Rational clinical examination of the critically ill patient

In this thesis the evidence of clinical examination of the cardiovascular system was evaluated in critically ill patients. Current guidelines advocate the use of clinical examination to diagnose circulatory shock. Shock is a life-threatening condition wherein the blood circulation and cardiac output is insufficient to provide sufficient oxygen to vital organs. Previous studies showed that physicians may be insufficiently capable of estimating cardiac output solely based on the clinical examination; their diagnostic accuracy was comparable to a flip of a coin. These studies were, however, conducted more than 20 years ago and of low methodologic quality.During this PhD-thesis an observational study of high methodologic quality was conducted to educate physicians on the diagnostic and prognostic value of clinical examination. A study-design with pre-specified hypotheses was published and guidelines for statistical analysis plans were written to promote transparency in observational studies. The first main observation was that clinical signs are important warning signals that a patient deteriorates but cannot reliably indicate what the cardiac output is, and what the underlying cause is. Second, it was observed that clinical examination performs reasonably for distinguishing 90-day survivors from non-survivors, but that this ability was similar to established prognostic scores. This PhD-thesis also investigated if dopamine, a drug used to increase cardiac output, was beneficial in critically ill patients with cardiac dysfunction. In a systematic review we observed that the evidence for using dopamine was sparse and of low quality, which implicates that contemporary use of dopamine can neither be recommended nor refuted