Clinical Examination for the Prediction of Mortality in the Critically Ill: The Simple Intensive Care Studies-I.
Crit Care Med. 2019 Jul 25;:
Authors: Hiemstra B, Eck RJ, Wiersema R, Kaufmann T, Koster G, Scheeren TWL, Snieder H, Perner A, Pettilä V, Wetterslev J, Keus F, van der Horst ICC, SICS Study Group
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: 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 (AUC). Robustness of our findings was tested by internal bootstrap validation and adjustment of the threshold for statistical significance.
MAIN RESULTS: 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 (AUC = 0.74; 95% CI, 0.71-0.78). Clinical examination had a similar discriminative value as compared with the Simplified Acute Physiology Score-II (SAPS-II) (AUC = 0.76; 95% CI, 0.73-0.79; p = 0.29) and Acute Physiology and Chronic Health Evaluation-IV (APACHE-IV) (AUC = 0.77; 95% CI, 0.74-0.80; p = 0.16) and was significantly better than the Sequential Organ Failure Assessment (SOFA) (AUC = 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 SAPS-II and APACHE-IV and outperformed the SOFA score.
PMID: 31356472 [PubMed - as supplied by publisher]