Clinical examination for diagnosing circulatory shock: The Simple Intensive Care Studies-I

INTRODUCTION. The latest consensus on circulatory shock advocates clinical examination and ultrasonography for diagnosing circulatory shock. Propagation of daily clinical examination contrasts with available studies, which are of limited quality and quantity so that its level of evidence is considered 'best practice'. We hypothesize that clinical estimation of circulatory shock, should be based on multiple variables including combinations of clinical, laboratory and ultrasonography variables. OBJECTIVES. To evaluate the value of clinical examination, biochemical and ultrasonography variables in the critically ill, specifically for estimation which combinations of variables are associated with cardiac output. METHODS. We initiated the Simple Intensive Care Studies-I (SICS-I) which was designed as a prospective cohort study to include all patients acutely admitted to the intensive care unit. Clinical examination was performed in a standardized fashion in all patients according to predefined criteria including variables of heart rate, blood pressures, central venous pressure, mental state, auscultation of heart and lungs, respiratory rate, urine output, capillary refill times, central to peripheral temperatures gradients, skin mottling; biochemical variables including lactate; and ultrasonography of heart and lungs. These clinical, biochemical, and ultrasonography variables were recorded following a published protocol (NCT02912624). Circulatory shock was defined by the requirement of vasopressors and/or inotropes and measured by cardiac output using transthoracic ultrasonography. All researchers, including medical students, underwent focused training for recording of all variables, including obtaining specific ultrasonography images. Cardiac function was clinically estimated as well before being measured by ultrasonography. RESULTS. Between March 2015 and December 2016 a total of 704 out of 791 eligible patients were included. An independent Core laboratory assessed that ultrasonography images from 632 patients (90%) were of sufficient quality. Vasopressors and/or inotropes were used upon admission in 363 cases (52%). 173 patients (25%) had died at 90-day follow-up. The data of all patients included until July 1st, 2017 will be analysed to identify combinations of variables independently associated with cardiac output. At the congress, these results will be presented and these variables will inform the second phase of the on-going registry. CONCLUSIONS. Standardized clinical examination and ultrasonography in critically ill patients by novices is feasible. We will be able to answer whether clinical assessment of the presence of shock can reliably be established and if so, which combinations of variables are most informative for estimation of the patients' cardiac output.