The Predictive Validity of the Full Outline of UnResponsiveness Score Compared to the Glasgow Coma Scale in the ICU: A Systematic Review
Javier Amador-Casta?eda, BHS, RRT, FCCM
| Respiratory Care Practitioner | Author | Speaker | Veteran | ESICM Representative, North America
Schey, J.E., Schoch, M. & Kerr, D. The Predictive Validity of the Full Outline of UnResponsiveness Score Compared to the Glasgow Coma Scale in the Intensive Care Unit: A Systematic Review. Neurocrit Care (2024). https://doi.org/10.1007/s12028-024-02150-8
Summary of "The Predictive Validity of the Full Outline of UnResponsiveness Score Compared to the Glasgow Coma Scale in the Intensive Care Unit: A Systematic Review"
Summary:
This systematic review evaluates the predictive validity of the Full Outline of UnResponsiveness (FOUR) score compared to the Glasgow Coma Scale (GCS) for ICU patients. Analyzing 20 observational studies, the review identifies the strengths and limitations of each scale in predicting mortality and functional outcomes. It highlights the FOUR score’s superior responsiveness and predictive performance, especially in intubated and sedated patients, compared to the GCS.
Key Points:
1. FOUR vs. GCS Components: The FOUR score incorporates assessments of brainstem reflexes and respiratory patterns, unlike the GCS, making it more applicable in sedated and intubated patients.
2. Mortality Prediction: The FOUR score achieved higher area under the receiver operating characteristic curve (AUROC) values than the GCS in most studies for hospital and ICU mortality.
3. Functional Outcomes: Both scores showed comparable accuracy in predicting poor functional outcomes, but the FOUR score provided slightly better specificity.
4. Sample Limitations: Studies predominantly included patients with neurological illnesses, with limited inclusion of sedated or non-neurological ICU populations.
5. Responsiveness of FOUR: The FOUR score is more responsive than the GCS, detecting subtle neurological changes in comatose patients with low GCS scores.
6. Clinical Practice Implications: The FOUR score may offer better utility in ICU mortality prediction models, supporting critical care decision-making and organ donation assessment.
7. Limitations of GCS: The GCS’s verbal component is unusable in intubated patients, limiting its accuracy and applicability in critical care settings.
8. Research Gaps: Further studies are needed to validate findings across diverse ICU populations, including those with non-neurological illnesses and sedation.
9. Prediction of Extubation Failure: One study demonstrated the FOUR score’s superior accuracy in predicting extubation failure at 14 days compared to the GCS.
10. Broader Adoption: The findings suggest the FOUR score could replace or complement the GCS in ICU settings, though its complexity may require additional training.
Conclusion:
The FOUR score shows superior predictive validity for ICU mortality and responsiveness in low-consciousness states compared to the GCS. Its integration into ICU practice could improve patient assessment and outcome predictions. However, further research in varied populations is required to establish its generalizability.
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Discussion Questions:
1. What are the barriers to implementing the FOUR score as a standard assessment tool in ICUs, and how can they be addressed?
2. How can ICU protocols integrate the FOUR score to improve predictions of extubation outcomes and organ donation potential?
3. What strategies could enhance training for ICU staff to effectively use the FOUR score in clinical practice?
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