GLASGOW COMA SCALE SCORE IN THE EVALUATION OF OUTCOME IN THE INTENSIVE-CARE UNIT - FINDINGS FROM THE ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION-III STUDY
GLASGOW COMA SCALE SCORE IN THE EVALUATION OF OUTCOME IN THE INTENSIVE-CARE UNIT - FINDINGS FROM THE ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION-III STUDY
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DOI：
10.1097/00003246-199310000-00012
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发表时间：
1993-10-01
影响因子：
8.8
通讯作者：
KNAUS, WA
中科院分区：
文献类型：
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作者：
BASTOS, PG;SUN, XL;KNAUS, WA
目的：探讨格拉斯哥昏迷评分（Glasgow Coma Scale score）对无创伤的成人内科 - 外科重症监护病房（ICU）患者医院死亡率的预测能力。
设计：对来自美国40家具有全国代表性医院的成人内科 - 外科患者进行前瞻性队列分析。
患者：15973例连续的非创伤性ICU入院患者以及687例头部创伤入院患者作为对照组。
干预措施：无。
测量与主要结果：记录患者的性别、年龄、入住ICU前的治疗地点、合并症、入院诊断、每日生理指标测量值、格拉斯哥昏迷评分、急性生理与慢性健康评估（APACHE III™）评分、后续医院死亡率以及特定病房的镇静措施。按所有入院患者入住ICU第一天的格拉斯哥昏迷评分对医院死亡率进行分层。还研究了两种高死亡率内科疾病诊断（心脏骤停后和败血症）的格拉斯哥昏迷评分与预后的关系，并与头部创伤患者的关系进行了比较。
入住ICU时的格拉斯哥昏迷评分与无创伤的ICU患者的后续预后呈极显著（r² = 0.922，p < 0.0001）但非线性的关系。对患者进行高风险或低风险预后分组的区分效果良好，但在中间水平（格拉斯哥昏迷评分为7 - 11分）的区分能力下降。这种关系在手术组和非手术组内不同，在不同疾病类别、不同年龄组以及格拉斯哥昏迷评分的某些范围内也不同。与败血症相关的初始格拉斯哥昏迷评分降低是多种因素共同作用的结果，其死亡率高于头部创伤患者。因镇静/麻痹而无法确定格拉斯哥昏迷评分的患者比例在不同ICU之间差异很大。通过纳入格拉斯哥昏迷评分，APACHE III预后评分系统的整体预测能力得到提高。
结论：我们证明了入住ICU时通过格拉斯哥昏迷评分测量的意识水平对ICU和医院死亡率具有预后重要性。我们得出结论，格拉斯哥昏迷评分可用于对普通重症监护患者进行分层和预测死亡风险，但应注意在格拉斯哥昏迷评分的中间范围缺乏敏感性。理想情况下，格拉斯哥昏迷评分还应结合其他生理信息以及患者的具体诊断来应用。不同ICU使用镇静剂的差异意味着，对于无法获得的格拉斯哥昏迷评分，用正常值以外的值进行估算或替代可能会在后续的预后预测中引入较大的治疗偏差。
Objective: To investigate the ability of the Glasgow Coma Scale score to predict hospital mortality rate for adult medical-surgical intensive care unit (ICU) patients without trauma.Design: A prospective cohort analysis of adult medical-surgical patients from a nationally representative sample of 40 U.S. hospitals.Patients: 15,973 consecutive, nontraumatic ICU admissions and a comparison group of 687 head trauma admissions.Interventions: None.Measurements and Main Results: Patients' gender, age, treatment location before ICU admission, comorbidities, admission diagnosis, daily physiologic measurements, Glasgow Coma Scale score, Acute Physiology and Chronic Health Evaluation (APACHE III(TM)) score, subsequent hospital mortality rate, and unit-specific sedation practices were noted. Hospital mortality rates were stratified by the first ICU day Glasgow Coma Scale score for all admissions. The relationship between the Glasgow Coma Scale score and outcome for two high mortality medical diagnoses (post-cardiac arrest and sepsis) were also examined and compared to the relationship found in patients with head trauma.The Glasgow Coma Scale score on ICU admission had a highly significant (r2=.922, p < .0001) but nonlinear relationship with subsequent outcome in ICU patients without trauma. Discrimination of patients into high- or low-risk prognostic groups was good, but discrimination in the intermediate levels (Glasgow Coma Scale score of 7 to 11) was reduced. This relationship varied within the operative and nonoperative groups, and also within different disease categories, various age groups, and certain ranges of the Glasgow Coma Scale score. A reduced initial Glasgow Coma Scale score associated with sepsis was a combination of factors associated with a higher mortality rate than that found in patients with head trauma. The proportion of patients who could not be assigned a Glasgow Coma Scale score because of sedation/paralysis varied widely across ICUs. The overall predictive capability of the APACHE III Prognostic Scoring System was improved by incorporating the Glasgow Coma Scale score.Conclusions: We demonstrated the prognostic importance of admission levels of consciousness as measured by the Glasgow Coma Scale score on ICU and hospital mortality rates. We concluded that the Glasgow Coma Scale score may be used to stratify and predict mortality risk in general intensive care patients, but lack of sensitivity in the intermediate range of Glasgow Coma Scale Score should be noted. Ideally, the Glasgow Coma Scale score should also be applied in the context of other physiologic information and the patient's specific diagnosis. Variation in the use of sedatives in different ICUs means that imputing or substituting a value other than normal for an unobtainable Glasgow Coma Scale score may introduce a substantial treatment bias into subsequent outcome predictions.