Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: A pilot study

Abstract

Objective:To assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill intubated patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS).Patients and Methods:All intubated critically ill patients with a disturbed level of consciousness were assessed using both the FOUR score and the GCS. The FOUR score and the GCS were compared regarding their predictive value for successful extubation at 14 days after intubation as a primary outcome measure. The 28-day mortality and the neurological outcome at 3 months were used as secondary outcome measures.Results:Eighty-six patients were included in the study. Median age was 63 (50–77) years. Sex–ratio (M/F) was 1.46. On admission, median GCS was 7 (3–10) while median FOUR score was 8.5 (2.3–11). A GCS ≤ 7 predicted the extubation failure at 14 days after intubation with a sensitivity of 88.5% and specificity of 68.3%, whereas a FOUR score <10 predicted the same outcome with a sensitivity of 80.8% and a specificity of 81.7%. The areas under the curves was significantly higher with the FOUR score than with GCS (respectively 0.867 confidence interval [CI]: 95% [0790–0.944] and 0.832 CI: 95% [0.741–0.923]; P = 0.014). When calculated before extubation, FOUR score <12 predicted extubation failure with a sensitivity of 92.3% and a specificity of 85%, whereas a GCS <12 predicted the same outcome with a sensitivity of 73% and a specificity of 61.7%. Both scores had similar accuracy for predicting 28-day mortality and neurological outcome at 3 months.Conclusion:The FOUR score is superior to the GCS for the prediction of successful extubation of intubated critically ill patients.

The Relationship of the FOUR Score to Patient Outcome: A Systematic Review

“…For longer-term mortality (beyond 2 weeks), FOUR score was determined to be mostly fair or good (AUC value, 0.70–0.89), as shown in eight studies, 14,25,26,30,31,34,44,50,52 two of which have low risk of bias 14,34 (Fig. 3).…”

“…In six studies, <50% of patients had an impairment of consciousness attributable to a neurological cause. 15,30–34 Fourteen reports included solely patients with TBI. 16,17,39–42,19,25–27,35–38 Twenty other studies included patients with non-traumatic neurological causes of impairment of consciousness, including brain tumor, intracranial aneurysm, stroke, encephalopathy, seizure, pneumocephalus, and hydrocephalus.…”

“…7,14,31,34,43–50,15,51,52,20–23,28–30 Three studies excluded patients who were intubated, 14,38,45 whereas 12 studies included mostly (>50% of study population) intubated patients. 19,25,48,51,30,32,34,35,40,41,43,44…”

“…Of these studies, 25 described in-hospital mortality 7,14,23,24,29,33,35,36,38–41,15,42,45–47,49,16–22 as the end point, 5 investigated mortality only up to 2 weeks post-event, 25,26,28,37,38 and 11 studies explored longer-term mortality up to 3–6 months. 14,25,52,26,30–32,34,42,44,45 The mortality rate between included studies varied widely—from 7.8% 36 to 70% 28 —among studies where FOUR score was assessed within 24 h of admission. Studies using later time points of FOUR score assessment reported mortality within the above range (Supplementary Table S3).…”

Comparison of Glasgow Coma Scale and GCS-Age Prognosis Score in Older Adult Patients

“…There are several studies, noted that the calibration for GCS or other scoring systems is varying in different studies (24,25). These discrepancies and different sensitivity and specificity values in some studies (9,16,27) can be illuminated by the fact, when predictive models are used in a population different from the population for which it was first validated, they will not have the precision (13). Recalibrating these models frequently can be helpful to overcome these problems with considering the changes in population, quality of care and critical care management.…”