Prediction of Mortality in the Medical Intensive Care Unit with Serial Full Outline of Unresponsiveness Score in Elderly Patients
Jamileh Ramazani, Mohammad Hosseini
Elderly, Full outline of unresponsiveness score, Medical intensive care, Nonsurvivors, Survivors
Citation Information :
Ramazani J, Hosseini M. Prediction of Mortality in the Medical Intensive Care Unit with Serial Full Outline of Unresponsiveness Score in Elderly Patients. Indian J Crit Care Med 2022; 26 (1):94-99.
Background: Advanced age is one of the key risk factors for mortality and morbidity in intensive care units. The full outline of unresponsiveness (FOUR) score has been developed and introduced to address the limitations of the Glasgow Coma Scale (GCS). The current study aimed to evaluate the ability of the FOUR score in predicting the outcomes (survivors, nonsurvivors).
Materials and methods: This observational study of 168 consecutive elderly patients admitted to medical intensive care during the 14 months carried out prospectively. FOUR score in the 24, 48, and 72 hours of admission, and demographic characteristics of all elderly patients were calculated, then recorded. The receiver operating characteristic (ROC) curve, logistic regression, and Hosmer-Lemeshow test were used (95% confidence interval) for statistical analysis.
Results: FOUR scores in 24, 48, and 72 hours between survivors and nonsurvivors (p <0.0001, p <0.0001, and p <0.0001, respectively) were statistically different. The discrimination power of FOUR score 24 hours of admission was excellent [area under ROC (AUC): 85.7% [standard error (SE)]: 2.8%]; it was acceptable for 48 and 72 hours of admission [AUC: 76.3% (SE: 3.6%), AUC: 75/0% (SE: 3.8%), respectively]. The FOUR score of 24 and 48 hours (x2 = 10.06, p = 0.261, x2 = 6.82, p = 0.448, respectively) showed acceptable calibration.
Conclusions: The FOUR score is a suitable scoring system for prognostication of outcomes in critically ill elderly patients. The FOUR score 24 hours of admission was superior in terms of discrimination power than 48 and 72 hours, but better calibration power belonged to FOUR score 48 hours.
Murthy JM, Meena AK, Kumar SR. Severity-of-illness scoring systems and models: neurological and neurosurgical intensive care units. Neurol India 2001;Suppl. 1:S91–S94. PMID: 11889480.
Hosseini M, Ramazani J. Evaluation of acute physiology and chronic health evaluation II and sequential organ failure assessment scoring systems for prognostication of outcomes among intensive care unit's patients. Saudi J Anaesth 2016;10(2):168–173. DOI: 10.4103/1658-354X.168817.
Ramazani J, Hosseini M. Comparison of the predictive ability of the pediatric risk of mortality III, pediatric index of Mortality3, and pediatric logistic organ dysfunction-2 in medical and surgical intensive care units. J Comprehensive Pediatrics 2019;10(2):e82830. DOI: 10.5812/compreped.82830.
Sikka P, Jaafar WM, Bozkanat E, El-Solh AA. A comparison of severity of illness scoring systems for elderly patients with severe pneumonia. Intensive Care Med 2000;26(12):1803–1810. DOI: 10.1007/s001340000719.
Cohen J. Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population. J Neurosci Nurs 2009;41(5): 261–267; quiz 268–269. DOI: 10.1097/jnn.0b013e3181b2c766.
Chen B, Grothe C, Schaller K. Validation of a new neurological score (FOUR Score) in the assessment of neurosurgical patients with severely impaired consciousness. Acta Neurochir (Wien) 2013;155(11):2133–2139; discussion 9. DOI: 10.1007/s00701-013-1854-2.
Marcati E, Ricci S, Casalena A, Toni D, Carolei A, Sacco S. Validation of the Italian version of a new coma scale: the FOUR score. Intern Emerg Med 2012;7(2):145–152. DOI: 10.1007/s11739-011-0583-x.
Ramazani J, Hosseini M. Comparison of Glasgow Coma Scale and GCS-Age Prognosis Score in Older Adult Patients/Yasli Hastalarda Glasgow Koma Skalasi ve GCS-Yas Prognoz Skorunun Karsilastirilmasi. J Dahili ve Cerrahi Bilimler Yoğun Bakım Dergisi 2018;10(2):35–41. DOI: 10.33381/dcbybd.2019.2068.
Peng J, Deng Y, Chen F, Zhang X, Wang X, Zhou Y, et al. Validation of the Chinese version of the FOUR score in the assessment of neurosurgical patients with different level of consciousness. BMC Neurol 2015;15:254. DOI: 10.1186/s12883-015-0508-9.
Zeiler FA, Lo BWY, Akoth E, Silvaggio J, Kaufmann AM, Teitelbaum J, et al. Predicting outcome in Subarachnoid Hemorrhage (SAH) utilizing the Full Outline of UnResponsiveness (FOUR) score. Neurocrit Care 2017;27(3):381–391. DOI: 10.1007/s12028-017-0396-5.
Ramazani J, Hosseini M. Prediction of ICU mortality in critically ill children: comparison of SOFA, GCS, and FOUR score. Med Klin Intensivmed Notfmed 2019;114(8):717–723. DOI: 10.1007/s00063-018-0484-0.
Saika A, Bansal S, Philip M, Devi BI, Shukla DP. Prognostic value of FOUR and GCS scores in determining mortality in patients with traumatic brain injury. Acta Neurochir 2015;157(8):1323–1328. DOI: 10.1007/s00701-015-2469-6.
Ramazani J, Hosseini M. Comparison of full outline of unresponsiveness score and Glasgow Coma Scale in Medical Intensive Care Unit. Ann Card Anaesth 2019;22(2):143–148. DOI: 10.4103/aca.ACA_25_18.
Kasprowicz M, Burzynska M, Melcer T, Kübler A. A comparison of the Full Outline of UnResponsiveness (FOUR) score and Glasgow Coma Score (GCS) in predictive modelling in traumatic brain injury. Br J Neurosurg 2016;30(2):211–220. DOI: 10.3109/02688697. 2016.1161173.
Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 2009;84(8):694–701. DOI: 10.1016/S0025-6196(11)60519-3.
Okasha AS, Fayed AM, Saleh AS. The FOUR score predicts mortality, endotracheal intubation and ICU length of stay after traumatic brain injury. Neurocrit Care 2014;21(3):496–504. DOI: 10.1007/s12028-014-9995-6.
Akavipat P. Endorsement of the FOUR score for consciousness assessment in neurosurgical patients. Neurol Med Chir (Tokyo) 2009;49(12):565–571. DOI: 10.2176/nmc.49.565.
Nyam TTE, Ao KH, Hung SY, Shen ML, Yu TC, Kuo JR. FOUR score predicts early outcome in patients after traumatic brain injury. Neurocrit Care 2017;26(2):225–231. DOI: 10.1007/s12028-016-0326-y.
Said T, Chaari A, Hakim K, Hamama D, Casey W. Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: a pilot study. Int J Crit Illn Inj Sci 2016;6(4):172–177. DOI: 10.4103/2229-5151.195401.
Khanal K, Bhandari SS, Shrestha N, Acharya SP, Marhatta MN. Comparison of outcome predictions by the Glasgow coma scale and the Full Outline of UnResponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit. Indian J Crit Care Med 2016;20(8):473–476. DOI: 10.4103/0972-5229.188199.
Metz CE. Basic principles of ROC analysis. Semin Nucl Med 1978;8(4):283–298. DOI: 10.1016/s0001-2998(78)80014-2.
Hosseini M, Ramazani J. Comparison of acute physiology and chronic health evaluation II and Glasgow Coma Score in predicting the outcomes of Post Anesthesia Care Unit's patients. Saudi J Anaesth 2015;9(2):136–141. DOI: 10.4103/1658-354X.152839.
Akavipat P, Sookplung P, Kaewsingha P, Maunsaiyat P. Prediction of discharge outcome with the full outline of unresponsiveness (FOUR) score in neurosurgical patients. Acta Med Okayama 2011;65(3):205–210. DOI: 10.18926/AMO/46633.
Fugate JE, Rabinstein AA, Claassen DO, White RD, Wijdicks EF. The FOUR score predicts outcome in patients after cardiac arrest. Neurocrit Care 2010;13(2):205–210. DOI: 10.1007/s12028-010-9407-5.
Weiss N, Venot M, Verdonk F, Chardon A, Le Guennec L, Llerena MC, et al. Daily FOUR score assessment provides accurate prognosis of long-term outcome in out-of-hospital cardiac arrest. Rev Neurol (Paris) 2015;171(5):437–444. DOI: 10.1016/j.neurol.2015.02.013.
Kocak Y, Ozturk S, Ege F, Ekmekci H. A useful new coma scale in acute stroke patients: FOUR score. Anaesth Intensive Care 2012;40(1):131–136. DOI: 10.1177/0310057X1204000115.
McNett M, Amato S, Gianakis A, Grimm D, Philippbar SA, Belle J, et al. The FOUR score and GCS as predictors of outcome after traumatic brain injury. Neurocrit Care 2014;21(1):52–57. DOI: 10.1007/s12028-013-9947-6.
Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care 2012;16(1):95–101. DOI: 10.1007/s12028-011-9617-5.
Cheng K, Bassil R, Carandang R, Hall W, Muehlschlegel S. The estimated verbal GCS subscore in intubated traumatic brain injury patients: is it really better? J Neurotrauma 2017;34(8):1603–1609. DOI: 10.1089/neu.2016.4657.
Cerro L, Valencia J, Calle P, Leon A, Jaimes F. [Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units]. Rev Esp Anestesiol Reanim 2014;61(3):125–132. DOI: 10.1016/j.redar.2013.11.014.