{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T17:09:52Z","timestamp":1788887392919,"version":"build-2803163510"},"reference-count":49,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVES:<\/jats:title>\n                    <jats:p>Assessment of tissue perfusion remains a central challenge in the management of hemodynamically unstable patients, as normalization of macrocirculatory variables does not necessarily reflect restoration of effective organ perfusion. This concise definitive review examines contemporary approaches to multimodal perfusion assessment and discusses how available monitoring tools may be integrated into a stepwise, physiology-driven framework to guide escalation of monitoring at the bedside.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>DATA SOURCES:<\/jats:title>\n                    <jats:p>Relevant physiologic and clinical studies addressing peripheral perfusion assessment, hemodynamic monitoring, and circulatory shock were identified from the peer-reviewed literature and complemented by established physiologic concepts and clinical experience.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>STUDY SELECTION:<\/jats:title>\n                    <jats:p>Randomized clinical trials, observational studies, physiologic investigations, and narrative and systematic reviews evaluating perfusion monitoring modalities in critically ill patients were considered.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>DATA EXTRACTION AND DATA SYNTHESIS:<\/jats:title>\n                    <jats:p>Available monitoring tools\u2014including capillary refill time, peripheral perfusion indices, serum lactate, venous oxygenation variables, tissue oxygenation, spectral imaging techniques, and advanced hemodynamic assessments were analyzed with emphasis on physiologic rationale, clinical applicability, strengths, and limitations. These elements were integrated into a pragmatic framework emphasizing dynamic interpretation and proportional escalation of monitoring rather than normalization of isolated variables.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>Multimodal perfusion assessment should be interpreted as an integrated physiologic process rather than a search for a single superior marker. Capillary refill time provides a pragmatic clinical anchor, while complementary tools may refine interpretation when physiologic coherence is uncertain. Escalation of monitoring should be guided by patient risk and unresolved uncertainty, supporting individualized, physiology-driven resuscitation while minimizing unnecessary therapeutic escalation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1097\/ccm.0000000000007232","type":"journal-article","created":{"date-parts":[[2026,6,4]],"date-time":"2026-06-04T14:00:15Z","timestamp":1780581615000},"page":"2452-2459","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Multimodal Perfusion Assessment in Hemodynamically Unstable Patients: A Concise Definitive Review"],"prefix":"10.1097","volume":"54","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0871-5997","authenticated-orcid":false,"given":"Carlos","family":"Sanchez-Escalante","sequence":"first","affiliation":[{"name":"Critical Care Medicine, Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xavier","family":"Monnet","sequence":"additional","affiliation":[{"name":"Universit\u00e9 Paris-Saclay, Facult\u00e9 de M\u00e9decine, Service de m\u00e9decine intensive-r\u00e9animation, H\u00f4pital de Bic\u00eatre, AP-HP, DMU 4 CORREVE Maladies du c\u0153ur et des vaisseaux, IHU SEPSIS, Groupe de recherche clinique CARMAS, Inserm U1358, Le Kremlin-Bic\u00eatre, France."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,6,4]]},"reference":[{"key":"R1-20260908","doi-asserted-by":"crossref","first-page":"1971","DOI":"10.1007\/s00134-025-08137-z","article-title":"ESICM guidelines on circulatory shock and hemodynamic monitoring 2025.","volume":"51","author":"Monnet","year":"2025","journal-title":"Intensive Care Med"},{"key":"R2-20260908","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1186\/s13054-025-05555-9","article-title":"Gingival capillary refill time: A new approach to assess tissue perfusion.","volume":"29","author":"Jacquet-Lagr\u00e8ze","year":"2025","journal-title":"Crit Care"},{"key":"R3-20260908","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1001\/jama.2019.0071","article-title":"Effect of a resuscitation strategy targeting peripheral perfusion status vs serum lactate levels on 28-day mortality among patients with septic shock: The ANDROMEDA-SHOCK randomized clinical trial.","volume":"321","author":"Hern\u00e1ndez","year":"2019","journal-title":"JAMA"},{"key":"R4-20260908","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1186\/s13054-019-2560-0","article-title":"Capillary refill time variation induced by passive leg raising predicts capillary refill time response to volume expansion.","volume":"23","author":"Jacquet-Lagr\u00e8ze","year":"2019","journal-title":"Crit Care"},{"key":"R5-20260908","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1186\/s13054-023-04714-0","article-title":"Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock.","volume":"27","author":"Fage","year":"2023","journal-title":"Crit Care"},{"key":"R6-20260908","doi-asserted-by":"crossref","first-page":"1813","DOI":"10.1007\/s00134-010-2005-3","article-title":"Monitoring the microcirculation in the critically ill patient: Current methods and future approaches.","volume":"36","author":"De Backer","year":"2010","journal-title":"Intensive Care Med"},{"key":"R7-20260908","first-page":"226","article-title":"Clinical assessment of peripheral circulation.","volume":"21","author":"Lima","year":"2015","journal-title":"Curr Opin Crit Care"},{"key":"R8-20260908","doi-asserted-by":"crossref","first-page":"5782","DOI":"10.3390\/jcm13195782","article-title":"Capillary refill time as a part of routine physical examination in critically ill patients undergoing vasoactive therapy: A prospective study.","volume":"13","author":"Weso\u0142ek","year":"2024","journal-title":"J Clin Med"},{"key":"R9-20260908","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1177\/102490790801500202","article-title":"Inter-observer variability of capillary refill time.","volume":"15","author":"Anderson","year":"2008","journal-title":"Hong Kong J Emerg Med"},{"key":"R10-20260908","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1016\/j.ajem.2021.12.048","article-title":"Impact of posture on capillary refilling time: Intravascular fluid also affects results.","volume":"57","author":"Jouffroy","year":"2022","journal-title":"Am J Emerg Med"},{"key":"R11-20260908","doi-asserted-by":"crossref","first-page":"932","DOI":"10.1016\/S0196-0644(88)80675-9","article-title":"Defining normal capillary refill: Variation with age, sex, and temperature.","volume":"17","author":"Schriger","year":"1988","journal-title":"Ann Emerg Med"},{"key":"R12-20260908","doi-asserted-by":"crossref","first-page":"46","DOI":"10.1016\/0735-6757(94)90196-1","article-title":"Adverse lighting condition effects on the assessment of capillary refill.","volume":"12","author":"Brown","year":"1994","journal-title":"Am J Emerg Med"},{"key":"R13-20260908","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1186\/s12873-022-00681-x","article-title":"Capillary refill time for the management of acute circulatory failure: A survey among pediatric and adult intensivists.","volume":"22","author":"Jacquet-Lagr\u00e8ze","year":"2022","journal-title":"BMC Emerg Med"},{"key":"R14-20260908","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1007\/s00134-011-2163-y","article-title":"Mottling score predicts survival in septic shock.","volume":"37","author":"Ait-Oufella","year":"2011","journal-title":"Intensive Care Med"},{"key":"R15-20260908","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1186\/s13054-019-2496-4","article-title":"Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters.","volume":"23","author":"Dumas","year":"2019","journal-title":"Crit Care"},{"key":"R16-20260908","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1186\/2110-5820-3-31","article-title":"Alteration of skin perfusion in mottling area during septic shock.","volume":"3","author":"Ait-Oufella","year":"2013","journal-title":"Ann Intensive Care"},{"key":"R17-20260908","doi-asserted-by":"crossref","first-page":"956","DOI":"10.1378\/chest.99.4.956","article-title":"Blood lactate levels are superior to oxygen-derived variables in predicting outcome in human septic shock.","volume":"99","author":"Bakker","year":"1991","journal-title":"Chest"},{"key":"R18-20260908","first-page":"315","article-title":"Lactate and shock state: The metabolic view.","volume":"12","author":"Levy","year":"2006","journal-title":"Curr Opin Crit Care"},{"key":"R19-20260908","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/S2213-8587(13)70154-2","article-title":"Stress hyperlactataemia: Present understanding and controversy.","volume":"2","author":"Garcia-Alvarez","year":"2014","journal-title":"Lancet Diabetes Endocrinol"},{"key":"R20-20260908","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1016\/j.mito.2014.05.007","article-title":"Comprehensive review on lactate metabolism in human health.","volume":"17","author":"Adeva-Andany","year":"2014","journal-title":"Mitochondrion"},{"key":"R21-20260908","doi-asserted-by":"crossref","first-page":"155286","DOI":"10.1016\/j.jcrc.2025.155286","article-title":"What every intensivist should know about the biphasic kinetics of lactate in septic shock.","volume":"91","author":"Castro","year":"2026","journal-title":"J Crit Care"},{"key":"R22-20260908","doi-asserted-by":"crossref","first-page":"155287","DOI":"10.1016\/j.jcrc.2025.155287","article-title":"Decoding lactate kinetics in septic shock: From flow to metabolism.","volume":"91","author":"Lakbar","year":"2026","journal-title":"J Crit Care"},{"key":"R23-20260908","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1186\/s13613-020-00732-1","article-title":"A lactate-targeted resuscitation strategy may be associated with higher mortality in patients with septic shock and normal capillary refill time: A post hoc analysis of the ANDROMEDA-SHOCK study.","volume":"10","author":"Kattan","year":"2020","journal-title":"Ann Intensive Care"},{"key":"R24-20260908","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1097\/SHK.0000000000002507","article-title":"Understanding hemodynamic incoherence: Mechanisms, phenotypes, and implications for treatment.","volume":"63","author":"Huang","year":"2025","journal-title":"Shock"},{"key":"R25-20260908","doi-asserted-by":"crossref","first-page":"e151","DOI":"10.1097\/CCM.0000000000004768","article-title":"Changes in the plethysmographic perfusion index during an end-expiratory occlusion detect a positive passive leg raising test.","volume":"49","author":"Beurton","year":"2021","journal-title":"Crit Care Med"},{"key":"R26-20260908","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1097\/CCM.0000000000006899","article-title":"Targeted tissue perfusion versus macrocirculatory-guided standard care in patients with septic shock: A randomized clinical trial-the TARTARE-2S trial.","volume":"54","author":"Pettil\u00e4","year":"2026","journal-title":"Crit Care Med"},{"key":"R27-20260908","doi-asserted-by":"crossref","first-page":"1368","DOI":"10.1056\/NEJMoa010307","article-title":"Early goal-directed therapy in the treatment of severe sepsis and septic shock.","volume":"345","author":"Rivers","year":"2001","journal-title":"N Engl J Med"},{"key":"R28-20260908","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1007\/s00134-015-4133-2","article-title":"Can venous-to-arterial carbon dioxide differences reflect microcirculatory alterations in patients with septic shock?","volume":"42","author":"Ospina-Tasc\u00f3n","year":"2016","journal-title":"Intensive Care Med"},{"key":"R29-20260908","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1186\/s13054-021-03671-w","article-title":"Pathophysiology and clinical implications of the veno-arterial PCO2 gap.","volume":"25","author":"Ltaief","year":"2021","journal-title":"Crit Care"},{"key":"R30-20260908","doi-asserted-by":"crossref","first-page":"17256","DOI":"10.1038\/s41598-021-96806-6","article-title":"Central venous-to-arterial PCO2 difference as a marker to identify fluid responsiveness in septic shock.","volume":"11","author":"Nassar","year":"2021","journal-title":"Sci Rep"},{"key":"R31-20260908","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s40560-025-00801-2","article-title":"Combination of Cv-aCO2\/Ca-vO2 and Pv-aCO2 as markers of resuscitation or microcirculation in patients with septic shock: A pilot study.","volume":"13","author":"Cheng","year":"2025","journal-title":"J Intensive Care"},{"key":"R32-20260908","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1186\/s13613-025-01569-2","article-title":"Use of CO2-derived variables in critically ill patients.","volume":"15","author":"Mallat","year":"2025","journal-title":"Ann Intensive Care"},{"key":"R33-20260908","doi-asserted-by":"crossref","first-page":"1412","DOI":"10.1097\/CCM.0b013e318275cece","article-title":"Lactate and venoarterial carbon dioxide difference\/arterial-venous oxygen difference ratio, but not central venous oxygen saturation, predict increase in oxygen consumption in fluid responders.","volume":"41","author":"Monnet","year":"2013","journal-title":"Crit Care Med"},{"key":"R34-20260908","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1186\/s40001-024-02048-3","article-title":"Peripheral perfusion index of pulse oximetry in adult patients: A narrative review.","volume":"29","author":"Sun","year":"2024","journal-title":"Eur J Med Res"},{"key":"R35-20260908","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1186\/s13054-024-05085-w","article-title":"Testing preload responsiveness by the tidal volume challenge assessed by the photoplethysmographic perfusion index.","volume":"28","author":"Bruscagnin","year":"2024","journal-title":"Crit Care"},{"key":"R36-20260908","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/s13054-019-2306-z","article-title":"The effects of passive leg raising may be detected by the plethysmographic oxygen saturation signal in critically ill patients.","volume":"23","author":"Beurton","year":"2019","journal-title":"Crit Care"},{"key":"R37-20260908","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.1007\/s10877-019-00445-2","article-title":"Do changes in perfusion index reflect changes in stroke volume during preload-modifying manoeuvres?","volume":"34","author":"de Courson","year":"2020","journal-title":"J Clin Monit Comput"},{"key":"R38-20260908","first-page":"167","article-title":"Peripheral perfusion\u2013guided resuscitation versus standard management in sepsis and septic shock.","volume":"99","author":"Yilmaz","year":"2025","journal-title":"Am J Emerg Med"},{"key":"R39-20260908","doi-asserted-by":"crossref","first-page":"1434","DOI":"10.3390\/s23031434","article-title":"Overestimation of oxygen saturation measured by pulse oximetry in hypoxemia. Part 1: Effect of optical pathlengths-ratio increase.","volume":"23","author":"Elron","year":"2023","journal-title":"Sensors"},{"key":"R40-20260908","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1186\/s13054-025-05363-1","article-title":"Clinical outcomes and peripheral tissue oxygen saturation monitoring of the knee region by near-infrared spectroscopy in circulatory shock: A prospective observational cohort study.","volume":"29","author":"Varis","year":"2025","journal-title":"Crit Care"},{"key":"R41-20260908","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1177\/0885066620907307","article-title":"Near-infrared spectroscopy in adult circulatory shock: A systematic review.","volume":"35","author":"Varis","year":"2020","journal-title":"J Intensive Care Med"},{"key":"R42-20260908","doi-asserted-by":"crossref","first-page":"eadw1968","DOI":"10.1126\/sciadv.adw1968","article-title":"AI-powered skin spectral imaging enables instant sepsis diagnosis and outcome prediction in critically ill patients.","volume":"11","author":"Seidlitz","year":"2025","journal-title":"Sci Adv"},{"key":"R43-20260908","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1186\/s13054-018-2171-1","article-title":"The meaning of blood pressure.","volume":"22","author":"Magder","year":"2018","journal-title":"Crit Care"},{"key":"R44-20260908","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1152\/ajplegacy.1951.164.2.319","article-title":"On the physical equilibrium of small blood vessels.","volume":"164","author":"Burton","year":"1951","journal-title":"Am J Physiol"},{"key":"R45-20260908","doi-asserted-by":"crossref","first-page":"e2305","DOI":"10.1097\/CCM.0000000000006805","article-title":"Assessment of tissue perfusion pressure in patients with septic shock: Beyond mean arterial pressure.","volume":"53","author":"Sanchez","year":"2025","journal-title":"Crit Care Med"},{"key":"R46-20260908","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1186\/2110-5820-1-27","article-title":"Microcirculatory alterations: Potential mechanisms and implications for therapy.","volume":"1","author":"De Backer","year":"2011","journal-title":"Ann Intensive Care"},{"key":"R47-20260908","doi-asserted-by":"crossref","first-page":"e009961","DOI":"10.1161\/JAHA.118.009961","article-title":"Alterations in portal vein flow and intrarenal venous flow are associated with acute kidney injury after cardiac surgery: A prospective observational cohort study.","volume":"7","author":"Beaubien-Souligny","year":"2018","journal-title":"J Am Heart Assoc"},{"key":"R48-20260908","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s13054-018-1957-5","article-title":"Cardiac output monitoring: Throw it out\u2026 or keep it?","volume":"22","author":"Monnet","year":"2018","journal-title":"Crit Care"},{"key":"R49-20260908","doi-asserted-by":"crossref","first-page":"330","DOI":"10.3390\/s25020330","article-title":"A new approach to non-invasive microcirculation monitoring: Quantifying capillary refill time using oximetric pulse waves.","volume":"25","author":"Xia","year":"2025","journal-title":"Sensors"}],"container-title":["Critical Care Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.1097\/CCM.0000000000007232","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T17:01:20Z","timestamp":1788886880000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.1097\/CCM.0000000000007232"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,4]]},"references-count":49,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.1097\/ccm.0000000000007232","relation":{},"ISSN":["0090-3493","1530-0293"],"issn-type":[{"value":"0090-3493","type":"print"},{"value":"1530-0293","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,4]]}}}