Shock Index and Outcomes in Patients Admitted to the ICU With Sepsis

Biney, Isaac; Shepherd, April; Thomas, Joylene; Mehari, Alem

doi:10.1378/chest.2281151

Cited by 4 publications

(6 citation statements)

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“…While there is a body of literature describing the association of shock index with mortality and resuscitation requirements in injured patients, the use of shock index in the posthemostasis/ICU phase of care has not been validated. [25][26][27][28] Third, the definition of "high-intensity" posthemostasis resuscitation though novel is arbitrary based on our high-volume, institutional practice. The thresholds for blood product and crystalloid use were selected as they approximate the top decile of each therapeutic modality in our study cohort, and while we expect that our practice is comparable to like centers, prospective multicenter validation of such a prediction model will likely require adjustment.…”

Section: Discussionmentioning

confidence: 99%

Predicting high-intensity resuscitation needs in injured patients in the post-hemostasis phase of care following intervention

Weykamp,

Beni,

Stern

et al. 2023

J Trauma Acute Care Surg

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Background Best resuscitation practices in the post-hemostasis phase of care are poorly defined; this phase of care is characterized by a range of physiologic derangements and multiple therapeutic modalities used to address them. Using a cohort of injured patients who required an immediate intervention in the operating room or angiography suite following arrival to the emergency department, we sought to define high-intensity resuscitation (HIR) in this post-hemostasis phase of care; we hypothesized that those who would require HIR could be identified, using only data available at ICU admission. Methods Clinical data was extracted for consecutive injured patients (2016-19) admitted to the ICU following an immediate procedure in the operating room or angiography suite. HIR thresholds were defined as the top decile of blood product (≥3 units) and/or crystalloid (≥4 Liters) use in the initial twelve hours of ICU care and/or vasoactive medication use between ICU hours 2-12. The primary outcome, HIR, was a composite of any of these modalities. Predictive modeling of HIR was performed using logistic regression with predictor variables selected using Least Absolute Shrinkage and Selection Operator (LASSO) estimation. Model was trained using 70% of the cohort and tested on the remaining 30%; model predictive ability was evaluated using area under receiver operator curves. Results Six-hundred-and-five patients were included. Patients were 79% male, young (median age: 39 years), severely injured (median ISS: 26), and an approximately 3:2 ratio of blunt to penetrating mechanisms of injury. A total of 215 (36%) required HIR. Predictors selected by LASSO included: shock index, lactate, base deficit, hematocrit, and INR. The area under receiver operator curve for the LASSO-derived HIR prediction model was 0.82. Conclusions ICU admission data can identify subsequent HIR in the post-hemostasis phase of care. Use of this model may facilitate triage, nursing ratio determination, and resource allocation. Level of Evidence Retrospective Cohort, Level IV

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Section: Discussionmentioning

confidence: 99%

Predicting high-intensity resuscitation needs in injured patients in the post-hemostasis phase of care following intervention

Weykamp,

Beni,

Stern

et al. 2023

J Trauma Acute Care Surg

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“…[14][15][16] The Shock Index is a simple risk score (heart rate divided by systolic blood pressure) that was developed to detect changes in cardiovascular performance before the onset of shock and an elevated Shock Index is associated with poor outcomes. [17][18][19] NEWS2 is the official score used to identify those at risk of poor outcomes from sepsis in the United Kingdom National Health Service. 14,[20][21][22][23][24] COVID-19-specific risk stratification scores, such as the Quick COVID-19 Severity Index (qCSI), 25 have been developed to incorporate hallmark symptoms of the disease into bedside risk assessment.…”

Section: Introductionmentioning

confidence: 99%

“…qSOFA was developed to determine the risk of poor outcomes from sepsis in nonintensive care unit (ICU) settings 14–16 . The Shock Index is a simple risk score (heart rate divided by systolic blood pressure) that was developed to detect changes in cardiovascular performance before the onset of shock and an elevated Shock Index is associated with poor outcomes 17–19 . NEWS2 is the official score used to identify those at risk of poor outcomes from sepsis in the United Kingdom National Health Service 14,20–24 .…”

Section: Introductionmentioning

confidence: 99%

Performance of point‐of‐care severity scores to predict prognosis in patients admitted through the emergency department with COVID‐19

Prasad

Correia

Fang

et al. 2023

Journal of Hospital Medicine

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Background Identifying COVID‐19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID‐19 patients but have not been evaluated in a large cohort. Objective To determine whether well‐known risk scores can predict poor outcomes among hospitalized COVID‐19 patients. Designs, Settings, and Participants A retrospective cohort study of adults presenting with COVID‐19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021. Intervention Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System‐2 (NEWS2), and quick COVID‐19 Severity Index (qCSI) at presentation. Main Outcome and Measures The primary outcome was in‐hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated. Results We identified 90,376 patients with community‐acquired COVID‐19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in‐hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA‐positive, 45.1% Shock Index‐positive, 49.8% NEWS2‐positive, and 37.6% qCSI‐positive at ED‐triage. NEWS2 exhibited the highest AUROC for in‐hospital mortality (0.593, confidence interval [CI]: 0.588–0.597), ICU admission (0.602, CI: 0.599–0.606), mechanical ventilation (0.614, CI: 0.610–0.619), and vasopressor receipt (0.600, CI: 0.595–0.604). Conclusions Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID‐19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID‐19 patients to develop more effective risk‐based triage.

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“…Patients with higher and sustained Shock Index scores are more likely to experience morbidity, such as hyperlactatemia, vasopressor use, and organ failure, and also have an increased risk of mortality. [12][13][14] Although the predictive abilities of these bedside risk stratification scores have been assessed individually using standard binary cut-points, the comparative performance of qSOFA, the Shock Index, and NEWS2 has not been evaluated in patients presenting to an emergency department (ED) with suspected sepsis. Our objective was to provide a head-to-head comparison of the test characteristics of qSOFA, the Shock Index, and NEWS2 calculated at ED triage for predicting in-hospital mortality and ED-to-ICU admission in patients with suspected sepsis to help health systems and providers select screening measures.…”

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confidence: 99%

“…Although it was not developed for infection and has not been regularly applied in the sepsis literature, the Shock Index might be useful for identifying patients at increased risk of poor outcomes. Patients with higher and sustained Shock Index scores are more likely to experience morbidity, such as hyperlactatemia, vasopressor use, and organ failure, and also have an increased risk of mortality 12‐14 …”

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confidence: 99%

Identifying the Sickest During Triage: Using Point‐of‐Care Severity Scores to Predict Prognosis in Emergency Department Patients With Suspected Sepsis

Prasad

Fang

Martínez

et al. 2021

Journal of Hospital Medicine

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BACKGROUND: Sepsis progresses rapidly and is associated with considerable morbidity and mortality. Bedside risk stratification scores can quickly identify patients at greatest risk of poor outcomes; however, there is lack of consensus on the best scale to use. OBJECTIVE: To compare the ability of quick Sequential Organ Failure Assessment (qSOFA), the National Early Warning System (NEWS2), and the Shock Index—which does not require mental status assessment—to predict poor outcomes among patients with suspected sepsis during triage. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of adults presenting to an academic emergency department (ED) from June 2012 to December 2018 who had blood cultures and intravenous antibiotics within 24 hours. MAIN OUTCOMES AND MEASURES: Clinical data were collected from the electronic health record. Patients were considered positive at qSOFA ≥2, Shock Index >0.7, or NEWS2 ≥5 scores. We calculated test characteristics and area under the receiver operating characteristics curves (AUROCs) to predict in-hospital mortality and ED-to-intensive care unit (ICU) admission. RESULTS: We included 23,837 ED patients; 1,921(8.1%) were qSOFA-positive, 4,273 (17.9%) Shock Index-positive, and 11,832 (49.6%) NEWS2-positive. There were 1,427 (6.0%) deaths and 3,149 (13.2%) ED-to-ICU admissions in the sample. NEWS2 had the highest sensitivity for in-hospital mortality (76.0%) and ED-to-ICU admission (78.9%). qSOFA had the highest specificity for in-hospital mortality (93.4%) and ED-to-ICU admission (95.2%). Shock Index exhibited the highest AUROC for in-hospital mortality (0.648; 95 CI, 0.635-0.662) and ED-to-ICU admission (0.680; 95% CI, 0.617-0.689). Test characteristics were similar among those with sepsis. CONCLUSIONS: Institution priorities should drive score selection, balancing sensitivity and specificity. In our study, qSOFA was highly specific and NEWS2 was the most sensitive for ruling out patients at high risk. Performance of the Shock Index fell between qSOFA and NEWS2 and could be considered because it is easy to implement.

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Shock Index and Outcomes in Patients Admitted to the ICU With Sepsis

Cited by 4 publications

References 0 publications

Predicting high-intensity resuscitation needs in injured patients in the post-hemostasis phase of care following intervention

Predicting high-intensity resuscitation needs in injured patients in the post-hemostasis phase of care following intervention

Performance of point‐of‐care severity scores to predict prognosis in patients admitted through the emergency department with COVID‐19

Identifying the Sickest During Triage: Using Point‐of‐Care Severity Scores to Predict Prognosis in Emergency Department Patients With Suspected Sepsis

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