Shock Index-A Useful Noninvasive Marker Associated With Age-Specific Early Mortality in Children With Severe Sepsis and Septic Shock: Age-Specific Shock Index Cut-Offs

Abstract

Background:

Aim of the study was to analyze the association of shock index (SI) from 0 to 6 hours with early mortality in severe sepsis/septic shock and to explore its age-specific cut-off values. To investigate association of change in SI over first 6 hours with early mortality.

Methods:

A prospective cohort study of children (<14 years) admitted in emergency department, tertiary care hospital with severe sepsis or septic shock, divided into 3 groups: group 1: 1 month to <1 year; group 2: 1 to <6 years; group 3: 6 to 12 years. Shock index (SI = heart rate/systolic blood pressure) measured at admission (X0) and hourly till 6 hours (X1-6). Primary outcome was death within 48 hours of admission. Area under receiver operating characteristic curves were constructed for SI (0-6). Optimal cut-offs of SI 0 and SI 6, maximizing both sensitivity and specificity were determined and positive and negative predictive values (PPV, NPV) were calculated.

Results:

From 2015 to 2016, 120 children were recruited. Septic shock was present at admission in 56.7% children. Early mortality was 50%. All hourly shock indices (SI 0-6) were higher among nonsurvivors in group 2 (P ≤ .03) and group 3 (P < .001). In group 1, SI after 2 hours was higher in nonsurvivors (P 2-6: ≤ .02). Area under receiver operating characteristic curves (95% CI) for SI at 0 hour was 0.72 (0.5-0.9), 0.66 (0.5-0.8), and 0.77 (0.6-0.9) and at 6 hours was 0.8 (0.6-1), 0.75 (0.6-0.9), and 0.8 (0.7-1) in 3 groups. The cut-off values of SI 0 (sensitivity; specificity; PPV; NPV) in 3 groups: 1.98 (77; 75; 67; 83), 1.50 (65; 65; 68; 63), and 1.25 (90; 67; 77; 83) and SI6: 1.66 (85; 80; 73; 89), 1.36 (73; 70; 73; 70), and 1.30 (74; 73; 78; 69). Improvement of SI over 6 hours was associated with better outcome. Children with higher SI at both time points had higher mortality than those with SI score below the cut-offs (P = .001).

Conclusions:

Age-specific SI cut-off values may identify children at high risk of early mortality in severe sepsis/septic shock and allow for better targeted management.

Keywords

septic shock mortality sepsis shock index cut-off children

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References

Weiss

Fitzgerald

Pappachan

, et al. Global epidemiology of pediatric severe sepsis: the sepsis prevalence, outcomes, and therapies study. Am J Respir Crit Care Med. 2016;191(10):1147–1157.

Kaur

Vinayak

Mittal

Kushik

Aamir

. Clinical outcome and predictors of mortality in children with sepsis, severe sepsis and septic shock from Rohtak, Haryana: a prospective observational study. Indian J Crit Care Med. 2014;18(7):437–441.

Rivers

Nguyen

Havstad

, et al. Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–1377.

Osborn

Nguyen

Rivers

. Emergency medicine and the surviving sepsis campaign: an international approach to managing severe sepsis and septic shock. Ann Emerg Med. 2005;46(3):228–231.

Allgöwer

Buri

. Shock index. Dtsch Med Wochenschr. 1967; 92(43):1947–1950.

Rady

Nightingale

Little

Edwards

. Shock index: a re-evaluation in acute circulatory failure. Resuscitation. 1992;23(3):227–234.

Reinstadler

Fuernau

Eitel

, et al. Shock index as a predictor of myocardial damage and clinical outcome in ST-elevation myocardial infarction. Circ J. 2016;80(4):924–930.

Cevik

Dolgun

Oner

, et al. Elevated lactate level and shock index in nontraumatic hypotensive patients presenting to the emergency department. Eur J Emerg Med. 2015;22(1):23–28.

Cerovic

Golubovic

Spec-Marn

Kremzar

Vidmar

. Relationship between injury severity and lactate levels in severely injured patients. Intensive Care Med. 2003;29(8):1300–1305.

10.

Jaimes

Farbiarz

Alvarez

Martínez

. Comparison between logistic regression and neural networks to predict death in patients with suspected sepsis in the emergency room. Crit Care. 2005;9(2):R150–R156.

11.

Linnaus

Notrica

Langlais

, et al. Prospective validation of the shock index pediatric-adjusted (SIPA) in blunt liver and spleen trauma: an ATOMAC + study. J Pediatr Surg. 2017;52(2):340–344.

12.

Acker

Ross

Partrick

Tong

Bensard

. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015;50(2):331–334.

13.

Kevin

Charry

Calle-Toro

Nunez

Poveda

. Shock index as a mortality predictor in patients with acute polytrauma. J Acute Dis. 2015;4(3):202–204.

14.

Cannon

Braxton

Kling-Smith

Mahnken

Carlton

Moncure

. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009;67(6):1426–1430.

15.

Myint

Musonda

Sankaran

, et al. Confusion, urea, respiratory rate and shock index or adjusted shock index (CURSI or CURASI) criteria predict mortality in community-acquired pneumonia. Eur J Intern Med. 2010;21(5):429–433.

16.

Sankaran

Kamath

Tariq

, et al. Are shock index and adjusted shock index useful in predicting mortality and length of stay in community-acquired pneumonia?. Eur J Intern Med. 2011;22(3):282–285.

17.

Otero

Trujillo-Santos

Cayuela

, et al.

Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?

Eur Respir J. 2007;30(6):1111–1116.

18.

Nathan

El Ayadi

Hezelgrave

, et al.

Shock index: an effective predictor of outcome in postpartum haemorrhage?

BJOG. 2015;122(2):268–275.

19.

Rady

Smithline

Blake

Nowak

Rivers

. A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med. 1994;24(4):685–690.

20.

Zarzaur

Croce

Fischer

Magnotti

Fabian

. New vitals after injury: shock index for the young and age x shock index for the old. J Surg Res. 2008;147(2):229–236.

21.

Witting

Gallagher

. Unique cutpoints for sitting-to-standing orthostatic vital signs. Am J Emerg Med. 2003;21(1):45–47.

22.

Birkhahn

Gaeta

Terry

Bove

Tloczkowski

. Shock index in diagnosing early acute hypovolemia. Am J Emerg Med. 2005;23(3):323–326.

23.

Robert

Stanton

BMD

Geme

Schor

. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders, Elsevier; 2007.

24.

Goldstein

Giroir

Randolph

; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2–8.

25.

Rousseaux

Grandbastien

Dorkenoo

Lampin

Leteurtre

Leclerc

. Prognostic value of shock index in children with septic shock. Pediatr Emerg Care. 2013;29(10):1055–1059.

26.

Yasaka

Khemani

Markovitz

. Is shock index associated with outcome in children with sepsis/septic shock?*. Pediatr Crit Care Med. 2013;14(8):e372–e379.

27.

Ray

Cvetkovic

Brierley

, et al. Shock index values and trends in pediatric sepsis: predictors or therapeutic targets? A retrospective observational study. Shock. 2016;46(3):279–286.

28.

Dellinger

Levy

Carlet

, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36(1):296–327.

29.

Kabra

Lodha

. Pediatric Intensive Care Protocols of AIIMS. New Delhi, India: Indian Journal of Pediatrics; 2014.

30.

Mayr

Yende

Angus

. Epidemiology of severe sepsis. Virulence. 2014;5(1):4–11.

31.

Bruijns

Guly

Bouamra

Lecky

Lee

. The value of traditional vital signs, shock index, and age-based markers in predicting trauma mortality. J Trauma Acute Care Surg. 2013;74(6):1432–1437.

32.

Nordin

Coleman

Shi

. Validation of the age-adjusted shock index using pediatric trauma quality improvement program data. J Pediatr Surg. 2018;53(1):130–135.

33.

Yussof

Zakaria

Mohamed

Bujang

Lakshmanan

Asaari

. Value of Shock Index in prognosticating the short-term outcome of death for patients presenting with severe sepsis and septic shock in the emergency department. Med J Malaysia. 2012;67(4):406–411.

34.

King

Plewa

Buderer

Knotts

. Shock index as a marker for significant injury in trauma patients. Acad Emerg Med. 1996;3(11):1041–1045.

35.

Berger

Green

Horeczko

, et al. Shock index and early recognition of sepsis in the emergency department: pilot study. West J Emerg Med. 2013;14(2):168–174.

36.

McNab

Burns

Bhullar

Chesire

Kerwin

. A prehospital shock index for trauma correlates with measures of hospital resource use and mortality. Surgery. 2012;152(3):473–476.

37.

Arbuthnot

Armstrong

Mooney

. Can we safely decrease intensive care unit admissions for children with high grade isolated solid organ injuries? Using the shock index, pediatric age-adjusted and hematocrit to modify APSA admission guidelines. J Pediatr Surg. 2017;52(6):989–992.

38.

Vandewalle

Peceny

Dolejs

Raymond

Rouse

. Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries. J Pediatr Surg. 2018;53(2):362–366.

39.

Schellenberg

Strumwasser

Grabo

, et al. Delta shock index in the emergency department predicts mortality and need for blood transfusion in trauma patients. Am Surg. 2017;83(10):1059–1062.