Author:

Editor(s):

Updated:

ULY CLINIC

25 Mei 2025, 09:24:28

Capillary Refill Time (CRT), Increased

Capillary refill time (CRT) refers to the duration required for color to return to a blanched nail bed following the application of gentle pressure. It is a non-invasive measure of peripheral perfusion and vasomotor function. Under normal physiological conditions, CRT is less than 3 seconds. Prolongation of CRT is not diagnostic in isolation but may indicate underlying vascular or cardiac pathology, especially when interpreted in conjunction with other clinical findings.

Clinical Significance

A prolonged CRT typically suggests impaired peripheral perfusion. It is commonly observed in peripheral arterial occlusive diseases and in states of reduced cardiac output. CRT is routinely assessed during cardiovascular examinations but is not prioritized in emergent scenarios where more critical signs manifest earlier.

History and physical examination

When prolonged CRT is identified, perform a comprehensive assessment that includes:

Vital signs
Peripheral pulse palpation in the affected limb
Inspection for cyanosis or cool extremities
Evaluation of pain or altered sensation, especially post-cold exposure

Elicit a focused history concerning:

Previous diagnoses of peripheral vascular disease
Current medications, particularly vasoconstrictors
Smoking history

Etiological considerations

Table 1 below showing the medical and other causes of increased capillary refill time, along with key features for each:

Cause	Capillary Refill Time Location	Key Signs and Symptoms
Aortic Aneurysm (Dissecting)	Fingers and toes (thoracic); toes only (abdominal)	Pulsating abdominal mass, systolic bruit, substernal/back/abdominal pain
Aortic Arch Syndrome	Fingers	Absent carotid pulses, unequal radial pulses, fever, night sweats, arthralgia, weight loss, rash, splenomegaly
Arterial Occlusion (Acute)	Affected limb	Absent pulses, cool pale/cyanotic limb, claudication, pain, numbness, paresthesia/paralysis
Buerger’s Disease	Toes (may involve fingers)	Cold/cyanotic feet, redness, tingling, claudication, weak pulses, ulceration, muscle atrophy, gangrene
Cardiac Tamponade	Generalized (late sign)	Paradoxical pulse, tachycardia, cyanosis, dyspnea, JVD, hypotension
Hypothermia	Generalized (early sign)	Shivering, low LOC, slurred speech, rigidity, bradycardia/tachycardia, cool pale skin
Peripheral Arterial Trauma	Affected extremity	Bruising, pulsating bleeding, weak pulse, cyanosis, paresthesia, sensory loss, cool pale skin
Peripheral Vascular Disease	Affected extremities (late sign)	Weakening pulses, claudication, coolness, pallor, hair loss, possible impotence
Raynaud’s Disease	Fingers	Blanching, cyanosis, erythema, paresthesia, relieved by warmth, possible sclerodactyly and ulceration
Volkmann’s Contracture	Affected extremity	Vasospasm, immobility, weakness
Cardiac Catheterization	Affected limb	Arterial hematoma or clot
Drugs (vasoconstrictors)	Generalized	Due to alpha-adrenergic stimulation
Arterial/Umbilical Line	Affected limb	Hematoma, obstructed distal flow
Improperly Fitting Cast	Affected limb	Circulatory constriction

Clinical management

Frequent monitoring of vital signs, limb perfusion, and neurological status is essential. Assess dorsalis pedis and posterior tibial pulses in lower limbs. Diagnostic imaging such as Doppler ultrasonography or arteriography may be warranted to assess vascular integrity.

Patient education and counseling

Educate patients on recognizing symptoms of compromised circulation. Emphasize the importance of smoking cessation and lifestyle modifications to improve vascular health. Instruct on limb elevation, warmth preservation, and avoidance of cold exposure in relevant cases.

Pediatric considerations

While increased CRT in neonates may be benign (e.g., acrocyanosis), persistent prolongation in children is often linked to cardiovascular pathology, particularly post-surgical states involving congenital heart defect repairs.

References

Akre M, Finkelstein M, Erickson M, Liu M, Vanderbilt L, Billman G. Sensitivity of the pediatric early warning score to identify patient deterioration. Pediatrics. 2010;125(4):e763–e769.
Al Salloum AA, El Mouzan MI, Al Herbish AS, Al Omar AA, Qurashi MM. Blood pressure standards for Saudi children and adolescents. Ann Saudi Med. 2009;29(3):173–178.
Archbold KH, Johnson NL, Goodwin JL, Rosen CL, Quan SF. Normative heart rate parameters during sleep for children aged 6 to 11 years. J Clin Sleep Med. 2010;6(1):47–50.
McGee S. Evidence-Based Physical Diagnosis. 4th ed. Philadelphia: Elsevier; 2018.
Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 13th ed. Philadelphia: Wolters Kluwer; 2020.
Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. 20th ed. New York: McGraw-Hill Education; 2018.
Kumar P, Clark M. Kumar and Clark's Clinical Medicine. 10th ed. Edinburgh: Elsevier; 2020.
Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski JS, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York: McGraw-Hill Education; 2020.
Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 8th ed. Philadelphia: Wolters Kluwer; 2018.
American Heart Association. 2020 AHA Guidelines for CPR and ECC. Dallas: American Heart Association; 2020.
Rutherford RB. Vascular Surgery. 8th ed. Philadelphia: Elsevier Saunders; 2014.
LeWinter MM, Mann DL. Diseases of the Aorta. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, editors. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia: Elsevier; 2019.
Spittell JA, Spittell PC Jr. Aortic Dissection and Aneurysm. Mayo Clin Proc. 1993;68(12):1199–1217.