Knee Mottling

Score
Marisa Yoder MSN, RN
Sepsis Champion
St. Lukes Meridian ICU
Surviving Sepsis Guidelines Updates
2021
 “For adults with septic shock, we suggest using capillary refill time to guide resuscitation
as an adjunct to other measures of perfusion”.
 “For adults with septic shock on norepinephrine with inadequate mean arterial pressure
levels, we suggest adding vasopressin instead of escalating the dose of norepinephrine”.
 ”For adults with septic shock, we suggest invasive monitoring of arterial blood pressure
over noninvasive monitoring, as soon as practical and if resources are available”.
 ”For adults with septic shock, we suggest starting vasopressors peripherally to restore
mean arterial pressure rather than delaying initiation until central venous access is
secured”.
 “For adults with sepsis-induced hypoxemic respiratory failure, we suggest the use of
high-flow nasal oxygen over noninvasive ventilation”.
 “For adults with sepsis or septic shock, we suggest against using IV vitamin C”.
 “For adults with sepsis or septic shock, we recommend that the principles of palliative
care (which may include palliative care consultation based on clinician judgement) be
integrated into the treatment plan, when appropriate, to address patient and family
symptoms and suffering”.
  Skin mottling is defined as a patchy
skin discoloration.
 Mottling reflects a reduction in skin
blood flow.
 It is a sign of cutaneous hypoperfusion
What Causes that typically manifests around the
knees.
Mottling in  Recent studies revealed a significant
relationship between mottling
Sepsis? extension and visceral organ vascular
tone.
 Therefore, mottling may reflect
intestinal organ perfusion. (Storz &
Seidlitz, 2020).
Knee Mottling Score

The knee mottling score is

estimated from 0-5
Subjective assessment
according to mottling over
technique to evaluate
the knee and described as
tissues perfusion at the
a clinical evaluation of
bedside.
tissue perfusion (Ferraris et
al., 2020).
Assessment Technique
Skin Microcirculatory
Perfusion
 Peripheral perfusion and
oxygenation can be assessed in
the skin for patients with septic
shock.
 Thermography or Laser Doppler
Mapping evaluation methods.
 Changes in microcirculatory
perfusion can indicated relative
hemoglobin concentration in
conjunction with the mottling
score.
Infrared
Thermography
 Mottling score from 0 to 4 (from
left to right)
 Non-invasive technique to assess
surface skin temperature.
 An approach to determining
circulator abnormalities.
Why The Knee Mottling
Score? Why Do We Care?
 Post sepsis survivability odds increased with
lower knee mottling scores when compared
to QSOFA scores in the first 28 days after
surviving sepsis (Kazune et al., 2019).
 Advancing assessment technique, noticing
changes faster.
 You know your patient is septic, now what?
 Mortality related to sepsis increased the
further along patients are in the stages of
sepsis.
Knee Mottling Score Contraindications
 Antiphospholipid Syndrome
 Lupus
 Autoimmune disease that directly
 Chronic autoimmune disease that
impacts the blood vessels.
causes systemic inflammation.
 Knee or wrist skin mottling is one
 Butterfly rash of the symptoms.
Summary
 The stages of knee mottling can indicate how
severely compromised the microcirculatory
system is.
 Use the stages of knee mottling as an additional
assessment
 Recognizing clinical indications of organ
perfusion compromise.
 Subjective assessment technique that should be
used when appropriate.
 The goal is to recognizing progressing sepsis
sooner.