Using Aggregate Vasoactive-Inotrope Scores to Predict Clinical Outcomes in Pediatric Sepsis

Abstract

ObjectivesThe heterogeneity of sepsis makes it difficult to predict outcomes using existing severity of illness tools. The vasoactive-inotrope score (VIS) is a quantitative measure of the amount of vasoactive support required by patients. We sought to determine if a higher aggregate VIS over the first 96 h of vasoactive medication initiation is associated with increased resource utilization and worsened clinical outcomes in pediatric patients with severe sepsis.DesignRetrospective cohort study.SettingSingle-center at Children's Wisconsin in Milwaukee, WI.PatientsOne hundred ninety-nine pediatric patients, age less than 18 years old, diagnosed with severe sepsis, receiving vasoactive medications between January 2017 and July 2019.InterventionsRetrospective data obtained from the electronic medical record, calculating VIS at 2 h intervals from 0–12 h and at 4 h intervals from 12–96 h from Time 0.MeasurementsAggregate VIS derived from the hourly VIS area under the curve (AUC) calculation based on the trapezoidal rule. Data were analyzed using Pearson's correlations, Mann-Whitney test, Wilcoxon signed rank test, and classification, and regression tree (CART) analyses.Main ResultsHigher aggregate VIS is associated with longer hospital LOS (p < 0.0001), PICU LOS (p < 0.0001), MV days (p = 0.018), increased in-hospital mortality (p < 0.0001), in-hospital cardiac arrest (p = 0.006), need for ECMO (p < 0.0001), and need for CRRT (p < 0.0001). CART analyses found that aggregate VIS >20 is an independent predictor for in-hospital mortality (p < 0.0001) and aggregate VIS >16 for ECMO use (p < 0.0001).ConclusionsThere is a statistically significant association between aggregate VIS and many clinical outcomes, allowing clinicians to utilize aggregate VIS as a physiologic indicator to more accurately predict disease severity/trajectory in pediatric sepsis.

Clinical parameters to predict adverse outcomes in patients with shunt-dependent physiology with a Blalock–Taussig–Thomas shunt

“…Previous studies have identified factors associated with cardiopulmonary arrest in critically ill children. Previous studies have demonstrated ST-segment variability, vasoactive-inotrope score, higher inadequate oxygen delivery index, venous saturation, serum lactate, cerebral dysfunction by electroencephalography, a history of a previous cardiac arrest, specific cardiac lesions, and specific cardiac surgeries among others[ 3 4 5 6 7 8 9 10 11 12 13 14 15 16 ] as risk factors for adverse outcomes. Risk factors for mortality have often mirrored the risk factors for cardiac arrest.…”

SOFA-based Prognostication in PICU: A Cardiovascular Critique!

“…Specific to PICU, however, literature characteristically demonstrates poor outcomes in the backdrop of high hemodynamic support. 4 , 5 Employing described formulas like vasoactive-inotropic score (VIS) for reporting cardiovascular support, Musick et al highlight an escalating relative risk of mortality alongside an increasing VIS in PICU. 4 Adding to the debate and propounding an update of the cvSOFA, Pölkki et al recently discover an improved mortality predictive accuracy of the SOFA score on replacing the cvSOFA with maximum VIS or the VIS max , in a setting involving 8,079 ICU patients with a 30-day mortality rate of 13%.…”

“… 1 To that end, a retrospective cohort study by Shah et al outlines the merit of estimating the aggregate VIS, computed using the hourly VIS area under the curve calculation premised on the trapezoidal rule. 5 Amidst an elevated aggregate VIS being associated with in-hospital mortality and the need for continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) ( p < 0.0001, for all the parameters), classification and regression tree (CART) analysis revealed aggregate VIS >16 and >20 as respective independent predictors of ECMO use and in-hospital mortality ( p < 0.0001). 5 Indeed, the role of catering to outcomes like ECMO or CRRT in a prospective observational PICU-based study like the one by Lois and Save, can also not be overemphasized.…”

“… 5 Indeed, the role of catering to outcomes like ECMO or CRRT in a prospective observational PICU-based study like the one by Lois and Save, can also not be overemphasized. 1 , 5 …”

Clinical parameters to predict adverse outcomes in patients with parallel circulation with a Blalock-Taussig-Thomas shunt

“…The resulting score had an area under the curve of 0.84 with an optimal Previous studies have identi ed factors associated with cardiopulmonary arrest in critically ill children. Previous studies have demonstrated ST-segment variability, vasoinotrope score, higher inadequate oxygen delivery index, venous saturation, serum lactate, cerebral dysfunction by electroencephalography, a history of a previous cardiac arrest, speci c cardiac lesions, and speci c cardiac surgeries among others[3][4][5][6][7][8][9][10][11][12][13][14][15][16]. Risk factors for mortality have often mirrored the risk factors for cardiac arrest.…”