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Is Capillary Refill Time Still A Reliable And Useful Test For Evaluating Tissue Perfusion In Injured Limb
Yuwarat Monteerarat, MD; Roongsak Limthongthang, MD; Saichol Wongtrakul, MD; Panupan Songcharoen, MD; Torpon Vathana, MD
Siriraj Hospital, Mahidol University, Bangkok, Thailand

Introduction: Capillary refill time (CRT) is traditionally used as a clinical indicator of tissue vascularity either after limb injury or after revascularization. However, some argued that CRT is an unreliable method as some devasculaized digits can appear to have normal CRT. In addition, previous studies failed to demonstrate the correlation between capillary refill time and tissue perfusion. CRT can be examined at several areas where the most frequently used is the fingernail, however no convincing evidence demonstrated which area is more accurate than others. We therefore investigated whether the test itself is unreliable or the area of the test is not an appropriate site to assess CRT.
Material and Method: CRT was tested in twenty four healthy volunteers, age between 20-30 years old. Three registered nurses were included as rater for evaluate inter-observer variability. Tourniquet 250 mmHg was applied to upper arm to mimic total occlusion of brachial artery of that limb. CRT was blindly assessed both tourniquet was on or off at four different areas in index finger; fingernail, lateral paronychia, proximal and distal pulp. All CRT tests were performed in controlled environment including light and temperature.

Results: CRT of all four areas of digit demonstrated significant mean different between tourniquet and non-tourniquet (p<0.05). However, the fingernail shown to have subtle different in CRT (1.22 seconds) compared to lateral paronychia (3.26 seconds), proximal pulp (4.46 seconds) and distal pulp (4.085 seconds). In normal limb (non-tourniquet) CRT had fair inter-observer reliability (ICC=0.51) but very poor ICC in occluded limb (ICC=0.13) when tested at fingernail. However, CRT still had reasonable inter-observer reliability when tested at lateral paronychia and finger pulp (ICC= 0.75-0.81 in non-tourniquet vs 0.62-0.68 in tourniquet).
Conclusion: CRT at appropriate area is still a useful and reliable method to evaluate tissue perfusion in injured limb. From our study, the most reliable and applicable area for CRT testing is finger pulp either proximal or distal pulp. Lateral paronychia is also one of reliable area, however difficult to assess due to its position especially in splinted hand. The unreliable fingernail CRT could explained why CRT had poor sensitivity in previous studies.

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