title: Toe-to-room temperature gradient correlates with tissue perfusion and predicts outcome in selected critically ill patients with severe infections.
abstract: BACKGROUND
  Microcirculatory disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in severe sepsis and septic shock. As microcirculatory disorders have been identified as strong predictive factors of unfavourable outcome, there is a need to develop accurate parameters at the bedside to evaluate tissue perfusion. We evaluated whether different body temperature gradients could relate to sepsis severity and could predict outcome in critically ill patients with severe sepsis and septic shock.
  
  
  METHODS
  We conducted a prospective observational study in a tertiary teaching hospital in France. During a 10-month period, all consecutive adult patients with severe sepsis or septic shock who required ICU admission were included. Six hours after initial resuscitation (H6), we recorded the hemodynamic parameters and four temperature gradients: central-to-toe, central-to-knee, toe-to-room and knee-to-room.
  
  
  RESULTS
  We evaluated 40 patients with severe sepsis (40/103, 39 %) and 63 patients with septic shock (63/103, 61 %). In patients with septic shock, central-to-toe temperature gradient was significantly higher (12.5 [9.2; 13.8] vs 6.9 [3.4; 12.0] °C, P < 0.001) and toe-to-room temperature gradient significantly lower (1.2 [-0.3; 5.2] vs 6.0 [0.6; 9.5] °C, P < 0.001) than in patients with severe sepsis. Overall ICU mortality rate due to multiple organ failure (MOF) was 21 %. After initial resuscitation, toe-to-room temperature gradient was significantly lower in patients dead from MOF than in the survivors (-0.2 [-1.1; +1.3] °C vs +3.9 [+0.5; +7.2] °C, P < 0.001) and the difference in gradients increased during the first 24 h. Furthermore, toe-to-room temperature gradient was related to tissue perfusion parameters such as arterial lactate level (r = -0.54, P < 0.0001), urine output (r = 0.37, P = 0.0002), knee capillary refill time (r = -0.42, P < 0.0001) and mottling score (P = 0.001).
  
  
  CONCLUSIONS
  Toe-to-room temperature gradient reflects tissue perfusion at the bedside and is a strong prognosis factor in critically ill patients with severe infections.
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Université Pierre et Marie Curie-Paris 6, Paris, France.
authors.forename: Simon
authors.initials: S
authors.lastname: Bourcier
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Université Pierre et Marie Curie-Paris 6, Paris, France.
authors.forename: Claire
authors.initials: C
authors.lastname: Pichereau
authors.affiliation: Service de santé publique, AP-HP, Hôpital Saint-Antoine, 75571, Paris Cedex 12, France.
authors.forename: Pierre-Yves
authors.initials: PY
authors.lastname: Boelle
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Service de Réanimation polyvalente Quincy-sous-Sénart, Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France.
authors.forename: Safaa
authors.initials: S
authors.lastname: Nemlaghi
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Université Pierre et Marie Curie-Paris 6, Paris, France.
authors.forename: Vincent
authors.initials: V
authors.lastname: Dubée
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Lejour
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Baudel
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Service de Réanimation polyvalente Quincy-sous-Sénart, Générale de Santé, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Galbois
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
authors.forename: Jean-Rémi
authors.initials: JR
authors.lastname: Lavillegrand
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
authors.forename: Naïke
authors.initials: N
authors.lastname: Bigé
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.
authors.forename: Jalel
authors.initials: J
authors.lastname: Tahiri
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Leblanc
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Université Pierre et Marie Curie-Paris 6, Paris, France.|Inserm U1136, 75012, Paris, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Maury
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France.|Université Pierre et Marie Curie-Paris 6, Paris, France.|Inserm U1136, 75012, Paris, France.
authors.forename: Bertrand
authors.initials: B
authors.lastname: Guidet
authors.affiliation: Service de réanimation médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75571, Paris Cedex 12, France. hafid.aitoufella@sat.aphp.fr.|Université Pierre et Marie Curie-Paris 6, Paris, France. hafid.aitoufella@sat.aphp.fr.|Inserm U970, Centre de recherche cardiovasculaire de Paris (PARCC), Paris, France. hafid.aitoufella@sat.aphp.fr.
authors.forename: Hafid
authors.initials: H
authors.lastname: Ait-Oufella
keywords: Microcirculation; Outcome; Sepsis; Shock; Temperature gradient