Clinical Examination for the Prediction of Mortality in the Critically Ill

The Simple Intensive Care Studies-I

Bart Hiemstra, MD; Ruben J. Eck, MD; Renske Wiersema, BSc; Thomas Kaufmann, MD; Geert Koster, MD; Thomas W.L. Scheeren, MD, PhD; Harold Snieder, PhD; Anders Perner, MD, PhD; Ville Pettilä, MD, PhD; Jørn Wetterslev, MD, PhD; Frederik Keus, MD, PhD; Iwan C.C. van der Horst, MD, PhD; SICS Study Group

Disclosures

Crit Care Med. 2019;47(10):1301-1309. 

In This Article

Abstract and Introduction

Abstract

Objectives: Caregivers use clinical examination to timely recognize deterioration of a patient, yet data on the prognostic value of clinical examination are inconsistent. In the Simple Intensive Care Studies-I, we evaluated the association of clinical examination findings with 90-day mortality in critically ill patients.

Design: Prospective single-center cohort study.

Setting: ICU of a single tertiary care level hospital between March 27, 2015, and July 22, 2017.

Patients: All consecutive adults acutely admitted to the ICU and expected to stay for at least 24 hours.

Interventions: A protocolized clinical examination of 19 clinical signs conducted within 24 hours of admission.

Measurements Main Results: Independent predictors of 90-day mortality were identified using multivariable logistic regression analyses. Model performance was compared with established prognostic risk scores using area under the receiver operating characteristic curves. Robustness of our findings was tested by internal bootstrap validation and adjustment of the threshold for statistical significance. A total of 1,075 patients were included, of whom 298 patients (28%) had died at 90-day follow-up. Multivariable analyses adjusted for age and norepinephrine infusion rate demonstrated that the combination of higher respiratory rate, higher systolic blood pressure, lower central temperature, altered consciousness, and decreased urine output was independently associated with 90-day mortality (area under the receiver operating characteristic curves = 0.74; 95% CI, 0.71–0.78). Clinical examination had a similar discriminative value as compared with the Simplified Acute Physiology Score-II (area under the receiver operating characteristic curves = 0.76; 95% CI, 0.73–0.79; p = 0.29) and Acute Physiology and Chronic Health Evaluation-IV (using area under the receiver operating characteristic curves = 0.77; 95% CI, 0.74–0.80; p = 0.16) and was significantly better than the Sequential Organ Failure Assessment (using area under the receiver operating characteristic curves = 0.67; 95% CI, 0.64–0.71; p < 0.001).

Conclusions: Clinical examination has reasonable discriminative value for assessing 90-day mortality in acutely admitted ICU patients. In our study population, a single, protocolized clinical examination had similar prognostic abilities compared with the Simplified Acute Physiology Score-II and Acute Physiology and Chronic Health Evaluation-IV and outperformed the Sequential Organ Failure Assessment score.

Introduction

Patients acutely admitted to the ICU have a high mortality, and survivors may suffer from long-term morbidity and reduced quality of life.[1,2] These critically ill patients frequently present with clinical signs of circulatory shock such as low blood pressure, oliguria, and skin mottling. These signs often guide treatment, assuming that they indicate vital organ hypoperfusion and are associated with increased mortality.[3–7] Indeed, guidelines on the management of shock recommend treating patients based on clinical examination, supplemented with critical care ultrasonography (CCUS).[8]

Data on the prognostic value of clinical examination findings are inconsistent. Previous studies have identified different predictors of mortality such as low blood pressure,[6,9,10] oliguria,[3,5] prolonged capillary refill time (CRT),[11,12] and skin mottling.[4,13] They often evaluated one or two clinical signs in isolation, instead of assessing a combination of signs and symptoms, which would more accurately reflect daily clinical practice. Furthermore, most studies had relatively small sample sizes or included a selected subgroup such as patients with sepsis, cardiogenic shock, and severe trauma (eTable 1, Supplemental Digital Content 2, http://links.lww.com/CCM/E746).

The prognostic value of clinical examination remains to be established in a large, consecutive cohort of critically ill patients. Compared with well-established prognostic scores, which are complex to calculate and unsuited for individual patient prognostication,[14,15] a simple bedside clinical examination might better inform caregivers in their decision making. Accordingly, our aim was to evaluate which clinical examination findings were independently associated with 90-day mortality in acutely admitted ICU patients. In addition, we hypothesized that combined clinical examination findings would have similar prognostic value compared with existing prognostic scores.

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