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Crit Care Med. 2019 Nov;47(11):1513-1521. doi: 10.1097/CCM.0000000000003899.

Physician Judgment and Circulating Biomarkers Predict 28-Day Mortality in Emergency Department Patients.

Author information

1
Department of Emergency Medicine, University of Washington, Seattle, WA.
2
Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
3
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
4
Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA.
5
Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA.

Abstract

OBJECTIVES:

To determine whether biomarkers of endothelial activation and inflammation provide added value for prediction of in-hospital mortality within 28 days when combined with physician judgment in critically ill emergency department patients.

DESIGN:

Prospective, observational study.

SETTING:

Two urban, academic emergency departments, with ≈80,000 combined annual visits, between June 2016 and December 2017.

PATIENTS:

Admitted patients, greater than 17 years old, with two systemic inflammatory response syndrome criteria and organ dysfunction, systolic blood pressure less than 90 mm Hg, or lactate greater than 4.0 mmol/L. Patients with trauma, intracranial hemorrhage known prior to arrival, or without available blood samples were excluded.

INTERVENTIONS:

Emergency department physicians reported likelihood of in-hospital mortality (0-100%) by survey at hospital admission. Remnant EDTA blood samples, drawn during the emergency department stay, were used to measure angiopoietin-1, angiopoietin-2, tumor necrosis factor receptor-1, interleukin-6, and interleukin-8.

MEASUREMENTS AND MAIN RESULTS:

We screened 421 patients and enrolled 314. The primary outcome of in-hospital mortality within 28 days occurred in 31 (9.9%). When predicting the primary outcome, the best biomarker model included angiopoietin-2 and interleukin-6 and performed moderately well (area under the curve, 0.72; 95% CI, 0.69-0.75), as did physician judgment (area under the curve, 0.78; 95% CI, 0.74-0.82). Combining physician judgment and biomarker models improved performance (area under the curve, 0.85; 95% CI, 0.82-0.87), with area under the curve change of 0.06 (95% CI, 0.04-0.09; p < 0.01) compared with physician judgment alone.

CONCLUSIONS:

Predicting in-hospital mortality within 28 days among critically ill emergency department patients may be improved by including biomarkers of endothelial activation and inflammation in combination with emergency department physician judgment.

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