Development and validation of the VitaL CLASS score to predict mortality in stage IV solid cancer patients with septic shock in the emergency department: a multi-center, prospective cohort study

Abstract

Background Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores. Methods This multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score’s performance was compared to that of the previous severity scores. Results New scoring system for 28-day mortality was based on six variables (score range, 0–8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%). Conclusions The VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.

Prognostic Impact of Neutropenia in Cancer Patients with Septic Shock: A 2009–2017 Nationwide Cohort Study

“…Due to the recent advances in cancer treatment and sepsis management, the overall survival rate of cancer patients with septic shock has improved [ 43 ]. Moreover, appropriate selection of the patients to be admitted to the ICU would be helpful for a better outcome [ 34 , 44 ]. The recent guidelines for ICU admission in patients with cancer suggest that the classical predictors of mortality are not relevant, and the triage criteria usually used are unreliable [ 45 ].…”

Machine Learning Model Development and Validation for Predicting Outcome in Stage 4 Solid Cancer Patients with Septic Shock Visiting the Emergency Department: A Multi-Center, Prospective Cohort Study

“…In addition, the 28-day mortality rate is higher in these patients [ 4 , 31 ]. However, the demand for the ICUs care usually exceeds the supply; therefore, the triage and allocation decisions for the ICUs care for critically ill patients are important [ 32 ]. Moreover, considering the high mortality rates associated with stage 4 solid cancer patients with septic shock visiting the ED, it is necessary to establish a risk score for providing professionals and families with more precise information for making the decision of whether to go ahead with an invasive procedure.…”

Short and Long-Term Mortality Trends for Cancer Patients with Septic Shock Stratified by Cancer Type from 2009 to 2017: A Population-Based Cohort Study

“…In the early 2000s, an ICU admission of cancer patients with septic shock was thought to be a medically futile effort. However, the consensus on this has changed over time in relation to such ICU care for cancer patients, and it is now considered that the outcomes for cases with and those without cancer could be similar with appropriate patient selection [ 16 , 17 , 32 ]. Such changes in the ICU treatment approaches for cancer patients with septic shock have also encouraged more aggressive interventions and led to improved outcomes.…”

“…Although a preexisting diagnosis of cancer was known as an independent risk factor of death from sepsis in patients admitted to the intensive care unit (ICU) [ 14 , 15 ], the survival outcome in cancer patients with sepsis has been improved over time [ 6 , 16 , 17 ]. However, cancer patients who develop septic shock still pose a difficult dilemma for clinicians in terms of use of resources and costs of the health care, especially in the emergency department (ED) setting [ 16 ]. Minimal reliable data are available to guide the physicians, cancer patients, and their families in their medical decision-making, and better information to assist with this is therefore urgently needed [ 16 , 17 ].…”

“…However, cancer patients who develop septic shock still pose a difficult dilemma for clinicians in terms of use of resources and costs of the health care, especially in the emergency department (ED) setting [ 16 ]. Minimal reliable data are available to guide the physicians, cancer patients, and their families in their medical decision-making, and better information to assist with this is therefore urgently needed [ 16 , 17 ]. Moreover, recent improvements in oncology care and early protocol-driven resuscitation bundled with therapy for sepsis are likely to have contributed to the more favorable outcomes in cancer patients with septic shock, so there is a need to reevaluate the prognosis in these cases.…”