Capillary refill time, increased
Capillary refill time is the duration required for color to return to the nail bed of a finger or toe after application of slight pressure, which causes blanching. This duration reflects the quality of peripheral vasomotor function. Normal capillary refill time is less than 3 seconds.
Increased refill time isn’t diagnostic of any disorder but must be evaluated along with other signs and symptoms. However, this sign usually signals obstructive peripheral arterial disease or decreased cardiac output.
Capillary refill time is typically tested during a routine cardiovascular assessment. It isn’t tested with suspected life-threatening disorders because other, more characteristic signs and symptoms appear earlier.
History and physical examination
If you detect increased capillary refill time, take the patient’s vital signs and check pulses in the affected limb. Does the limb feel cold or look cyanotic? Does the patient report pain or any unusual sensations in his fingers or toes, especially after exposure to cold?
Take a brief medical history, especially noting previous peripheral vascular disease. Find out which medications the patient is taking.
Medical causes
Aortic aneurysm (dissecting)
Capillary refill time is increased in the fingers and toes in a dissecting aneurysm in the thoracic aorta; it’s prolonged in just the toes in a dissecting aneurysm in the abdominal aorta. Common accompanying signs and symptoms include a pulsating abdominal mass, a systolic bruit, and substernal back or abdominal pain.
Aortic arch syndrome
Increased capillary refill time in the fingers is an early sign of aortic arch syndrome. The patient displays absent carotid pulses and possibly unequal radial pulses. Other signs and symptoms usually precede loss of pulses and include fever, night sweats, arthralgia, weight loss, anorexia, nausea, malaise, rash, splenomegaly, and pallor.
Aortic bifurcation occlusion (acute)
Increased capillary refill time in the toes is a late sign in this rare but usually fatal disorder. All lower-extremity pulses are absent, and the patient complains of sudden moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Both legs are cold, pale, totally numb, and flaccid.
Arterial occlusion (acute)
Increased capillary refill time occurs early in the affected limb. Arterial pulses are usually absent distal to the obstruction; the affected limb appears cool and pale or cyanotic. Intermittent claudication, moderate to severe pain, numbness, and paresthesia or paralysis of the affected limb may occur.
Buerger’s disease
Capillary refill time is increased in the toes in Buerger’s disease. Exposure to low temperatures initially turns the feet cold, cyanotic, and numb; later they become red, hot, and tingly. Other findings include intermittent claudication of the instep and weak peripheral pulses; in later stages the patient may experience ulceration, muscle atrophy, and gangrene. If the disease affects the hands, increased capillary refill time may accompany painful fingertip ulcerations.
Cardiac tamponade
Increased capillary refill time is a late sign of decreased cardiac output. Associated signs include paradoxical pulse, tachycardia, cyanosis, dyspnea, jugular vein distention, and hypotension.
Hypothermia
Increased capillary refill time may appear early as a compensatory response. Associated signs and symptoms depend on the degree of hypothermia and may include shivering, fatigue, weakness, decreased level of consciousness (LOC), slurred speech, ataxia, muscle stiffness or rigidity, tachycardia or bradycardia, hyporeflexia or areflexia, diuresis, oliguria, bradypnea, decreased blood pressure, and cold, pale skin.
Peripheral arterial trauma
Any trauma to a peripheral artery that reduces distal blood flow also increases capillary refill time in the affected extremity. Related findings in that extremity include bruising or pulsating bleeding, weakened pulse, cyanosis, paresthesia, sensory loss, and cool, pale skin.
Peripheral vascular disease
Increased capillary refill time in the affected extremities is a late sign. Peripheral pulses gradually weaken and then disappear. Intermittent claudication, coolness, pallor, and decreased hair growth are associated signs. Impotence may accompany arterial occlusion in the descending aorta or femoral areas.
Raynaud’s disease
Capillary refill time is prolonged in the fingers, the usual site of this disease’s characteristic episodic arterial vasospasm. Exposure to cold or stress produces blanching in the fingers, then cyanosis, and then erythema before the fingers return to normal temperature. Warmth relieves the symptoms, which may include paresthesia. Chronic disease may produce trophic changes, such as sclerodactyly, ulcerations, or chronic paronychia.
Shock
Increased capillary refill time appears late in almost all types of shock. Accompanying signs include hypotension, tachycardia, tachypnea, and cool, clammy skin.
Volkmann’s contracture
Increased capillary refill time results from this contracture’s characteristic vasospasm. The affected extremity may also exhibit loss of mobility and strength.
Other causes
Diagnostic tests
Cardiac catheterization can cause arterial hematoma or clot formation and increased capillary refill time.
Drugs
Drugs that cause vasoconstriction (particularly alpha-adrenergic blockers) increase capillary refill time.
Treatments
Increased capillary refill time can result from an arterial line or umbilical line (which can cause arterial hematoma and obstructed distal blood flow) or from an improperly fitting cast (which constricts circulation).
Special considerations
Frequently assess the patient’s vital signs, LOC, and affected extremity, and report any changes, such as progressive cyanosis or loss of an existing pulse. Prepare the patient for diagnostic tests, such as arteriography or Doppler ultrasonography, to help confirm or rule out arterial occlusion.
Pediatric pointers
Capillary refill time may be increased in neonates with acrocyanosis; however, this is a normal finding. Typically, increased capillary refill time is associated with the same disorders in children as in adults. However, the most common cause in children is cardiac surgery, such as the repair of congenital heart defects.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Whitening
» Next page: Pallor (Professional Guide to Signs & Symptoms (Fifth Edition))
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