip pulp or sternum, respectively.

• Fingertip CRT requires raising the hand to heart level.

Thank you