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Capillary refill

Capillary refill time (CRT), also known as the capillary nail refill test, is a noninvasive clinical assessment technique that evaluates peripheral tissue perfusion and hydration status by measuring the time required for blood to return to the capillaries of the nail bed or skin after temporary compression-induced blanching.^[1]^[2] First described in 1947 by Beecher et al. for assessing circulatory status in wounded soldiers, CRT is widely used in human and veterinary medicine as a simple, equipment-free bedside tool to detect conditions such as hypovolemia, dehydration, shock, and sepsis, though its interpretation is influenced by factors like temperature and patient characteristics.^[1]^[3]

Definition and Physiology

Definition

Capillary refill time (CRT) is a clinical test that measures the duration required for blood to return to the capillaries of the skin or nail bed, thereby restoring normal coloration after the tissue has been manually blanched by applied pressure.^[1] This simple, non-invasive assessment evaluates the efficiency of peripheral microcirculation by observing the time it takes for hyperemic rebound to occur following the release of compression that temporarily displaces blood from the superficial capillaries.^[4] The test was first described in 1947 by Beecher et al. as a bedside method to gauge circulatory adequacy in critically ill patients, particularly those in shock from battlefield injuries during World War II, where rapid evaluation of perfusion status was essential.^[5] Beecher's original categorization distinguished between normal refill, definite slowing, and very sluggish refill, correlating these observations with degrees of blood loss and hypovolemic shock severity.^[6] Unlike other perfusion indicators such as pulse oximetry, which quantifies arterial oxygen saturation, or serum lactate levels, which reflect tissue hypoxia and metabolic acidosis, CRT specifically targets the dynamic response of cutaneous capillaries to mechanical stress as a proxy for overall hemodynamic stability.^[1] This distinction positions CRT as a direct, visual indicator of peripheral tissue perfusion, complementing but not replacing more invasive or laboratory-based measures in acute care settings.^[7]

Physiological Basis

Capillary refill time (CRT) is fundamentally a manifestation of microcirculatory dynamics, involving the coordinated function of arterioles, capillary beds, and venules in peripheral tissues. Arterioles, as resistance vessels, control the inflow of blood into the capillary network by adjusting their diameter through smooth muscle contraction and relaxation, thereby regulating perfusion pressure and flow volume. Capillary beds, composed of thin-walled vessels with endothelial linings, serve as the primary site for nutrient and oxygen exchange with surrounding tissues; during the test, applied pressure expels blood from these capillaries, causing blanching, and upon release, reperfusion depends on the rapid re-entry of oxygenated blood from upstream arterioles. Venules then drain the refilled capillaries, completing the local circuit and influencing the overall refill speed by modulating post-capillary resistance and facilitating venous return. This process provides a bedside proxy for tissue-level perfusion efficiency.^[8]^[1] The rate of capillary refill is modulated by several hemodynamic factors that govern systemic and local blood flow. Cardiac output serves as the primary driver, supplying the pressure gradient necessary for arterial blood to reach peripheral microvessels; reductions in output, such as from low stroke volume, diminish this driving force and delay reperfusion. Intravascular volume directly impacts preload and central venous pressure, ensuring adequate filling of the vascular tree—depletions lead to compensatory mechanisms that can initially preserve but eventually compromise microcirculatory flow. Vasomotor tone, regulated by sympathetic innervation and humoral factors like catecholamines, alters arteriolar resistance; heightened tone constricts vessels to redirect blood to vital organs, slowing peripheral refill. Endothelial function plays a critical role through the release of vasoactive substances, such as nitric oxide for vasodilation and endothelin for constriction, maintaining vascular integrity and responsiveness to shear stress during refill.^[1]^[9] In pathophysiological states like hypovolemia, such as that seen in hemorrhage or dehydration, diminished intravascular volume reduces effective circulating blood, lowering cardiac output and perfusion pressure, which prolongs CRT by limiting the volume available for rapid capillary replenishment. This delay reflects a systemic effort to prioritize core organ perfusion over cutaneous microcirculation. Similarly, vasoconstriction—often triggered by sympathetic activation in early shock or cold exposure—increases arteriolar resistance, impeding blood entry into capillary beds and extending refill time as a marker of redistributed flow away from the periphery. These changes highlight CRT's sensitivity to imbalances in microcirculatory homeostasis, where endothelial dysfunction may further exacerbate delays by impairing local vasodilation.^[1]^[10]

Assessment Procedure

Standard Technique

The standard technique for the capillary refill test begins with selecting a suitable anatomical site, such as the nail bed of the index finger or toe in adults, or the sternum or forehead in infants, ensuring the area is free of nail polish, rings, or other obstructions that could interfere with observation.^[1]^[5] The patient should be positioned supine with the tested extremity elevated to heart level in a warm environment maintained at 20–25°C to minimize vasoconstriction and promote accurate assessment of peripheral perfusion.^[11] Cold extremities must be avoided, as low temperatures can falsely prolong refill times by inducing peripheral shutdown.^[12] To execute the procedure, apply moderate to firm digital pressure sufficient to blanch the tissue pale white, holding the pressure steadily for 5 seconds to ensure complete displacement of blood from the capillaries.^[1] Upon release, immediately observe and time the interval required for the original skin color to return uniformly, using a stopwatch for precise measurement or a consistent mental count if a timer is unavailable; good lighting, preferably natural daylight, enhances visibility of color changes.^[1]^[11] This method assesses the rate of capillary reperfusion after transient occlusion, providing a non-invasive indicator of microvascular function.^[1]

Variations by Population

In adults, capillary refill is typically assessed by applying pressure to the nail bed of the distal phalanx of a finger or toe until blanching occurs, with normal refill times averaging 1.9 seconds and an upper limit of 3 seconds, reflecting efficient peripheral perfusion compared to younger populations.^[1] This site is preferred due to its accessibility and vascularity, but the technique's reliability diminishes in cases of peripheral edema, where tissue fluid accumulation can obscure blanching and prolong apparent refill times, or in darkly pigmented skin, where melanin hinders visualization of color changes; alternative central sites like the palm, forehead, or lip mucosa are recommended in these scenarios to ensure accurate assessment.^[1]^[13] In infants and children, central sites such as the sternum or forehead are favored over peripheral fingertips because of the thinner skin and greater susceptibility to vasoconstriction in extremities, which can lead to falsely prolonged peripheral refill times.^[5] Studies show fingertip capillary refill is significantly faster than sternal refill in children aged 0-12 years, with mean times of 1.08 seconds peripherally versus 1.5 seconds centrally, and normal upper limits of 2-3 seconds for both sites.^[14] Clinicians must account for artifacts from crying or excessive movement, which can artifactually extend refill times in agitated infants, necessitating a calm environment or repeated measurements for validity. In veterinary practice, capillary refill in small companion animals like dogs and cats is routinely evaluated at the gingival or buccal mucous membranes by applying digital pressure for 2-4 seconds, with normal times under 2 seconds indicating adequate perfusion; these non-furred sites minimize interference from hair.^[15] For larger animals such as horses or cattle, the gums remain the primary assessment site, where refill should occur within 2 seconds, but adjustments are required for body size—using firmer but controlled pressure to achieve blanching without distress—and for dense fur in some breeds, by prioritizing exposed mucosal areas like the vulva or conjunctiva to avoid obscuration.^[16]^[17]

Clinical Interpretation

Normal Values

In healthy adults, capillary refill time is typically less than 2 seconds when measured at room temperature on the fingertip or similar site.^[7] Some sources establish an upper limit of normal at less than 3 seconds, accounting for minor variations in measurement.^[1] For infants and children, normal values vary by age. In newborns and neonates, values ranging from 1 to 3.4 seconds have been observed in studies, with a mean around 2.2 seconds; the upper limit of normal is generally considered 3 seconds.^[18] Values may vary by site, with longer times observed on extremities compared to central sites like the sternum.^[19] In older infants and children beyond the neonatal period, the expected time is 2 seconds or less.^[20] Ambient temperature influences baseline capillary refill time, with cooler conditions causing vasoconstriction that can prolong it by approximately 1-2 seconds or more compared to room temperature measurements.^[21]^[22]

Abnormal Findings

Abnormal capillary refill time (CRT) deviates from the typical range of less than 2 seconds observed in healthy individuals and provides insight into underlying circulatory disturbances. Prolonged CRT, defined as greater than 2 to 3 seconds, primarily signals peripheral hypoperfusion, where inadequate blood flow to the tissues results from reduced cardiac output or intravascular volume depletion. This finding is commonly associated with conditions such as shock (including septic, hemorrhagic, and cardiogenic types), dehydration, sepsis, and heart failure, as these states impair the microcirculatory replenishment of blood after compression.^[1]^[4]^[12] In pathophysiological terms, prolonged CRT reflects a mismatch between oxygen delivery and demand, often exacerbated by vasoconstriction in response to systemic hypovolemia or inflammation, leading to delayed capillary filling. For instance, in septic shock, endothelial dysfunction and microvascular thrombosis contribute to this delay, while in heart failure, diminished pump efficiency reduces overall perfusion pressure.^[1]^[11] Clinically, such prolongation serves as an early indicator of tissue hypoxia and is linked to increased risk of organ dysfunction in critically ill patients.^[23] Conversely, rapid CRT, occurring in less than 1 second, may denote hyperdynamic circulatory states characterized by enhanced blood flow or vasodilation. This abnormality is frequently observed in early sepsis, where compensatory tachycardia and reduced vascular resistance accelerate refill, or in conditions like fever that promote systemic vasodilation.^[1]^[4] Pathophysiologically, it arises from an overactive sympathetic response or inflammatory mediators that dilate peripheral vessels, potentially masking initial hypovolemia before decompensation occurs.^[12] Asymmetrical CRT, where refill times differ significantly between extremities (e.g., prolonged on one side), points to localized vascular compromise rather than systemic issues. This can indicate arterial occlusion, such as in peripheral artery disease or embolism, or compartment syndrome, where elevated intracompartmental pressure restricts blood flow to affected tissues.^[7]^[1] Such findings warrant immediate targeted evaluation to prevent ischemic damage, as the asymmetry disrupts normal bilateral perfusion symmetry.^[4]

Applications

In Human Medicine

In human medicine, capillary refill time (CRT) serves as a non-invasive bedside tool to evaluate peripheral perfusion and detect circulatory compromise, particularly in acute settings where rapid assessment is essential. It is integrated into standardized protocols to guide initial triage and intervention, helping clinicians identify hypovolemic, distributive, or cardiogenic shock before more invasive monitoring is feasible.^[24] This assessment is especially valuable in resource-limited environments due to its simplicity and lack of need for equipment.^[1] In emergency medicine, CRT is a core component of the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach and the AVPU (Alert, Voice, Pain, Unresponsive) scale for assessing critically ill patients, aiding in the early detection of shock. During the "C - Circulation" phase, a prolonged CRT greater than 2 seconds, combined with tachycardia or weak pulses, signals inadequate tissue perfusion and prompts immediate actions such as fluid resuscitation or elevation of lower extremities.^[24] For instance, in undifferentiated shock, an abnormal CRT helps prioritize circulatory support within the first minutes of evaluation.^[25] In pediatric care, CRT plays a pivotal role in diagnosing and managing dehydration, as outlined in World Health Organization (WHO) guidelines for integrated management of childhood illness. A CRT exceeding 3 seconds is classified as a danger sign indicating severe dehydration or impending shock, triggering protocols for rapid oral rehydration therapy or intravenous fluids in children under 5 years.^[26] This threshold is particularly emphasized in outpatient and emergency settings for febrile or diarrheal illnesses, where it helps differentiate moderate from severe cases requiring hospital admission.^[27] Within critical care, particularly for sepsis management, CRT is recommended by the Surviving Sepsis Campaign to monitor responses to fluid boluses and vasopressors, serving as an adjunct to lactate levels for personalized resuscitation. In septic shock, targeting a CRT of less than 3 seconds has been shown to reduce organ dysfunction and fluid overload compared to lactate-guided strategies, as demonstrated in the ANDROMEDA-SHOCK trial.^[28] The 2025 ANDROMEDA-SHOCK-2 trial further demonstrated that CRT-targeted personalized hemodynamic resuscitation improved patient-centered outcomes, including shorter duration of vital support and less fluid administration, compared to usual care, though without a significant difference in mortality.^[29] Persistent prolongation despite interventions indicates ongoing hypoperfusion, guiding escalation to vasopressors like norepinephrine.^[29] CRT is often interpreted alongside complementary signs of poor perfusion, such as tachycardia or skin mottling, to enhance diagnostic accuracy in shock assessment; for example, the presence of mottling with a prolonged CRT and rapid heart rate strongly predicts mortality in septic patients.^[30] This multimodal evaluation underscores CRT's role in dynamic, real-time clinical decision-making across human medicine.^[31]

In Veterinary Medicine

Capillary refill time (CRT) is a vital assessment tool in veterinary medicine for evaluating peripheral perfusion and hydration status in animals, with applications tailored to species differences. In small animals, such as dogs and cats, CRT is frequently used to detect hypovolemia during trauma, surgery, or critical illnesses, where prolonged times indicate inadequate circulatory function and guide fluid therapy decisions.^[32]^[33] For instance, in canine patients, a standardized CRT exceeding 2 seconds after gingival blanching correlates with dehydration and hemodynamic instability, prompting immediate interventions like fluid boluses.^[34] In large animals, CRT assessment often targets the lip or gingival mucosa to monitor conditions like colic in horses or endotoxemia in cattle, where delayed refill signals vascular compromise and endotoxic shock.^[35]^[36] Horses with acute colic may exhibit CRT prolongation beyond 2 seconds due to venous pooling and hypoperfusion, aiding in severity triage and treatment escalation such as intravenous fluids.^[35] Similarly, in cattle, assessing CRT in the oral mucosa helps identify hypovolemic states during endotoxemia, with normal times under 2 seconds reflecting adequate perfusion.^[37] Species-specific norms and assessment sites account for physiological variations; for example, reptiles often show inherently slower CRT depending on environmental temperature, making it less reliable for perfusion evaluation compared to mammals, and alternative sites like cloacal mucosa may be used instead.^[38] In veterinary emergencies, such as parvovirus infection in dogs, CRT serves a critical triage role, where times greater than 2 seconds alongside pale mucous membranes indicate severe dehydration and septic shock, influencing aggressive supportive care protocols.^[39]^[40]

Limitations and Considerations

Factors Affecting Accuracy

Several environmental factors can influence the accuracy of capillary refill time (CRT) measurements. Cold ambient temperatures significantly prolong CRT, with studies showing an average of 0.85 seconds in warm rooms compared to 2.39 seconds in cool rooms. Similarly, lower skin temperatures extend refill duration, as a 1°C decrease in patient temperature can increase CRT by approximately 5%, independent of room conditions. Poor lighting conditions also impair visual assessment, reducing the proportion of normal CRT readings from 94.2% in daylight to 31.7% in darker environments.^[41] Patient-specific characteristics further compromise CRT reliability. Advanced age correlates with longer refill times, increasing by about 3.3% per decade of life. Darker skin pigmentation can obscure the color change upon reperfusion, leading to subjective misinterpretation by observers. Comorbidities such as Raynaud's phenomenon, which induces peripheral vasospasm, may artificially delay CRT due to impaired baseline perfusion. Additionally, vasoactive medications like vasopressors can alter peripheral blood flow dynamics, with CRT potentially improving rapidly after administration in responsive patients but remaining prolonged in others. Operator-dependent variables introduce substantial variability in CRT evaluation. Inconsistent application of pressure—such as varying duration or force—directly affects the blanching and refill process, with standardized pressure for 5 seconds recommended to minimize this. Ambient lighting inconsistencies and subjective visual judgment contribute to interobserver discrepancies, where some clinicians systematically overestimate or underestimate times compared to objective methods. Training level influences accuracy, though even experienced operators exhibit notable variability. Improper site selection exacerbates measurement errors. Sites with scarring, edema, or prior injury, such as the fingertips in chronic vascular disease, hinder accurate blanching and color return due to altered tissue compliance and vascular integrity. Guidelines emphasize selecting non-affected, distal phalangeal pads to avoid such confounders.

Evidence and Prognostic Value

Scientific evidence supports the use of capillary refill time (CRT) as a prognostic marker in sepsis and critically ill patients, though its predictive accuracy varies across studies. A 2023 systematic review and meta-analysis of 13 studies involving adults with acute circulatory failure found that prolonged CRT had a pooled area under the receiver operating characteristic curve (AUC-ROC) of 0.66 for predicting mortality, with a sensitivity of 54% and specificity of 72%.^[42] Another 2024 meta-analysis of 11 studies with over 11,000 critically ill patients demonstrated that prolonged CRT at admission was associated with a 73% increased risk of short-term mortality, yielding a pooled risk ratio of 1.73 (95% CI: 1.39–2.16).^[43] Prolonged CRT has been specifically linked to 28-day mortality in ICU patients with septic shock. In a 2021 prospective cohort study of 175 septic shock patients, CRT greater than 3.5 seconds at 6 hours post-resuscitation predicted 28-day mortality with an AUC-ROC of 0.819 and a risk ratio of 4.60, with only 4.44% survival in those with persistent prolongation compared to 79.20% in those with normalization.^[44] Furthermore, the response of CRT to fluid resuscitation serves as a dynamic prognostic marker; in a 2017 observational study of 95 hyperlactatemic sepsis patients, persistent abnormal CRT after initial fluid bolus was associated with 63% hospital mortality versus 9% in those with normalization, with a risk ratio of 6.7 (95% CI: 2.9–16).^[45] Despite these associations, evidence highlights limitations in CRT's standalone prognostic value, including low to moderate sensitivity ranging from 20% to 60% but consistently high specificity above 70%.^[42] Prognostic accuracy improves when CRT is combined with serum lactate levels, as shown in post-hoc analyses of the ANDROMEDA-SHOCK trial, where lactate-targeted resuscitation in patients with normal CRT was linked to higher mortality, suggesting complementary use enhances risk stratification in septic shock.^[46] Recent advances emphasize CRT's integration into pediatric sepsis management. A 2022 review in Frontiers in Pediatrics advocated for CRT as a bedside tool to guide fluid resuscitation and identify severe perfusion deficits in children with sepsis, aligning with updated guidelines that prioritize peripheral perfusion assessment alongside vital signs.^[11] As of 2025, emerging studies highlight the dynamic prognostic value of serial CRT measurements in sepsis and the utility of alternative sites like gingival CRT for more reliable perfusion assessment in challenging cases.^[47]^[48]

References

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Capillary refill time is a physical examination technique that provides clinicians with a simple, reliable, and quick way of determining peripheral perfusion ...Introduction · Specimen Requirements and... · Clinical Significance
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CRT in humans was first promoted in 1947 by Beecher as a way to assess a patient in shock.15 Initially parameters were considered “normal” (no signs of ...
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Microcirculation includes arterioles, capillaries, venules, and terminal lymphatics. Arterioles regulate flow, capillaries are for exchange, and venules have ...
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Sep 25, 2025 · From a physiological point of view, CRT is a complex variable integrating microvascular flow and reactivity. Additionally, it may be understood ...
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Feb 9, 2013 · Fingertip CRT was faster than sternum CRT. Normal CRT is 2-3 s. The current study questions the usefulness of CRT in the assessment of circulation in children.
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