Elsevier

The Journal of Pediatrics

Volume 149, Issue 5, November 2006, Pages 676-681
The Journal of Pediatrics

Original article
Capillary refill time as an independent prognostic indicator in severe and complicated malaria

https://doi.org/10.1016/j.jpeds.2006.07.040Get rights and content

Objectives

To improve algorithms for the identification of children at risk of dying of malaria in endemic areas.

Study design

In a prospective study of 2446 children with severe and complicated malaria admitted to a tertiary referral center in Ghana, West Africa, 12 clinical and laboratory signs were evaluated as indicators of death.

Results

A prolonged (>2 seconds) capillary refill time (pCRT) was identified as an independent prognostic indicator of death along with acidosis, coma, and respiratory distress. Among the clinical signs, pCRT increased the risk of dying from 4-fold to 11-fold when present in addition to coma and respiratory distress.

Conclusions

The recognition of pCRT as an independent indicator of death justifies its inclusion as a defining criterion of severe and complicated malaria and improves the use of clinical examinations in the triage of patients with malaria. As pCRT has been shown to reflect circulatory disturbances in children, it should be included in upcoming studies as a possible sign to indicate the need for intravenous fluid administration.

Section snippets

Study Subjects

The study was conducted in Komfo Anokye Teaching Hospital (KATH), a tertiary referral center in the city of Kumasi, Ghana, with 150 pediatric beds and 6000 annual pediatric admissions. It was carried out between 2001 and 2005, in parallel with the SMAC study, and its purpose was to investigate human genetic factors influencing severe malaria. Ethical approval was obtained from the Committee for Research, Publications, and Ethics of the School of Medical Sciences, Kwame Nkrumah University of

Results

Of 2446 patients studied (Figure 1), capillary refill time was assessed in 2342. Of these, 343 (14.6%) had a prolonged capillary refill time of <2 seconds (pCRT). Case fatality rate in the total group was 7.0%; among those with pCRT, it was 13.1%.

On univariate analysis, most of the clinical and laboratory parameters studied were significantly associated with fatality, including age, consciousness level, CRT, respiratory condition, hemoglobin, base excess, blood lactate, blood glucose, and

Discussion

The study group presented in the report was a subgroup of patients enrolled at a large tertiary referral centre in West Africa as part of the SMAC study.12 Multivariate analysis of patients presenting with the severe malaria complications of severe anemia, coma, and hyperlactatemia identified pCRT as an independent risk factor in addition to acidosis, coma, and respiratory distress. This indicates that pCRT was not associated with acidosis, coma, or respiratory distress specifically but

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    Capillary refill time (CRT) is a bedside measurement as widely promulgated as an acceptable method to identify hemodynamically compromised patients [1-3].

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    Prolonged CRT has been shown to be an early marker of inadequate tissue perfusion in acute circulatory shock (Bailey et al., 1990; Chien et al., 2007; McGee et al., 1999). Evans et al. proposed CRT as an independent indicator of mortality risk in severe and complicated malaria (Evans et al., 2006). Grissom et al. discovered an association between physical characteristics, including CRT, knee mottling, and cool extremities and pulmonary catheter parameters in acute lung injuries (Grissom et al., 2009).

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Supported by the German Ministry of Education and Research (BMBF) through the National Genome Research Network (NGFN, NIE-S17T19).

T.A. is the Principal Investigator and D.A., S.A., E.A.A., S.B.N., K.O.K., A.O.Y.A., A.O.O., D.S., and J.S. are members of the Kumasi Severe Malaria in African Children (SMAC) Research Team.

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