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Comparing three methods of assessing peripheral perfusion in critically ill children.

Article Excerpt
The assessment of perfusion in critically ill patients is a routine practice in most intensive care units (ICUs) and is described in the American Association of Critical Care Nurses Core Curriculum of Pediatric Nursing (Slota, 2006). Commonly, this assessment is done serially, such as every 2 to 4 hours throughout the patient's stay. Most pediatric intensive care units (PICUs) have policies or guidelines that specify the components of these assessments, which usually include the quality of peripheral pulses, capillary refill time, color, and extremity warmth. The evaluation of peripheral extremity warmth is an accepted practice in the assessment of peripheral perfusion. It is most commonly performed by caregiver tactile assessment of the warmth of the foot and/or toe. Peripheral warmth is an important aspect of care for critically ill children to assist in identifying alterations in perfusion, to monitor the effect of treatments, and to prevent decompensation through meticulous observations for early changes that allow timely interventions.

This qualitative method is widespread, although it is subjective and may lack inter-rater reliability. The nurse typically documents the degree of warmth based on descriptions that may or may not be standardized by individual units, such as warm, slightly warm, slightly cool, cool, and cold. It might be difficult to demonstrate a high level of inter-rater reliability within these categories. For example, what one provider might assess as slightly cool might be assessed as slightly warm by another. This provides for subjectivity in care across providers, shifts, and units. When available, objective and quantitative assessment parameters are preferred over those that are subjective or qualitative in nature. For this reason, a review of the literature was performed to determine the usefulness of a measured foot temperature as well as the derived perfusion indicator, which is available through the pulse oximeter signal on some monitors. A review of the literature demonstrated the validity of the measured peripheral skin temperature as an assessment of perfusion. Only one study was identified on the application of the perfusion indicator.

Review of the Literature

A classic study by Ibsen (1967) demonstrated that a decrease in effective circulating blood volume causes vasoconstriction, decreased peripheral perfusion, and a decrease in peripheral skin temperature. In this study, the skin temperature was measured on the thumb of adults as 500 mL of blood was removed. He recorded normal vital signs, with a drop in skin temperature. He postulated the blood pressure (BP) was maintained by vasoconstriction as measured by cooling of the thumb temperature. As the blood was re-infused, an increase in skin temperature was observed with no change in BP.

Additional studies in adult patients have found measured foot or toe temperatures to be valid assessment techniques. In an evaluation of 50 critically ill adults, toe temperature and tissue perfusion were compared. Tissue perfusion was evaluated by serum lactate values and cardiac index. Findings demonstrated a predictable correlation between toe temperature with serum lactate and cardiac index (Puri & Groves, 1984). Toe temperature was also used as an indication of the severity of shock in 100 adult patients (Joly & Weil, 1969). They described...

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