Role of Capillary Refill Time as an Early Warning Sign for Patients with Sepsis in the Emergency Department: a Systematic Review and Synthesis of Practice Recommendations for Thailand
Keywords:
capillary refill time, sepsis, tissue hypoperfusion, emergency department, systematic reviewAbstract
Sepsis and septic shock carry high mortality rates worldwide. Early assessment of tissue hypoperfusion is a key component of clinical management. Capillary refill time (CRT) is a simple, rapid, non-invasive, and cost-free tool for measuring peripheral perfusion. However, its systematic application in Thailand is lacking. This study aimed to review evidence of CRT, compare pressing devices, synthesize standardized measurement protocols, and develop practice recommendations for Thailand. It followed PRISMA 2020 guidelines (PROSPERO: CRD42024513094), searching five databases (2016–2026) based on Sepsis-3 criteria. A total of 47 articles and 10 guidelines were selected: 6 RCTs, 9 systematic reviews/meta-analyses, 22 observational studies, 6 cross sectional studies, and 4 narrative reviews/expert consensuses. Data duplication was managed by reporting overlapping studies only once and extracting primary outcomes from the highest quality or most recent systematic review. Quality was assessed using Cochrane RoB 2, Newcastle Ottawa scale, JBI Checklist, AMSTAR 2, and GRADE. CRT showed a pooled sensitivity of 62.0–74.0% and specificity of 82.0–84.0% (LR+ 4.1, LR 0.36), consistent with meta-analyses by Putowski and Ma. The ANDROMEDA SHOCK trial demonstrated a mortality reduction trend (HR 0.75; 95% CI 0.55–1.02; p=0.06), and a Bayesian reanalysis by Zampieri indicating >90% probability of benefit. GRADE rated diagnostic accuracy as moderate and CRT as a resuscitation target as high. CRT is a moderately accurate screening tool with high practical value, suitable for resource constrained Thai emergency settings. Developing national practice recommendations will help raise the standard of care for sepsis patients. It is recommended for Thailand that finger pressing should be used (GRADE 2B) and inter observer variability can be reduced by training.
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