Abstract:
A device for measuring the capillary refill time and blood oxygenation includes light sources and a light detector. The device also includes an actuator for applying pressure to a selected portion of the body of the patient, such as the nail bed of a finger or toe of the patient, to cause the removal of blood from the nail bed when actuated. A timer commences a time interval with a deactuation of the actuator. The deactuation relieves the pressure applied by the actuator to the body portion of the patient and allows blood to return to the portion. The timing interval is terminated by a reduction in the amount of light received by the light detector as a result of the restoration of blood to the body portion. The time interval so determined comprises an indication of the capillary refill time of the patient.

Description:
FIELD OF THE INVENTION 
     The present invention relates to a measurement device that can be used to both measure the capillary refill time of a patient as well as to carry out pulse oximetry. 
     BACKGROUND OF THE INVENTION 
     Capillary refill time (CRT), also known as capillary filling time, is a clinically accepted measure of the amount of blood flow, or perfusion, to tissue occurring in a patient. It can provide a quick indication of how well the patient&#39;s vascular system is functioning, as well as the state of hydration/dehydration of the patient. A clinician typically measures capillary refill time by applying pressure to a fingernail or toenail of the patient until the nail bed under the fingernail or toenail turns white or blanches. This indicates that blood has been forced from the bed tissue. The pressure is then released and the time required for the nail bed tissue to regain its original color is measured. A time interval of two seconds or less is ordinarily taken as an indication that the patient&#39;s vascular system functioning and hydration is normal. 
     While apparatus is known in the prior art for carrying out the measurement of capillary refill time, as in U.S. Pat. No. 6,685,635, such apparatus has not found wide acceptance. Thus, at the present time in standard clinical practice, capillary refill time measurements are usually completely manual in nature. That is, the clinician must decide when to take a capillary refill time measurement, carry out the steps necessary to make the measurement, record or remember the measured capillary refill time, and, if applicable, trend the values over time. These circumstances increase the clinician&#39;s physical and mental workload and present opportunities for errors and omissions. The information is often in analog form, i.e. patient chart entries, so that collection and statistical treatment of the information by computer becomes more difficult. 
     Pulse oximetry is another commonly used technique for assessing the condition of a patient&#39;s circulatory system. Pulse oximetry measures the amount of oxygen in a patient&#39;s blood, specifically, the extent of oxygen saturation (SpO 2 ) of arterial hemoglobin in the blood. 
     A pulse oximeter has two basic components. One is an electro-optical sensor, or probe, that is applied to the patient. A number of body locations may be used for this purpose. The probe may be placed on a finger or toe of the patient as well as on the nose, forehead, or earlobe of the patient can also be used. The probe has two light sources, each generating light of a different wavelength in the red-orange spectral range. The light is applied to patient&#39;s tissue and received by a light detector that measures the amount of light that has not been absorbed by blood hemoglobin in the tissue. The light detector is connected to the second component of the pulse oximeter, namely, a signal processor that computes oxygen saturation (SpO 2 ) based on the ratio of the amount of light of each wavelength sensed by the detector. The signal processor distinguishes hemoglobin saturation in arterial blood from that in venous and capillary blood by sensing the pulsatile nature of the former thus giving rise to the term “pulse” oximetry. 
     Pulse oximeters have been used to provide an indication of tissue perfusion by taking the ratio of the pulsatile to non-pulsatile components in a plethysmographic signal of the pulse oximeter. Changes in the perfusion index (PI) so formed, over time, may quantify peripheral perfusion by indirectly monitoring changes in arterial blood flow. However, capillary refill time is a more direct and immediate measurement of tissue perfusion. 
     It would therefore be advantageous to have a single device that could measure multiple parameters relating to the vascular system of a patient, namely capillary refill time and arterial blood hemoglobin oxygen saturation. 
     SUMMARY OF THE INVENTION 
     An embodiment of the present invention provides a single device capable of measuring multiple, clinically useful parameters of a patient. More specifically, the device combines a measurement of capillary refill time with that of arterial oxygen saturation of the blood. 
     The device, and the method, of embodiments of the present invention are capable of automating such measurements so as to ensure that periodic measurements are carried out in a timely fashion and to automatically record and statistically treat periodic determinations, particularly, of capillary refill time. The device of the present invention is simple and economical in construction and use and the method is easy to carry out. The device can be applied and the method carried out at a number of patient body locations thereby to adapt to the circumstances of a particular patient and lend a desirable flexibility in obtaining pulse oximetry and capillary refill time measurements. 
     Briefly, an embodiment of the invention comprises a device for measuring the capillary refill time of a patient and for use in determining an amount of oxygen in the blood of the patient. The device has light sources and a light detector for use in carrying out pulse oximetry. The device also includes an actuator for applying pressure to a selected portion of the patient&#39;s body at which the application of pressure to the portion will cause a removal of blood from the tissue of the portion. For example, the actuator may apply pressure to the nail bed of a nail of a finger or toe of the patient to cause the removal of blood from the nail bed and thus a whitening or blanching of the nail bed tissue. A control means is coupled to the actuator for controlling its actuation and deactuation and thus a whitening or blanching of the nail bed tissue. The control means is also coupled to the light detector for determining the amount of light received by the light detector. A timer is coupled to the control means for determining a time interval that is commenced with a deactuation of the actuator. The deactuation relieves pressure previously applied by the actuator to the portion of the patient&#39;s body and allows blood to return to the portion. The timing interval is terminated by a reduction in the amount of light received by the light detector as a result of the restoration of blood to the body portion. The time interval so determined comprises an indication of the capillary refill time of the patient. The device also includes a temperature detector for compensating the indication of capillary refill time in accordance with a skin temperature measurement proximate to the body portion of the patient used to determine capillary refill time. 
     An embodiment of the present invention also comprises a method for determining the capillary refill time of a patient utilizing apparatus that is also suitable for carrying out pulse oximetry. Light is applied to a selected portion of the patient&#39;s body, such as a nail bed of a patient&#39;s fingernail or toenail using a pulse oximetry light source. The selected portion is compressed by an actuator in the apparatus to cause removal of blood from the portion. Thereafter, the actuator is deactuated to allow restoration of blood to the portion. A timing interval is commenced upon deactuation of the actuator. The amount of light received by a light detector suitable for carrying out pulse oximetry is measured following deactuation of the actuator. The timing interval is terminated based on a reduction in the amount of light received by the light detector as a result of the restoration of blood to the selected body portion. The timing interval is an indication of the capillary refill time of the patient. The skin temperature of the patient proximate to the selected portion may be measured and the indication of capillary refill time altered based on the measured skin temperature. 
     The present invention will be further understood by reference to the following detailed description taken in conjunction with the drawing. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a perspective view of an embodiment of the device of the present invention. 
         FIG. 2  is a cross-sectional view of the device of  FIG. 1 . 
         FIG. 3  is a flow chart of the operation of the device. 
         FIG. 4  is a perspective view of another embodiment of the device of the present invention. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       FIG. 1  shows an embodiment of device  10  of the present invention for carrying out pulse oximetry and measuring capillary refill time of a patient. Device  10  is suitable for being placed on a selected portion of the body of the patient. As noted above, such portions include those in which blood can be removed from the tissue of the portion by the application of pressure. The selected portion is exemplarily shown as in  FIGS. 1 and 2  as finger  12 . When device  10  is in place, a portion of the device will be above fingernail  14  and a portion will be positioned at the end of the finger below the fingernail. Device  10  includes a first member  16  and a second member  18  joined by spring loaded hinge  20  urging the members into a condition of contiguity. A clinician opens members  16  and  18  to allow device  10  to be placed on finger  12  by squeezing extensions  22  and  24  of members  16  and  18 , respectively, and thereafter releasing the extensions to clamp device  10  on finger  12  so that the device embraces the finger of the patient. 
     As shown most clearly in  FIG. 2  first member  16  includes light sources  26 ,  28  suitable for use in pulse oximetry measurement. In a typical pulse oximeter, one of the light sources will generate light having a wavelength of about 660 nm and the other light source will generate light having a wavelength of about 930 nm. Light sources  26  and  28  shine light onto the tissue of patient&#39;s finger  12 . A blood oxygen saturation measurement may use either light transmitted through the patient&#39;s finger or light reflected from the patient&#39;s finger.  FIG. 2  shows an arrangement using transmitted light. For this purpose, light detector  30  is provided in second member  18  to receive light passing through finger  12 . 
     Light sources  26 ,  28  and light detector  30  are connected to a signal processing circuitry for detecting arterial blood oxygen saturation. It is typical to employ a microprocessor in a separate computer or monitor  34  connected to device  10  by cable  36  for this purpose. Cable  36  also provides power to light sources  26 ,  28  and obtains the signal from light detector  30  for provision to monitor  34 . 
     For obtaining an indication of capillary refill time, first member  16  includes actuator  38 , such as a solenoid having a wire coil or winding surrounding a magnetic slug or armature and forming a linear actuator. Energizing the winding with electric current causes extension of the armature out of the coil and member  16  in the manner shown in  FIG. 2 . Actuator  38  is mounted in member  16  so that it will be positioned over fingernail  14  of finger  12  when device  10  is affixed to the finger  12  of the patient. For controlling actuator  38 , it may be connected to microprocessor  40  in member  16  or, via cable  36  to a corresponding microprocessor in monitor  34 . The operation of the microprocessor is, in turn, controlled by an appropriate user interface, such as a keyboard  42  for monitor  34  or suitable switches on member  16  associated with microprocessor  40 . The winding of actuator  38  is connected to an appropriate source of electrical energization, such as via cable  36  from monitor  34 . 
     Member  16  also includes temperature sensor  44  for measuring the patient&#39;s skin temperature proximate to nail  14 . Temperature sensor  44  is connected to the microprocessor used with device  10 . 
     In the operation of device  10 , the measurement of arterial blood hemoglobin oxygen saturation (SpO 2 ) is carried out in a conventional manner using the amount and pulse characteristics of the light from light sources  26  and  28  received by light detector  30  and the signal processing circuitry in monitor  34 . 
     The measurement of capillary refill time is carried out in the following manner, as shown by the flow chart of  FIG. 3 , as controlled by/employing microprocessor  40  or the signal processing circuitry in monitor  34 . 
     Light sources  26  and  28  and light detector  30  are used to obtain a signal corresponding to the amount of light transmitted through the tissue of the selected patient body portion, such as the patient&#39;s finger and nail bed. See step  100  of  FIG. 3 . One or both of the light sources may be utilized. As noted above, the amount of transmitted light comprises that which is not absorbed by the blood in the tissue of the patient&#39;s finger or other body portion. A signal value corresponding to this measured amount is stored in an appropriate memory associated with microprocessor  40  or the signal processing circuitry of monitor  34 . This occurs in step  102  and the stored amount serves as a reference value for the capillary refill time measurement. 
     Pressure is then applied to the body portion by energizing actuator  38  in step  104 . The measurement amount of transmitted light continues in step  106 . The pressure applied by linear actuator  38  will force the blood out of the capillaries of the selected body portion. The removal of blood from the tissue will reduce the absorbance of light from light source(s)  26 / 28  by the tissue of the patient, causing the amount of light transmitted to light detector  30  to increase. When the amount of transmitted light received by light detector  30  has increased to a point where it shows little or no further increase, it is an indication that blood that has been forced from the selected body portion. This is carried out in step  108 . Actuator  38  is then de-energized at step  110  and a timer in microprocessor  40  or in the signal processing circuitry of monitor  34  started at step  112 . As blood circulation returns to the body portion of the patient, the amount of transmitted light from light source(s)  26 / 28  received by light detector  30  will decrease as more light is absorbed by the returning blood. The amount of transmitted light is measured in step  114 . A signal value corresponding to the transmitted light measured in step  114  is compared with the stored value obtained in step  102 . This is carried out in step  116  as in a comparator associated with microprocessor  40  or the signal processing circuitry of monitor  34 . When the light measured in step  114  compares well to the stored value obtained in step  102 , the timing interval is stopped at step  118 . While it is possible to use an exact comparison of the transmitted light measured in step  114  with the stored value, the nature of the restoration of blood circulation to a body portion such as the nail bed of nail  14  is of a nature that it is deemed more practical to terminate the timing interval in step  118  when the amount of transmitted light measured in step  114  approximates the stored value obtained in step  102  as by being within a quantitative range or percentage, such as when the amount of light measured in step  114  attains a value equaling 75% of the stored value obtained in step  102 . 
     The timing interval between timing initiation in step  112  and timing termination in step  118  comprises a raw indication of the capillary refill time of the patient. See step  120 . 
     The skin temperature of the patient proximate to the selected body portion such as nail  14  affects the capillary refill time in that as skin temperature increases, capillary refill time also tends to increase. For this reason, a skin temperature measurement is made at step  122  using temperature sensor  44  and the raw indication of capillary refill time corrected on the basis of the temperature measurement, in step  124 , to provide a final capillary refill time value. The final capillary refill time may be displayed and/or stored in step  126 . Display  46  on device  10  or the display of monitor  34  may be used to show the capillary refill time. 
     The capillary refill time value obtained in step  124  will typically comprise a digital value. The digital value is stored, as in microprocessor  40  or the signal processing circuitry of monitor  34 , in step  126 , to provide a record of the measurement and for comparison to previous values to allow trending, averaging, or other statistical analysis of capillary refill times in step  128  for use by the attending clinician. 
     The measurement of capillary refill times may be automatically initiated at periodic intervals under the control of microprocessor  40  or the signal processing circuitry of monitor  34 , as shown at step  130  of  FIG. 3 . The storage, manipulation, and automatic restart relieves the clinician of the need to manually store, statistically treat, and repeat capillary refill time measurements. 
     While  FIGS. 1 and 2  show a pulse oximeter probe that clamps on the selected body portion of the patient, other types of pulse oximetry probes are adhesively affixed to a portion of the patient, as shown in  FIG. 4 . Also, while the actuator and temperature sensing elements used to obtain the capillary refill time measurement have been described, above, as integral with a device also forming a pulse oximetry probe, actuator  38 , microprocessor  40 , and temperature sensor  44  may comprise an attachment to the portions of the device used for pulse oximetry, if desired. Still further, while the foregoing describes the device and method of the present invention as using transmitted light, they may, as noted above, instead use reflected light. 
     Various alternatives and embodiments are contemplated as being within the scope of the following claims particularly pointing out and distinctly claiming the subject matter regarded as the invention.