capillary rethink time andrew magnay university hospital of north staffordshire nhs trust nhs trust

Capillary rethink time Capillary rethink time Andrew MagnayAndrew Magnay

University Hospital of North University Hospital of North StaffordshireStaffordshire

NHS TrustNHS Trust

Introduction Introduction

Resuscitation of the critically ill or injured child is an APLS/PHPLS (&ATLS/PHTLS) “standard scenario”, tested in the *PLS courses

The method emphasises the approach of “as one identifies a critical problem, so one treats or enables its treatment”

The purpose: Prevent progression of illness whilst enabling definitive care

Purpose achieved by ABCDE

AgendaAgendaUse & abuse of CRT - an indirect clinical

assessment toolDehydration vs. HypovolaemiaConsequences of too much fluid?

– Trauma and cautiously hypovolaemic resusn – Special problems:

Meningitis / raised ICPCardiogenic shock & other non-hypovolaemic

shockARDS Infancy

Recognition of the ill childRecognition of the ill childA,BA,B APLS & ATLSAPLS & ATLS GIVE OXYGEN ASSESS

– AAirway patent?– BBreathing Rate Normal Values

APLS ATLS 7thEd < 1yr< 1yr <40 <40 <60 <60 1 - 2yr1 - 2yr <35 <35 <40 <40 2 – 5yr2 – 5yr <30 <30 <35 <35 5-12yr5-12yr <25 <25 <30 <30>12yr>12yr <20 <20 <30 <30

– Accessory resps, colour & consciousness

Recognition of the ill childRecognition of the ill childCC APLS & ATLSAPLS & ATLS OXYGEN ASSESS

– Pulse rate Normal Values<1yr < 160 1 - 5yr < 140 5 - 12yr < 120 >12 yr < 100

– Colour, Capillary refillCapillary refill, Coolness, Exsanguinating haemorrhage

– Consciousness (under-perfusion)

CirculationCirculationRestoration of volume Restoration of volume ATLS ATLS APLSAPLS

CRYSTALLOID / COLLOID20 ml/kg (or 10+10ml/kg)(or 10+10ml/kg)




BLOODBLOODBLOODBLOOD

SURGERY IF TRAUMASURGERY IF TRAUMASURGERY IF TRAUMASURGERY IF TRAUMA

Assess Assess responseresponse


C

CRYSTALLOID / COLLOID20 ml/kg

CRYSTALLOID / COLLOID20 ml/kg

Consider FFP, Cryo etcConsider FFP, Cryo etcConsider FFP, Cryo etcConsider FFP, Cryo etc






Case Illustration A.1Case Illustration A.1 12 yr boy, fall from tree 14 ft onto rough. Adm. A&E, facial injury no stridor or blood Resp 18 /min, normal air entry Bruising over lower left chest HR 134, CRT 4 sec, BP 80/50 GCS 9 (E2,V2,M5), PERL, Neuro L=R

Case Illustration A.1Case Illustration A.1 12 yr boy, fall from tree 14 ft onto rough. Adm. A&E, facial injury no stridor or blood Resp 18 /min, normal air entry Bruising over lower left chest HR 134, CRT 4 sec, BP 80/50 GCS 9 (E2,V2,M5), PERL, Neuro L=R 20ml/kg Saline HR 130 CRT 4 BP 85/45 20ml/kg Saline HR 126 CRT 4 BP 88/50 +Surgn


Blood HR 124 CRT 4 BP 88/50


Blood HR 124 CRT 4 BP 88/50 GCS=14 (E4,V3,M6) Splenectomy

Case Illustration A.1Case Illustration A.1 12 yr boy, fall from tree 14 ft onto rough. Adm. A&E, facial injury no stridor or blood Resp 18 /min, normal air entry Bruising over lower left chest HR 134, CRT 3 sec, BP 80/50 GCS 9 (E2,V2,M5), PERL, Neuro L=R 20ml/kg Saline HR 130 CRT 4CRT 4 BP 85/45 20ml/kg Saline HR 126 CRT 4CRT 4 BP 88/50 Blood HR 124 CRT 4CRT 4 BP 88/50 GCS=14 (E4,V3,M6) Splenectomy Suppose his temp was 35Suppose his temp was 3566C on arrival to O.R.?C on arrival to O.R.?

Case Illustration A.2Case Illustration A.2

12 yr boy, fall from tree 14 ft onto rough. Adm. A&E, facial injury no stridor or blood Resp 18 /min, normal air entry Bruising over lower left chest HR 68, CRT 4 sec, BP 120/76 GCS 9 (E2,V2, M5), PERL, Neuro L=R

Case Illustration A.2Case Illustration A.2

12 yr boy, fall from tree 14 ft onto rough. Adm. A&E, facial injury no stridor or blood Resp 18 /min, normal air entry Bruising over lower left chest HR 68, CRT 4 sec, BP 120/76 GCS 9 (E2,V2, M5), PERL, Neuro L=R 2 IVI, Maintenance N/Saline only;

CT Scan, neurosurgical opinion

Case Illustration B.1Case Illustration B.1 2yr girl, 48hr temp, lethargy, vomited x1 2hr petechial rash Admitted to A&E by GP (gave penicillin) Spontaneously breathing, RR50, Sats 98% (air) HR 180, CRT 4 sec, BP 65/30, Temp 386C Opens eyes to pain, E2 V1 M4 = 7

Case Illustration B.1Case Illustration B.1 2yr girl, 48hr temp, lethargy, vomited x1 2hr petechial rash Admitted to A&E by GP (gave penicillin) Spontaneously breathing, RR50, Sats 98% (air) HR 180, CRT 4 sec, BP 65/30, Temp 386C Opens eyes to pain, E2 V1 M4 = 7 Rx O2, 2 x 20ml Resuscitation fluid, BM=7

HR 175, CRT 4 sec, BP 70/35, RR 56, Sats 93% Still shocked, developing pulmonary oedema

Case Illustration B.2Case Illustration B.2

2yr girl, 48hr temp, lethargy, vomited x1 2hr petechial rash Admitted to A&E by GP (gave penicillin) Spontaneously breathing, RR50, Sats 98% (air) HR 110, CRT 4 sec, BP 100/70, Temp 386C Opens eyes to pain, E2 V1 M4 = 7

Case Illustration B.2Case Illustration B.2

2yr girl, 48hr temp, lethargy, vomited x1 2hr petechial rash Admitted to A&E by GP (gave penicillin) Spontaneously breathing, RR50, Sats 98% (air) HR 110, CRT 4 sec, BP 100/70, Temp 386C Opens eyes to pain, E2 V1 M4 = 7; BM 7.5 2xIVI, N/Saline maintenance only. Sats 98%.

Reduced conscious level due to…?

Connections Connections Decision to correct fluid deficit is a

“gestalt” NOT a “one-test-solves-all”Is the child ill? Potentially ill? Context?Is there a reason for extreme caution?

– Cerebral oedema, cardiac, infancy?Does the overall story with physical signs

indicate intravascular hypovolaemiaintravascular hypovolaemia?Does the overall story with physical signs

indicate dehydrationdehydration?

Capillary Refill TimeCapillary Refill TimeUses and abusesUses and abuses

Is it:– “reliable” (technique, IUV, environment)?– A predictorpredictor of hypovolaemic shock?– A predictorpredictor of anything useful?– Useful as a negative predictornegative predictor?

Is it used canonically by APLS providers?Is it used canonically by APLS instructors?

Some kind of shockSome kind of shockA true storyA true story

14 yr boy c/o faintness, breathlessnessHR 190, BP 80/40, weak pulse, CRT 5secRx 20ml/kg. No effectRx 20ml/kg. C/o chest pain, can’t breathe…..?!ECG, diuretic, adenosine x3, flecainideHome in 24hr

Some kind of shockSome kind of shockA true storyA true story 14 yr boy c/o faintness, breathlessness HR 190, BP 80/40, weak pulse, CRT 5sec Rx 20ml/kg. No effect Rx 20ml/kg. C/o chest pain, can’t breathe …..?! ECG, diuretic, adenosine x3, flecainide Home in 24hr

Problem: Misapplication of the APLS Method & CRT Test

Root cause: a) Dr believed CRT clinched need for volume Rxb) “APLS emphasises CRT as having supportive value in diagnosis of hypovolaemia” [wrong]

What could be done better?Tachycardic patient…..ECG Monitor shows more than a Number!

14 yr boy c/o severe chest pain & breathlessness HR 160, BP 80/40, weak pulse, CRT >4sec “Doctor he’s got severe chest pain…”

“Sorry nurse, but look, he’s really shocked, he’s got delayed CRT, get that saline running stat…”

Rx 1L crystalloid. C/o can’t breathe. CRT >4sec Rx 1L crystalloid, CRT >4sec; 1L colloid………! VF arrest…..!! DCShocks, Intubate+PEEP, diuretic, pacing,

aortic counterpulsation cardiac catheterisation ECG Anterolateral MI (anomalous LCA).

Cardiogenic shockCardiogenic shockAnother true storyAnother true story

14 yr boy c/o severe chest pain & breathlessness HR 160, BP 80/40, weak pulse, CRT >4sec “Doctor he’s got severe chest pain…”

“Sorry nurse, but look, he’s really shocked, he’s got delayed CRT, get that saline running stat…”

Rx 1L crystalloid. C/o can’t breathe. CRT >4sec Rx 1L crystalloid, CRT >4sec; 1L colloid………! VF arrest…..!! DCShock, Intubate+PEEP, diuretic, aortic counterpulsation and cardiac catheterisation ECG Anterolateral MI (anomalous LCA).

Cardiogenic shockCardiogenic shockAnother true storyAnother true story

Diagnosis: Abuse of the APLS Method

Root cause: a) Dr believed CRT clinched hypovolaemic shock b) Dr asserted that ABC precedes “diagnosis” c) Dr unable to listen to an experienced nurse

and finally d) Dysfunctional self-critiquing result – denial

Capillary Refill TimeCapillary Refill TimeHow useful is it really?How useful is it really?

Capillary refilling time in newborn babies: normal Capillary refilling time in newborn babies: normal values.values. Strozik, Pieper, Roller. Strozik, Pieper, Roller. Arch Dis Child 1997;76:F193-6Arch Dis Child 1997;76:F193-6

Ambient temp 23 ± 1Ambient temp 23 ± 100CCCot nursedBabies under radiant warmersBabies in incubators

2 populations of babies assessed by 2 independent observers. No inter-user reliability data included.

Upper limit of CRT 3.22sec in all 4 sites testedUpper limit of CRT 3.22sec in all 4 sites tested

Capillary refill time in the hands and feet of normal Capillary refill time in the hands and feet of normal newborn infants.newborn infants. Raju NV, Maisels MJ, Kring E, Raju NV, Maisels MJ, Kring E, Schwarz-Warner L. Schwarz-Warner L. Clinical Pediatrics 1999;38:139-44Clinical Pediatrics 1999;38:139-44

Healthy 36 – 42 wks gestation, Age 1hr – 120hr

Mean CRT (s) SD Range

Hand 4.2 sec Hand 4.2 sec 1.471.47 1.6 – 8.8 sec1.6 – 8.8 sec

Foot 4.6 secFoot 4.6 sec 1.41 1.41 2.2 – 9.9 sec2.2 – 9.9 sec

Capillary refill time in term neonates: bedside Capillary refill time in term neonates: bedside assessment. Raichur, Aralihond, Patil. assessment. Raichur, Aralihond, Patil. Indian Journal of paediatrics 2001;68:613-5Indian Journal of paediatrics 2001;68:613-5

Healthy 37 – 42 wks gestation, Age 1hr – 168hr; Room temp 26 – 300 C (mean 28.4)

Observer 1 Observer 2 Mean SD Range Mean SD Range p

ForeheadForehead 2.6 2.6 0.8 (1.2 - 3.7) 1.9 0.8 (1.2 - 3.7) 1.9 0.6 (0.8 – 3.6) 0.6 (0.8 – 3.6) <0.001<0.001ChestChest 2.7 2.7 0.4 (1.7 – 4.4) 2.6 0.4 (1.7 – 4.4) 2.6 0.7 (1.1 – 4.8) NS0.7 (1.1 – 4.8) NSPalm 3.0 0.6 (1.5 – 5.3) 2.8 1.1 (1.3 – 6.9) <0.05Heel 3.1 0.8 (1.8 – 5.6) 4.2 1.8 (1.6 – 10.0) <0.001

Capillary refill time in term neonates: bedside Capillary refill time in term neonates: bedside assessment. Raichur, Aralihond, Patil. assessment. Raichur, Aralihond, Patil. Indian Journal of paediatrics 2001;68:613-5Indian Journal of paediatrics 2001;68:613-5

Healthy 37 – 42 wks gestation, Age 1hr – 168hr; Room temp 26 – 300 C (mean 28.4)

2 SD upper limit (approx 95%)2 SD upper limit (approx 95%) Observer 1 Observer 2

Forehead 4.2 sec4.2 sec 3.1 sec 3.1 secChest 3.5 sec3.5 sec 4.0 sec 4.0 sec

Comment: longer CRT than one would expect for the ambient temperature? & note the variability between users

Capillary refilling time in newborn babies: normal Capillary refilling time in newborn babies: normal values. Strozik, Pieper, Roller. values. Strozik, Pieper, Roller. Arch Dis Child 1997;76:F193-6Arch Dis Child 1997;76:F193-6

Ambient temp 23 ± 10CCot nursedBabies under radiant warmersBabies in incubators

2 populations of babies assessed by 2 independent observers. No inter-user reliability data included.

Upper limit of CRT 3.22sec in all 4 sites tested !!Upper limit of CRT 3.22sec in all 4 sites tested !!

CRT relationship with HR and BP in 42 AGA term neonates 1-4hr old, Tax 36.5 – 37.0

Duration of pressure had substantial and highly significant difference to the result.

Moderate direct relationship with systolic, diastolic, and mean BP:

r pSys BP 0.35 0.02Mean BP 0.49 0.001Dia BP 0.43 0.005

Capillary refill time is an unreliable indicator of Capillary refill time is an unreliable indicator of cardiovascular status in term neonates. LeFlore JL, cardiovascular status in term neonates. LeFlore JL, Engle WD. Engle WD. Adv Neonatal Care 2005;5:174-54Adv Neonatal Care 2005;5:174-54

Capillary refill time significantly prolonged by > 1sec at low ambient temp (mean 19.5 C) compared with warmer ambient temp (mean 25.7 C) who had normal CRT of <2sec.

Significant inter-user variability even amongst experienced professionals.

Q: What ambient temp are your patients subjected to before and duringbefore and during assessment?

Effect of ambient temperature on capillary refill in Effect of ambient temperature on capillary refill in healthy children. Gorelick MH, Shaw KN, Baker healthy children. Gorelick MH, Shaw KN, Baker MD. MD. Pediatrics 1997 92: 699-702 Pediatrics 1997 92: 699-702

Capillary refill – is it a useful predictor of hypovolemic Capillary refill – is it a useful predictor of hypovolemic states?states? Schriger DL, Baraff LJ.Schriger DL, Baraff LJ. Annals of Emergency Annals of Emergency Medicine 1991;20:601-5Medicine 1991;20:601-5

Mean CRT SD Range

Blood Donors (500ml) Before 1.4 0.7 0.6 – 3.7 After 1.1 0.7 0.4 – 4.0

Clinically hypovolaemic patients *Orthostatic signs 1.9 0.7 0.8 – 3.3 Hypotension 2.8 1.2 1.1 – 5.1 Total 2.8 1.0 0.8 – 5.1

*Orthostatic signs: CRT sensitivity 47%

Prior probability Accuracy +Predictive -Predictiveof hypovolaemia Value Value

10% 89% 43% 93%25% 80% 69% 81%50% 64% 87% 59%90% 40% 98% 14%

Capillary refill – is it a useful predictor of hypovolemic Capillary refill – is it a useful predictor of hypovolemic states?states? Schriger DL, Baraff LJ.Schriger DL, Baraff LJ. Annals of Emergency Annals of Emergency Medicine 1991;20:601-5Medicine 1991;20:601-5

In an adult population in which half of the In an adult population in which half of the patients have hypovolaemia with patients have hypovolaemia with hypotension or abnormal postural vital hypotension or abnormal postural vital signs, capillary refill time measured by signs, capillary refill time measured by trained observers with stopwatches in a trained observers with stopwatches in a temperature-controlled environment with temperature-controlled environment with good lighting will classify subjects good lighting will classify subjects correctly only two thirds of the time.correctly only two thirds of the time.

Is measurement of capillary refill time useful as part Is measurement of capillary refill time useful as part of the initial assessment of children? Leonard PA, of the initial assessment of children? Leonard PA, Beattie TF. Beattie TF. Eur J Emergency Med 2004; 11: 158-63Eur J Emergency Med 2004; 11: 158-63

7 month cohort n=4878No significant association between CRT and:

– Meningococcal disease– Other significant bacterial illness

Significant association with:– More urgent triage category– Administration of fluid bolus– Duration of hospital stay

Best performance using > 3sec as criterion

Pos predictive value Neg predictive value

Triage Category 1,2 9% 97% Requiring Fluid Bolus 11% 99% Hospital Admission 55% 65% Stay >2d or Death 22% 91%

Is measurement of capillary refill time useful as part Is measurement of capillary refill time useful as part of the initial assessment of children? Leonard PA, of the initial assessment of children? Leonard PA, Beattie TF. Beattie TF. Eur J Emergency Med 2004; 11: 158-63Eur J Emergency Med 2004; 11: 158-63

Capillary refill time as indicator of Capillary refill time as indicator of shock in PICUshock in PICU Capillary refill time >= 6 sec predicted

abnormally low SVI (<30ml/m2) with sensitivity of 57% and specificity of 94%.

Likelihood ratio of positive test (CRT>=6) is 9.5 CRT >=3sec LR = 1.6.

Unlikely to be helpful at CRT >=2 !

Capillary refill and core-peripheral temperature gap as indicators of Capillary refill and core-peripheral temperature gap as indicators of haemodynamic status in paediatric intensive care patients.haemodynamic status in paediatric intensive care patients. Tibby, Tibby, SM, Hatherill M, Murdoch IA. Arch Dis Child 1999; 80:163-6SM, Hatherill M, Murdoch IA. Arch Dis Child 1999; 80:163-6

The Child with non-blanching rash: how likely is The Child with non-blanching rash: how likely is meningococcal disease? Wells LC, Smith JC, meningococcal disease? Wells LC, Smith JC, Weston VCD, Collier J, Rutter N. Weston VCD, Collier J, Rutter N. Arch Dis Child 2001;85:218-22Arch Dis Child 2001;85:218-22

Prospective study 233 non-blanching rash over 1yr Excluded 15 with “clear” alternative

diagnoses), leaving n=218 11% of 218 finally shown to have

meningococcal disease BP & other variables & signs are presented HR data were not presented

The Child with non-blanching rash: how likely is The Child with non-blanching rash: how likely is meningococcal disease? Wells LC, Smith JC, meningococcal disease? Wells LC, Smith JC, Weston VCD, Collier J, Rutter N. Weston VCD, Collier J, Rutter N. Arch Dis Child.Arch Dis Child.

Variable Sens% Spec% PPV % NPV% Odds Ratio

CRT>2sec 83 85 42 98 (92-100) 29.4Hypotension 28 97 71 84 12.7Fever >385 58 81 27 94 8.0Purpura too 83 88 47 98 (92-100) 37.2Illness (defined) 79 81 35 97 16.7CRP >6mg/L 100 54 18 100 (92-100) 0 (0-3%)Rash beyond SVC 100 38 17 100 (91-100) 0 (0-4%)

Population n=218 with 11% final prevalence of the diseasePopulation n=218 with 11% final prevalence of the disease who who already have a non-blanching rash.already have a non-blanching rash.

Maldistributive septic shock with Maldistributive septic shock with non-blanching rashnon-blanching rashAnother true story..Another true story..

19mo boy8hr earlier: vomited x3, not apparently ill3hr earlier: unwell, 1 blanching spot on chest1hr earlier: S/B Walk-In Clinic Dr:

New petechiae over chest, ill-lookingAdmitted to hospital urgently

Maldistributive septic shockMaldistributive septic shockAnother true story continues..Another true story continues..

Invasive Meningococcal DiseaseInvasive Meningococcal DiseaseMeningitis without shockMeningitis without shock Rising ICP and aggressive fluid therapy: a deadly

combination. Unconscious, petechiae, minimal- or easily- corrected

haemodynamic disturbance:THINK BRAIN

Early intubation to protect airway and control ventilation

Use cerebral protective drugs at intubation Ensure good perfusion, but don’t overdo volume

boluses. Think mannitol 0.25 – 0.5 g/kg

““Poor capillary refill and differential pulse Poor capillary refill and differential pulse volumes are neither sensitive nor specific volumes are neither sensitive nor specific indicators of shock in infants and children,indicators of shock in infants and children, but are useful clinical signs when used in but are useful clinical signs when used in conjunction with the other signs described. conjunction with the other signs described. They should not be used as the only They should not be used as the only indicators of shock, nor as quantitative indicators of shock, nor as quantitative measures of the response to treatment.”measures of the response to treatment.”

Advanced Paediatric Life Support, 3rd Ed. 2001; p16Advanced Paediatric Life Support, 4th Ed. 2005; p62-3

““Poor capillary refill and differential pulse Poor capillary refill and differential pulse volumes are neither sensitive nor specific volumes are neither sensitive nor specific indicators of shock in infants and children, indicators of shock in infants and children, but are useful clinical signs when used in but are useful clinical signs when used in conjunction with the other signs described.conjunction with the other signs described. They should not be used as the only They should not be used as the only indicators of shock, nor as quantitative indicators of shock, nor as quantitative measures of the response to treatment.”measures of the response to treatment.”


““Poor capillary refill and differential pulse Poor capillary refill and differential pulse volumes are neither sensitive nor specific volumes are neither sensitive nor specific indicators of shock in infants and children, indicators of shock in infants and children, but are useful clinical signs when used in but are useful clinical signs when used in conjunction with the other signs described. conjunction with the other signs described. They should not be used as the only They should not be used as the only indicators of shock, nor as quantitative indicators of shock, nor as quantitative measures of the response to treatment.”measures of the response to treatment.”


The validity and clinical reliability of clinical signs in the The validity and clinical reliability of clinical signs in the diagnosis of dehydration in children. Gorelick MH, Shaw diagnosis of dehydration in children. Gorelick MH, Shaw KN, Murphy KO. KN, Murphy KO. Pediatrics 99(5) 1997 URL e6 Pediatrics 99(5) 1997 URL e6

Diagnostic performance of 10 individual clinical findings

Sensitivity Specificity Kappaw

Decreased skin elasticity 0.35 0.97 0.55Capillary refill >2 sec 0.48 0.96 0.65 *General appearance 0.59 0.91 0.61 *Absent tears 0.67 0.89 0.75 *Abnormal respiration 0.43 0.86 0.40Dry mucous membranes 0.80 0.78 0.59 *Sunken eyes 0.60 0.84 0.50Abnormal radial pulse 0.43 0.86 0.59Tachycardia HR>150 0.46 0.79 -Decreased urine output 0.85 0.53 0.75

Is this child dehydrated? Steiner MJ, deWalt Is this child dehydrated? Steiner MJ, deWalt DA, Byerley JS. JAMA 2004;291:2746-53DA, Byerley JS. JAMA 2004;291:2746-53

Evidence-based assessment of literature 110 articles, 84 excluded. 3 assigned to Level 3 quality criteria 11 assigned to Level 4 quality criteria NONE at Level 1 or 2 Best individual signs for assessing dehydration are:

– prolonged CRT

– abnormal skin turgor

– abnormal respiratory patterns

APLS MessageAPLS MessageDehydrationDehydration

APLS uses CRT as an adjunct for determining the presence of shock.

APLS makes no mention of CRT in the workshop on fluids in connection with dehydration.

APLS TestingAPLS Testing(In)Appropriate use of CRT(In)Appropriate use of CRT

Scenarios and MCQ are not designed with opportunities to test for inappropriate use of the CRT as a guide to fluid therapy:– Trauma +/- exposure to elements– Brought in from the cold– Hypothermic– Non-hypovolaemic shock– Using CRT during cardiac arrest (!!!)– Communicating CRT with priority over HR,

BP, & features of underperfusion

CRT: SummaryCRT: SummaryA rapid clinical assessment of…something“Normal” value not especially age-relatedBut: is the clinical assessment tool reliable?Consequences of giving too much fluid?

– Special problemsNon-hypovolaemic shockMeningitisARDSInfancy

ConclusionConclusion ALSG could consider reallocating CRT from

Shock to Dehydration assessment ALSG could consider including testing for

appropriate use of CRT Fluid deficit correction is a “gestalt” approach

NOT a “one-test-solves-all”Is this child ill? Potentially ill? Context?Is there a reason for extreme caution?Does the overall story with findings indicate

intravascular hypovolaemia?Does the overall story with findings indicate

dehydration?

capillary rethink time andrew magnay university hospital of north staffordshire nhs trust nhs trust

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