1. SCH Journal Club The Agreement of Fingertip and Sternum Capillary Refill Time in Children Thurs 6 th June 2013 Lindsay Lewis St6 Image removed for copyright reasons

2. To determine the agreement of fingertip and sternum CRT in children Aim

3. 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

4. CRT 1 st 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

5. 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

6. Clinical Question PopulationPaediatric (< 18yrs) InterventionPerforming central CRT ComparisonPerforming peripheral CRT OutcomeTime / duration of CRT DesignObservational (Prospective, method- comparison study)

7. CRT AND Central and / or peripheral Limited to children (<16yrs) Searches; medline, embase, cochrane Literature Search

8. The agreement of fingertip and sternum capillary refill time in children Jodie Crook, Rachel M Taylor Archives of Diseases in Childhood Online First Feb 9 th 2013 Doi:10.1136/archdichild-2012-303046

9. 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

10. 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

11. 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

12. 1524 children in A+E 1421 not approached 103 eligible approached 100 consented 3 refused 8 excluded 92 studied

13. 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

14. Reason for attendance n (%) Diagnosis N (%) Minor injury53 (58)46 (50) Head injury17 (18) NAD0 (0)8 (9) Foreign body7 (8)4 (4) Rash4 (4)0 (0) Viral illness3 (3)4 (4) Burn/scald2 (2) Miscellaneous6 (7)11 (12) Reason for attendance to A&E

15. MeanRange Heart rate (beats per minute) 99±18.867–146 Respiratory rate (breaths per minute) 21.6±3.915–36 Temperature (°C)36.9±0.336.2–37.5 Oxygen saturation (%) 99±0.97.97–100 CRT—fingertip (s)1.08±0.440.05–2.78 CRT—Sternum (s) 1.5±0.330.85–2.38 Clinical Observations

16. 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

17. 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.

18. 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.

19. Lets Critique Are the results of the study valid? What are the results? Will the results help locally? www.casp-uk.net/

20. 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

21. 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

22. Will the results help me locally? To some extent Do the results of this study fit with other available evidence? Yes Critique - Usefulness

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

24. 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

25. 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.