Clinical examination for diagnosing circulatory shock

Hiemstra, Bart; Eck, Ruben J.; Keus, Frederik; Horst, Iwan C. C. van der

doi:10.1097/mcc.0000000000000420

Cited by 47 publications

(34 citation statements)

References 71 publications

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“…Clinical examination for diagnosing shock is fast, easy to conduct and low in cost, yet its diagnostic accuracy is questioned [3][4][5]. Particularly, physicians seem insufficiently capable of diagnosing a low cardiac index purely based on their clinical examination [6][7][8][9]. Previous studies scarcely specified their methods of clinical examination in terms of variables collected and definitions employed, leaving variability at the physician's discretion and making these studies difficult to reproduce [7,[9][10][11][12][13][14][15].…”

Section: Introductionmentioning

confidence: 99%

The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I

et al. 2019

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Purpose: Clinical examination is often the first step to diagnose shock and estimate cardiac index. In the Simple Intensive Care Studies-I, we assessed the association and diagnostic performance of clinical signs for estimation of cardiac index in critically ill patients. Methods: In this prospective, single-centre cohort study, we included all acutely ill patients admitted to the ICU and expected to stay > 24 h. We conducted a protocolised clinical examination of 19 clinical signs followed by critical care ultrasonography for cardiac index measurement. Clinical signs were associated with cardiac index and a low cardiac index (< 2.2 L min −1 m 2) in multivariable analyses. Diagnostic test accuracies were also assessed. Results: We included 1075 patients, of whom 783 (73%) had a validated cardiac index measurement. In multivariable regression, respiratory rate, heart rate and rhythm, systolic and diastolic blood pressure, central-to-peripheral temperature difference, and capillary refill time were statistically independently associated with cardiac index, with an overall R 2 of 0.30 (98.5% CI 0.25-0.35). A low cardiac index was observed in 280 (36%) patients. Sensitivities and positive and negative predictive values were below 90% for all signs. Specificities above 90% were observed only for 110/280 patients, who had atrial fibrillation, systolic blood pressures < 90 mmHg, altered consciousness, capillary refill times > 4.5 s, or skin mottling over the knee. Conclusions: Seven out of 19 clinical examination findings were independently associated with cardiac index. For estimation of cardiac index, clinical examination was found to be insufficient in multivariable analyses and in diagnostic accuracy tests. Additional measurements such as critical care ultrasonography remain necessary.

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Section: Introductionmentioning

confidence: 99%

The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I

et al. 2019

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“…Interestingly, the de nition of "delay" was depend on the length of exposure to severe sepsis in Han's study, while the actual onset time of severe sepsis is unknown truthfully, which might occurred outside the ICU, moreover, the etiologies for patients with unstable hemodynamics were not always explicit [23,24]. Although it's possible that patients would have received timely resuscitation regardless of the etiologies and whether the lactate level was measured or not, identifying patients could delay the lactate measurement and interventions.…”

Section: Discussionmentioning

confidence: 93%

Effect of Timely Lactate Measurement on In-hospital Mortality among Adults with Hypotension and Hyperlactatemia: An Observational Study on Two Cohorts

Chen

Bao

et al. 2020

Preprint

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Background: Whether patients presented with hypotension and hyperlactatemia can benefit from timely lactate measurement and further lactate-guide resuscitation were not fully understood.Methods: This was a retrospective observational study based on the data from the Medical Information Mart for Intensive Care (MIMIC)-III Database and the eICU Collaborative Research Database (eICU). Patients with hypotension (defined as a minimal systolic blood pressure ≤90 mm Hg or minimal mean arterial pressure ≤65 mm Hg or requiring any vasopressors support during the first 24 h after ICU admission) and hyperlactatemia (defined as an initial lactate level > 2.0 mmol/L after ICU admission) were eligible.The primary exposure was the timely lactate measurement, which was defined as an initial lactate level measured within 1 h after ICU admission. The primary outcome was in-hospital mortality. The statistical approaches included multivariate regression, propensity score matching (PSM) and an inverse probability of treatment weighing (IPTW) and causal mediation analysis (CMA) were utilized to elucidate the relationship between timely lactate measurement and in-hospital mortality. Results: A total of 9978 patients were identified, of which 4257 in MIMIC-III and 5721 in eICU. Timely lactate measurement was associated with lower risk-adjusted in-hospital mortality both in MIMIC (OR 0.70 (95%CI 0.58-0.85; p<0.001)) and eICU (OR 0.75 (95%CI 0.64-0.88; p<0.001)). Time to initial intravenous fluid (IVF) in MIMIC mediated 6.7% (95%CI 1.4%-38%; p<0.001) of the beneficial effect of timely lactate measurement (p<0.001 for average causal mediation effect (ACME)) in terms of in-hospital mortality. Finally, delayed initial lactate measurements are also associated an increased in-hospital mortality in MIMIC and eICU.Conclusions: Timely lactate measurement is associated with a lower risk-adjusted in-hospital mortality among patients with hypotension and hyperlactatemia, which was proportional mediated through shortening the time to IVF. Delay in initial lactate measurement showed a positive association with in-hospital mortality.

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“…mottled, cold and clammy vs. flushed skin, capillary refill) [1]. A systematic review [5] showed that estimation of the CO using three clinical signs including capillary refill time, mottling and skin temperature had a sensitivity of 12% and a specificity of 98%, suggesting a good performance to rule in the presence of low flow states [6]. The information from this clinical assessment often will guide the targeted expansion of the diagnostic workup.…”

Section: Clinical History and Physical Examinationmentioning

confidence: 99%

The crashing patient: hemodynamic collapse

Gidwani

Gómez²

2017

Current Opinion in Critical Care

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Purpose of review Rapid restoration of tissue perfusion and oxygenation are the main goals in the resuscitation of a patient with circulatory collapse. This review will focus on providing an evidence based framework of the technological and conceptual advances in the evaluation and management of the patient with cardiovascular collapse. Recent findings The initial approach to the patient in cardiovascular collapse continues to be based on the Ventilate–Infuse–Pump rule. Point of care ultrasound is the preferred modality for the initial evaluation of undifferentiated shock, providing information to narrow the differential diagnosis, to assess fluid responsiveness and to evaluate the response to therapy. After the initial phase of resuscitative fluid administration, which focuses on re-establishing a mean arterial pressure to 65mmHg, the use of dynamic parameters to assess preload responsiveness such as the passive leg raise test, stroke volume variation, pulse pressure variation and collapsibility of the inferior vena cava in mechanically ventilated patients is recommended. Summary The crashing patient remains a clinical challenge. Using an integrated approach with bedside ultrasound, dynamic parameters for the evaluation of fluid responsiveness and surrogates of evaluation of tissue perfusion have made the assessment of the patient in shock faster, safer and more physiologic.

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Clinical examination for diagnosing circulatory shock

Abstract: Supplemental Digital Content is available in the text

Cited by 47 publications

References 71 publications

The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I

The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I

Effect of Timely Lactate Measurement on In-hospital Mortality among Adults with Hypotension and Hyperlactatemia: An Observational Study on Two Cohorts

The crashing patient: hemodynamic collapse

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