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Hori T, Aihara KI, Watanabe T, Inaba K, Inaba K, Kaneko Y, Kawata S, Kawahito K, Kita H, Shimizu K, Hosoki M, Mori K, Kageji T, Uraoka H, Nakamura S. The Respiratory Adjusted Shock Index at Admission Is a Valuable Predictor of In-Hospital Outcomes for Elderly Emergency Patients with Medical Diseases at a Japanese Community General Hospital. J Clin Med 2024; 13:4866. [PMID: 39201007 PMCID: PMC11355747 DOI: 10.3390/jcm13164866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/09/2024] [Accepted: 08/16/2024] [Indexed: 09/02/2024] Open
Abstract
Background: The respiratory adjusted shock index (RASI) is a risk score whose usefulness in patients with sepsis and trauma has previously been reported. However, its relevance in elderly emergency patients with medical diseases is yet to be clarified. This study assessed the usefulness of the RASI, which can be evaluated without requiring special equipment, to provide objective and rapid emergency responses. Methods: In this retrospective study, we recruited patients with medical diseases, aged 65 years or older, who were transported to the emergency room from Tokushima Prefectural Kaifu Hospital and underwent arterial blood gas testing from 1 January 2022 to 31 December 2023. We investigated the association of the RASI with other indices, including the lactate level, National Early Warning Score 2 (NEWS2), Shock Index (SI), Sequential Organ Failure Assessment (SOFA) score, quick SOFA (qSOFA) score, and systemic inflammatory response syndrome (SIRS). Results: In this study, we included 260 patients (mean age, 86 years), of whom 234 were admitted to the hospital; 27 and 49 patients died within 7 and 30 days of admission, respectively. The RASI was positively correlated with the lactate level, NEWS2, SI, and increase in the SOFA score (p < 0.001). The RASI was higher in patients with a SIRS or qSOFA score ≥ 2 than in those without (p < 0.001). It predicted death within 7 and 30 days of admission with an area under the curve (AUC) of 0.80 (95% confidence interval [CI]: 0.73-0.87), sensitivity of 96.3%, and specificity of 53.6% when the cutoff value was set to 1.58 and with an AUC of 0.73 (95% CI: 0.66-0.81), sensitivity of 69.4%, and specificity of 70.6% when the cutoff value was set to 1.83, respectively. Conclusions: The RASI is a simple indicator that can be used for predicting in-hospital outcomes in elderly emergency patients with medical diseases. Larger prospective studies based on this study are needed.
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Affiliation(s)
- Taiki Hori
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
- Department of Hematology, Endocrinology and Metabolism, Tokushima University Graduate School of Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Ken-ichi Aihara
- Department of Community Medicine and Medical Science, Tokushima University Graduate School of Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Takeshi Watanabe
- Department of Preventive Medicine, Tokushima University Graduate School of Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Kaori Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Keisuke Inaba
- Department of General Medicine, Tokushima University Graduate School of Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
| | - Yousuke Kaneko
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Saki Kawata
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Keisuke Kawahito
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Hiroki Kita
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Kazuma Shimizu
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Minae Hosoki
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Kensuke Mori
- Department of Internal Medicine, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Teruyoshi Kageji
- Department of Neurosurgery, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Hideyuki Uraoka
- Department of Orthopedic Surgery, Tokushima Prefectural Kaifu Hospital, 266 Sugitani, Nakamura, Mugi-cho, Kaifu-gun, Tokushima 775-0006, Japan
| | - Shingen Nakamura
- Department of Community Medicine and Medical Science, Tokushima University Graduate School of Biomedical Sciences, 3-18-15 Kuramoto-cho, Tokushima 770-8503, Japan
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Rafieezadeh A, Prabhakaran K, Kirsch J, Klein J, Shnaydman I, Bronstein M, Con J, Zangbar B. Shock Index is a Stronger Predictor of Outcomes in Older Compared to Younger Patients. J Surg Res 2024; 300:8-14. [PMID: 38788482 DOI: 10.1016/j.jss.2024.04.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults. METHODS We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy). RESULTS A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both). CONCLUSIONS These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Joshua Klein
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ilya Shnaydman
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Matthew Bronstein
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jorge Con
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, New York.
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Padkins M, Kashani K, Tabi M, Gajic O, Jentzer JC. Association between the shock index on admission and in-hospital mortality in the cardiac intensive care unit. PLoS One 2024; 19:e0298327. [PMID: 38626151 PMCID: PMC11020967 DOI: 10.1371/journal.pone.0298327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/22/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND An elevated shock index (SI) predicts worse outcomes in multiple clinical arenas. We aimed to determine whether the SI can aid in mortality risk stratification in unselected cardiac intensive care unit patients. METHODS We included admissions to the Mayo Clinic from 2007 to 2015 and stratified them based on admission SI. The primary outcome was in-hospital mortality, and predictors of in-hospital mortality were analyzed using multivariable logistic regression. RESULTS We included 9,939 unique cardiac intensive care unit patients with available data for SI. Patients were grouped by SI as follows: < 0.6, 3,973 (40%); 0.6-0.99, 4,810 (48%); and ≥ 1.0, 1,156 (12%). After multivariable adjustment, both heart rate (adjusted OR 1.06 per 10 beats per minute higher; CI 1.02-1.10; p-value 0.005) and systolic blood pressure (adjusted OR 0.94 per 10 mmHg higher; CI 0.90-0.97; p-value < 0.001) remained associated with higher in-hospital mortality. As SI increased there was an incremental increase in in-hospital mortality (adjusted OR 1.07 per 0.1 beats per minute/mmHg higher, CI 1.04-1.10, p-Value < 0.001). A higher SI was associated with increased mortality across all examined admission diagnoses. CONCLUSION The SI is a simple and universally available bedside marker that can be used at the time of admission to predict in-hospital mortality in cardiac intensive care unit patients.
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Affiliation(s)
- Mitchell Padkins
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Meir Tabi
- Division of Cardiovascular Medicine, Department of Medicine, Jesselson Integrated Heart Center, Jerusalem, Israel
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
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Gendler S, Gelikas S, Talmy T, Nadler R, Tsur AM, Radomislensky I, Bodas M, Glassberg E, Almog O, Benov A, Chen J. Predictors of Short-Term Trauma Laparotomy Outcomes in an Integrated Military-Civilian Health System: A 23-Year Retrospective Cohort Study. J Clin Med 2024; 13:1830. [PMID: 38610595 PMCID: PMC11012665 DOI: 10.3390/jcm13071830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/03/2024] [Accepted: 03/14/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Trauma laparotomy (TL) remains a cornerstone of trauma care. We aimed to investigate prehospital measures associated with in-hospital mortality among casualties subsequently undergoing TLs in civilian hospitals. Methods: This retrospective cohort study cross-referenced the prehospital and hospitalization data of casualties treated by Israel Defense Forces-Medical Corps teams who later underwent TLs in civilian hospitals between 1997 and 2020. Results: Overall, we identified 217 casualties treated by IDF-MC teams that subsequently underwent a TL, with a mortality rate of 15.2% (33/217). The main mechanism of injury was documented as penetrating for 121/217 (55.8%). The median heart rate and blood pressure were within the normal limit for the entire cohort, with a low blood pressure predicting mortality (65 vs. 127, p < 0.001). In a multivariate analysis, prehospital endotracheal intubation (ETI), emergency department Glasgow coma scores of 3-8, and the need for a thoracotomy or bowel-related procedures were significantly associated with mortality (OR 6.8, p < 0.001, OR = 48.5, p < 0.001, and OR = 4.61, p = 0.002, respectively). Conclusions: Prehospital interventions introduced throughout the study period did not lead to an improvement in survival. Survival was negatively influenced by prehospital ETI, reinforcing previous observations of the potential deleterious effects of definitive airways on hemorrhaging trauma casualties. While a low blood pressure was a predictor of mortality, the median systolic blood pressure for even the sickest patients (ISS > 16) was within normal limits, highlighting the challenges in triage and risk stratification for trauma casualties.
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Affiliation(s)
- Sami Gendler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Shaul Gelikas
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
| | - Avishai M. Tsur
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Medicine, Sheba Medical Center, Tel-Hashomer 5262504, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
| | - Moran Bodas
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 5262100, Israel
- Department of Emergency & Disaster Management, School of Public Health, Faculty of Medicine, Tel-Aviv University, Tel-Aviv-Yafo 6139001, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
- The Uniformed Services, University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9112102, Israel
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed 5290002, Israel
| | - Jacob Chen
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan 5262504, Israel (J.C.)
- Meir Medical Center, Kfar Saba 4428164, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 69978, Israel
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5
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Wang YM, Chiu IM, Chuang YP, Cheng CY, Lin CF, Cheng FJ, Lin CF, Li CJ. RAPID-ED: A predictive model for risk assessment of patient's early in-hospital deterioration from emergency department. Resusc Plus 2024; 17:100570. [PMID: 38357677 PMCID: PMC10864627 DOI: 10.1016/j.resplu.2024.100570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/16/2024] Open
Abstract
Introduction The objective of this multi-center retrospective cohort study was to devise a predictive tool known as RAPID-ED. This model identifies non-traumatic adult patients at significant risk for cardiac arrest within 48 hours post-admission from the emergency department. Methods Data from 224,413 patients admitted through the emergency department (2016-2020) was analyzed, incorporating vital signs, lab tests, and administered therapies. A multivariable regression model was devised to anticipate early cardiac arrest. The efficacy of the RAPID-ED model was evaluated against traditional scoring systems like National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) and its predictive ability was gauged via the area under the receiver operating characteristic curve (AUC) in both hold-out validation set and external validation set. Results RAPID-ED outperformed traditional models in predicting cardiac arrest with an AUC of 0.819 in the hold-out validation set and 0.807 in the external validation set. In this critical care update, RAPID-ED offers an innovative approach to assessing patient risk, aiding emergency physicians in post-discharge care decisions from the emergency department. High-risk score patients (≥13) may benefit from early ICU admission for intensive monitoring. Conclusion As we progress with advancements in critical care, tools like RAPID-ED will prove instrumental in refining care strategies for critically ill patients, fostering an improved prognosis and potentially mitigating mortality rates.
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Affiliation(s)
- Yi-Min Wang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Yu-Ping Chuang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chi-Yung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chun-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chien-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
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Tabi M, Padkins M, Burstein B, Younis A, Asher E, Bennett C, Jentzer JC. Association of Shock Index with Echocardiographic Parameters in Cardiac Intensive Care Unit. J Crit Care 2024; 79:154445. [PMID: 37890356 DOI: 10.1016/j.jcrc.2023.154445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND A high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients. METHODS We included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7-0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables. RESULTS We included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = -0.59) and LVOT VTI (r = -0.41), as were both systemic vascular resistance index (r = -0.43) and LVEF (r = -0.23). CONCLUSION CICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment.
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Affiliation(s)
- Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America; Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Mitchell Padkins
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | | | - Anan Younis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Courtney Bennett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
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Benfor B, Haddad P, Bohle K, Atkins MD, Lumsden AB, Peden EK. Cardiovascular collapse during mechanical thrombectomy for acute pulmonary embolism and the role of extracorporeal membrane oxygenation in patient rescue. J Vasc Surg Venous Lymphat Disord 2023; 11:978-985.e3. [PMID: 37030443 DOI: 10.1016/j.jvsv.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Driven by the ability to avoid thrombolytics and provide a one stop procedure with immediate hemodynamic improvement, there has been a dramatic increase in the use of mechanical thrombectomy (MT) devices for the treatment of intermediate-to-high risk pulmonary embolism (PE). This study investigated the incidence and outcomes of cardiovascular collapse during MT procedures and demonstrates the role of extracorporeal membrane oxygenation (ECMO) in salvaging patients. METHODS This single-center retrospective review included patients with PE undergoing MT with the FlowTriever device between 2017 and 2022. Patients presenting periprocedural cardiac arrest were identified and their perioperative characteristics and postoperative outcomes were evaluated. RESULTS A total of 151 patients with a mean age of 64 ± 14 years who presented with intermediate-to-high risk PE received LBAT procedures during the study period. The simplified PE severity score was ≥1 in 83% of cases and the average RV/LV ratio was 1.6 ± 0.5, with and elevated troponin in 84%. Technical success was achieved in 98.7% and a significant decrease in pulmonary artery systolic pressure (PASP) was observed (37 mm Hg vs 56 mm Hg; P < .0001). Intraoperative cardiac arrest occurred in nine patients (6%). These patients were more likely to present PASP of ≥70 mm Hg (84% vs 14%; P < .001), were more hypotensive upon admission (systolic of 94 ± 14 mm Hg vs 119 ± 23 mm Hg; P = .004), presented lower oxygen saturation levels (87 ± 6% vs 92 ± 6%; P = .023) and were more likely to present with a history of recent surgery (67% vs 18%; P = .004). Four patients were rescued successfully with ECMO and their residual PE was subsequently removed before discharge by surgical embolectomy in two of the four cases and repeat MT in the other two. All five patients (3%) who did not receive ECMO support expired intraoperatively. The overall 30-day mortality was 8% with no death occurring in patients who were salvaged with ECMO. CONCLUSIONS Large-bore aspiration thrombectomy for acute PE is associated with favorable technical outcomes, but the concern for acute cardiac decompensation is non-negligible in patients presenting with high-risk features and a PASP of ≥70 mm Hg. ECMO can help to salvage some of these patients and should be considered in the treatment algorithms of patients deemed at high risk.
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Affiliation(s)
- Bright Benfor
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Paul Haddad
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Kihoon Bohle
- School of Engineering Medicine, Texas A&M University, Houston, TX
| | - Marvin D Atkins
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Alan B Lumsden
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX
| | - Eric K Peden
- Division of Vascular Surgery, Houston Methodist Debakey Heart and Vascular Center, Houston, TX.
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Van Wonderen SF, Pape M, Zuidema WP, Edwards MJR, Verhofstad MHJ, Tromp TN, Van Lieshout EMM, Bloemers FW, Geeraedts LMG. Sex Dimorphism in Outcome of Trauma Patients Presenting with Severe Shock: A Multicenter Cohort Study. J Clin Med 2023; 12:jcm12113701. [PMID: 37297896 DOI: 10.3390/jcm12113701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Background: The objective of this study was to determine the association between sex and outcome among severely injured patients who were admitted in severe shock. Methods: A retrospective multicenter study was performed in trauma patients (Injury Severity Score (ISS) ≥ 16) aged ≥ 16 presenting with severe shock (Shock Index > 1.3) over a 4-year period. To determine if sex was associated with mortality, Intensive Care Unit (ICU) admission, mechanical ventilation, blood transfusion and in-hospital complications, multivariable logistic regressions were performed. Results: In total, 189 patients were admitted to the Emergency Department in severe shock. Multivariable logistic regression analysis showed that female sex was independently associated with a decreased likelihood of acute kidney injury (OR 0.184; 95% CI 0.041-0.823; p = 0.041) compared to the male sex. A significant association between female sex and mortality, ICU admission, mechanical ventilation, other complications and packed red blood cells transfusion after admission could not be confirmed. Conclusion: Female trauma patients in severe shock were significantly less likely to develop AKI during hospital stay. These results could suggest that female trauma patients may manifest a better-preserved physiologic response to severe shock when compared to their male counterparts. Prospective studies with a larger study population are warranted.
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Affiliation(s)
- Stefan F Van Wonderen
- Department of Trauma Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Merel Pape
- Department of Trauma Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Wietse P Zuidema
- Department of Trauma Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Michael J R Edwards
- Department of Trauma Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Tjarda N Tromp
- Department of Trauma Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Leo M G Geeraedts
- Department of Trauma Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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The hypoxia-age-shock index at triage to predict the outcomes of Covid-19 patients. Am J Emerg Med 2023; 65:65-70. [PMID: 36586224 PMCID: PMC9773782 DOI: 10.1016/j.ajem.2022.12.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/05/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
STUDY OBJECTIVE The coronavirus disease 2019 (COVID-19) outbreak has caused a severe burden on medical professionals, as the rapid disposition of patients is important. Therefore, we aimed to develop a new clinical assessment tool based on the shock index (SI) and age-shock index (ASI). We proposed the hypoxia-age-shock index (HASI) and determined the usability of triage for COVID-19 infected patients in the first scene. METHODS The predictive power for three indexes on mortality, intensive care unit (ICU) admission, and endotracheal intubation rate was evaluated using the receiver operating curve (ROC). We used DeLong's method for comparing the ROCs. RESULTS The area under the curve (AUC) for ROC on mortality for SI, ASI, and HASI were 0.546, 0.771, and 0.773, respectively. The AUC on ICU admission mortality for SI, ASI, and HASI were 0.581, 0.700, and 0.743, respectively. The AUC for intubation for SI, ASI, and HASI were 0.592, 0.708, and 0.757, respectively. The AUC differences between HASI and SI showed statistically significant (P = 0.001) results on mortality, ICU admission, and intubation. Additionally, statistically significant results were found for the AUC difference between the HASI and ASI on ICU admission and intubation (P = 0.001 and P = 0.004, respectively). CONCLUSION HASI can provide a better prediction compared to ASI on ICU admission and endotracheal intubation. HASI was more sensitive in mortality, ICU admission, and intubation prediction than the ASI.
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Asim M, El-Menyar A, Chughtai T, Al-Hassani A, Abdelrahman H, Rizoli S, Al-Thani H. Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma. J Surg Res 2023; 283:438-448. [PMID: 36434840 DOI: 10.1016/j.jss.2022.10.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Shock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT. METHODS We conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality. RESULTS A total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = -0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = -0.377), Trauma and Injury Severity Score (r = -0.144), Revised Trauma Score (r = -0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02). CONCLUSIONS The present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.
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Affiliation(s)
- Mohammad Asim
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Talat Chughtai
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Sandro Rizoli
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Hassan Al-Thani
- Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
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Comparison of different scoring systems in predicting mortality and postoperative complications in acute care surgery patients at a Saudi Academic Centre. Eur J Trauma Emerg Surg 2023; 49:1321-1327. [PMID: 36631704 DOI: 10.1007/s00068-023-02218-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/31/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Emergency surgery carries an increased risk of death and complications. Scoring systems can help identify patients at higher risk of mortality and complications. Scoring systems can also help benchmark acute care services. This study aims to compare different scoring systems in predicting outcomes among acute care surgery patients. METHODS Our study is a retrospective cohort study that included all adult emergency surgery admissions between 2017 and 2019. Data were obtained from patients' electronic health records. Same admission mortality and postoperative complications were collected. Data were recorded to calculate the American Society of Anesthesiologists Physical Status classification system (ASA-PS), Shock Index Score (SI), Age Shock Index Score (AgeSI), and the Emergency Surgery Score (ESS). The probability of death and complications was correlated with each scoring system and was assessed by calculating the c-statistic. RESULTS During the study period, 1606 patients fulfilled inclusion criteria. The mortality rate was 2.2%, complication rate was 18.7%. ESS predicted mortality with a c-statistic of 0.87 better than ASA-PS, AgeSI, and SI with a calculated c-statistic of 0.81, 0.74, and 0.57, respectively. ESS also predicted the occurrence of complications with a c-statistic of 0.83 better than ASA-PS, AgeSI, and SI with a calculated c-statistic of 0.72, 0.71, and 0.63, respectively. CONCLUSION ESS demonstrated a better prognostic accuracy for hospital mortality and postoperative complications than other prognostic scoring systems. Our findings suggest that a scoring system designed for the acute care surgical population may provide enhanced prognostic performance over other surgical prognostic scoring systems.
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Hoch VC, Abdel-Hamid M, Liu J, Hall AE, Theyyunni N, Fung CM. ED point-of-care ultrasonography is associated with earlier drainage of pericardial effusion: A retrospective cohort study. Am J Emerg Med 2022; 60:156-163. [PMID: 35986978 PMCID: PMC9937040 DOI: 10.1016/j.ajem.2022.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To determine the association between emergency department point-of-care cardiac ultrasonography (POCUS) utilization and time to pericardial effusion drainage during an 8-year period when the emergency ultrasound program was established at our institution. METHODS We performed a single-center retrospective cohort study in patients undergoing pericardiocentesis or other procedure for evacuation of pericardial effusion. Data was collected using both direct queries to the electronic health record database and two-examiner chart review. The primary outcome was time to intervention for pericardial effusion drainage. Multivariable Cox regression, with and without inverse probability weighting for likelihood to receive POCUS, was used to determine the association between POCUS and time to intervention. Secondary outcomes included 28-day mortality. RESULTS 257 patient encounters were included with 137 receiving POCUS and 120 who did not. The proportion of patients receiving POCUS increased from 18.5% to 69.5% during the early to late periods of the study. POCUS was associated with an earlier median time to intervention of 21.6 h (95% CI 17.2, 24.2) compared to 34.6 h (27.0, 50.5) in the No POCUS group. After adjustment for patient demographics, anticoagulation, time of presentation and hemodynamic instability, POCUS was associated with earlier intervention (HR 2.08 [95% CI 1.56, 2.77]). POCUS use was not associated with a difference in 28-day mortality, which was evaluated as a secondary outcome. However, diagnosis of pericardial effusion by the ED physician using any means (POCUS or other imaging) was associated with decreased 28-day mortality (9.7% vs. 26.0%, -16.3% for POCUS [95% CI -29.1, -3.5]). CONCLUSION POCUS was associated with an earlier time to intervention for pericardial effusions after adjustment for multiple confounding factors. Failure to diagnose pericardial effusion in the ED using any diagnostic testing including POCUS, was associated with increased 28-day mortality.
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Affiliation(s)
- Victoria C Hoch
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mostafa Abdel-Hamid
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jia Liu
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ashley E Hall
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nik Theyyunni
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christopher M Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.
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Singh A, Kashav RC, Magoon R, Shri I, Kohli JK. Evolution of a Parsimonious Prognostic Index in COVID-19. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1750197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Armaanjeet Singh
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Ramesh Chand Kashav
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Iti Shri
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Jasvinder Kaur Kohli
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
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KABUL AIRPORT SUICIDE BOMBING ATTACK: MASS CASUALTY MANAGEMENT AT THE EMERGENCY'NGO HOSPITAL. J Trauma Acute Care Surg 2022; 93:552-557. [PMID: 35687804 DOI: 10.1097/ta.0000000000003724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Terrorist attacks with large numbers of civilian victims are not uncommon in war-torn countries, and present a unique challenge for health care facilities with limited resources. However, these events are largely under-reported and little is known about how the mass casualty events (MCE) are handled outside of a military setting. METHODS This study is a retrospective analysis of the MCE which ensued the Kabul Airport suicide attack (26th August 2021) at the Kabul EMERGENCY'NGO Hospital (Afghanistan). RESULTS Within six hours 93 causalities presented at our hospital. Out of them, 36 severe injured were admitted. Mean age was 30.8 years (SD 10.1). The most common injury mechanism was shell fragments. The most common injury site was head (63%; 23/36), followed by limbs (55.5%; 20/36) and thoracoabdominal region (30.5%; 11/36). Combined injuries occurred in 38.9% of cases. Patients receiving surgery presented more combined injuries in comparison with patients receiving only medical treatment (47.1% vs 31.6%). Thoraco-abdomen (25.0% vs 15.4%) and/or extremity injury (42.9% vs 28.6%) were more prevalent in the surgical group. Thirty major surgical procedures were carried out on 17 patients in the nine hours following the first arrival. The rate of Intensive Care Unit/High Dependency Unit admission was 36.1% and the 30-day in-hospital mortality was 16.6% (6/36). All deaths were recorded in the first 24 hours and none of them received surgery. CONCLUSIONS A large number of wounded patients must be anticipated after suicide bombing attacks. The authors report the challenges faced and key aspects of their management of MCEs. LEVEL OF EVIDENCE Retrospective analysis/incident management.
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van Bergen KM, van Kooten L, Eurlings CG, Foudraine NA, Lameijer H, Meeder JG, Rahel BM, Versteegen MG, van Osch FH, Barten DG. Prognostic value of the shock index and modified shock index in survivors of out-of-hospital cardiac arrest: A retrospective cohort study. Am J Emerg Med 2022; 58:175-185. [DOI: 10.1016/j.ajem.2022.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/19/2022] [Accepted: 05/21/2022] [Indexed: 12/09/2022] Open
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Spagnolello O, Gatti S, Esmati S, Shahir MAA, Portella G. Kabul airport suicide attack: report of a mass casualty. Eur J Trauma Emerg Surg 2022; 48:2687-2688. [PMID: 35178581 DOI: 10.1007/s00068-022-01898-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/30/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ornella Spagnolello
- EMERGENCY NGO Kabul Hospital, EMERGENCY Ong ONLUS, Kabul, Afghanistan. .,Department of Public Health and Infectious Diseases, University of Rome "La Sapienza", Rome, Italy.
| | - Sofia Gatti
- EMERGENCY NGO Kabul Hospital, EMERGENCY Ong ONLUS, Kabul, Afghanistan
| | - Shekiba Esmati
- EMERGENCY NGO Kabul Hospital, EMERGENCY Ong ONLUS, Kabul, Afghanistan
| | | | - Gina Portella
- EMERGENCY NGO Kabul Hospital, EMERGENCY Ong ONLUS, Kabul, Afghanistan
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Hagedoorn NN, Zachariasse JM, Borensztajn D, Adriaansens E, von Both U, Carrol ED, Eleftheriou I, Emonts M, van der Flier M, de Groot R, Herberg JA, Kohlmaier B, Lim E, Maconochie I, Martinón-Torres F, Nijman RG, Pokorn M, Rivero-Calle I, Tsolia M, Zavadska D, Zenz W, Levin M, Vermont C, Moll HA. Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study. Arch Dis Child 2022; 107:116-122. [PMID: 34158280 PMCID: PMC8784994 DOI: 10.1136/archdischild-2020-320992] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 06/06/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE (1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic value of the Shock Index for serious illness in febrile children. DESIGN/SETTING Observational study in 11 European EDs (2017-2018). PATIENTS Febrile children with measured blood pressure. MAIN OUTCOME MEASURES Serious bacterial infection (SBI), invasive bacterial infection (IBI), immediate life-saving interventions (ILSIs) and intensive care unit (ICU) admission. The association between high Shock Index (>95th centile) and each outcome was determined by logistic regression adjusted for age, sex, referral, comorbidity and temperature. Additionally, we calculated sensitivity, specificity and negative/positive likelihood ratios (LRs). RESULTS Of 5622 children, 461 (8.2%) had SBI, 46 (0.8%) had IBI, 203 (3.6%) were treated with ILSI and 69 (1.2%) were ICU admitted. High Shock Index was associated with SBI (adjusted OR (aOR) 1.6 (95% CI 1.3 to 1.9)), ILSI (aOR 2.5 (95% CI 2.0 to 2.9)), ICU admission (aOR 2.2 (95% CI 1.4 to 2.9)) but not with IBI (aOR: 1.5 (95% CI 0.6 to 2.4)). For the different outcomes, sensitivity for high Shock Index ranged from 0.10 to 0.15, specificity ranged from 0.95 to 0.95, negative LRs ranged from 0.90 to 0.95 and positive LRs ranged from 1.8 to 2.8. CONCLUSIONS High Shock Index is associated with serious illness in febrile children. However, its rule-out value is insufficient which suggests that the Shock Index is not valuable as a screening tool for all febrile children at the ED.
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Affiliation(s)
| | - Joany M Zachariasse
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dorine Borensztajn
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elise Adriaansens
- General Paediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr von Haunersches Children's Hospital, Children's Clinic and Children's Polyclinic of the Ludwig Maximilian University of Munich, Munchen, Germany,Partner Site Munich, German Centre for Infection Research, Braunschweig, Germany
| | - Enitan D Carrol
- Institute of Infection, Veterinary and Ecological Sciences, Global Health Liverpool, University of Liverpool, Liverpool, UK,Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Irini Eleftheriou
- Second Department of Paediatrics, P and A Kyriakou Children’s Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases and Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands,Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud University, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Ronald de Groot
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands,Section of Paediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud University, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Jethro Adam Herberg
- Division of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Emma Lim
- Paediatric Immunology, Infectious Diseases and Allergy, Great North Children's Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Federico Martinón-Torres
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ruud Gerard Nijman
- Division of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Marko Pokorn
- Department of Infectious Diseases, Ljubljana University Clinical Center, Ljubljana, Slovenia
| | - Irene Rivero-Calle
- Genetics, Vaccines, Infections and Paediatrics Research Group (GENVIP), University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Maria Tsolia
- Second Department of Paediatrics, P and A Kyriakou Children’s Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dace Zavadska
- Department of Pediatrics, Rigas Stradinas University, Riga, Latvia
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Division of Paediatric Infectious Diseases, Imperial College London, London, UK
| | - Clementien Vermont
- Department of Paediatric Infectious Diseases and Immunology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Henriette A Moll
- Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Tsai CL, Lu TC, Wang CH, Fang CC, Chen WJ, Huang CH. Trajectories of Vital Signs and Risk of In-Hospital Cardiac Arrest. Front Med (Lausanne) 2022; 8:800943. [PMID: 35047534 PMCID: PMC8761796 DOI: 10.3389/fmed.2021.800943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Little is known about the trajectories of vital signs prior to in-hospital cardiac arrest (IHCA), which could explain the heterogeneous processes preceding this event. We aimed to identify clinically relevant subphenotypes at high risk of IHCA in the emergency department (ED). Methods: This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 733,398 ED visits over a 7-year period. We selected one ED visit per person and retrieved patient demographics, triage data, vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature, respiratory rate, oxygen saturation), selected laboratory markers, and IHCA status. Group-based trajectory modeling was performed. Results: There were 37,697 adult ED patients with a total of 1,507,121 data points across all vital-sign categories. Three to four trajectory groups per vital-sign category were identified, and the following five trajectory groups were associated with a higher rate of IHCA: low and fluctuating SBP, high and fluctuating HR, persistent hypothermia, recurring tachypnea, and low and fluctuating oxygen saturation. The IHCA-prone trajectory group was associated with a higher triage level and a higher mortality rate, compared to other trajectory groups. Except for the persistent hypothermia group, the other four trajectory groups were more likely to have higher levels of C-reactive protein, lactic acid, cardiac troponin I, and D-dimer. Multivariable analysis revealed that hypothermia (adjusted odds ratio [aOR], 2.20; 95% confidence interval [95%CI], 1.35–3.57) and recurring tachypnea (aOR 2.44; 95%CI, 1.24–4.79) were independently associated with IHCA. Conclusions: We identified five novel vital-sign sub-phenotypes associated with a higher likelihood of IHCA, with distinct patterns in clinical course and laboratory markers. A better understanding of the pre-IHCA vital-sign trajectories may help with the early identification of deteriorating patients.
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Affiliation(s)
- Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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An Optimized Machine Learning Model Accurately Predicts In-Hospital Outcomes at Admission to a Cardiac Unit. Diagnostics (Basel) 2022; 12:diagnostics12020241. [PMID: 35204333 PMCID: PMC8871182 DOI: 10.3390/diagnostics12020241] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 11/21/2022] Open
Abstract
Risk stratification at the time of hospital admission is of paramount significance in triaging the patients and providing timely care. In the present study, we aim at predicting multiple clinical outcomes using the data recorded during admission to a cardiac care unit via an optimized machine learning method. This study involves a total of 11,498 patients admitted to a cardiac care unit over two years. Patient demographics, admission type (emergency or outpatient), patient history, lab tests, and comorbidities were used to predict various outcomes. We employed a fully connected neural network architecture and optimized the models for various subsets of input features. Using 10-fold cross-validation, our optimized machine learning model predicted mortality with a mean area under the receiver operating characteristic curve (AUC) of 0.967 (95% confidence interval (CI): 0.963–0.972), heart failure AUC of 0.838 (CI: 0.825–0.851), ST-segment elevation myocardial infarction AUC of 0.832 (CI: 0.821–0.842), pulmonary embolism AUC of 0.802 (CI: 0.764–0.84), and estimated the duration of stay (DOS) with a mean absolute error of 2.543 days (CI: 2.499–2.586) of data with a mean and median DOS of 6.35 and 5.0 days, respectively. Further, we objectively quantified the importance of each feature and its correlation with the clinical assessment of the corresponding outcome. The proposed method accurately predicts various cardiac outcomes and can be used as a clinical decision support system to provide timely care and optimize hospital resources.
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Hamade B, Murugan R, Lovelace E, Saul M, Huang DT, Al-Khafaji A. Shock Index, Modified Shock Index and MELD as Predictors of Mortality for Critically Ill Patients With Liver Disease. J Intensive Care Med 2021; 37:1037-1042. [PMID: 34812069 DOI: 10.1177/08850666211049749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Bachar Hamade
- 2569Center for Emergency Medicine - Emergency Services Institute, Department of Intensive Care and Resuscitation - Anesthesia Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Raghavan Murugan
- Department of CriticalCare Medicine, 20096University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Elijah Lovelace
- Veterans Affairs Pittsburgh Healthcare Systems - Center for HealthEquity Research and Promotion (CHERP), Pittsburgh, PA
| | - Melissa Saul
- 12317Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - David T Huang
- 6595Departments of Critical Care Medicine, Emergency Medicine, and Clinical and Translational Science, University of Pittsburgh MedicalCenter, Pittsburgh, PA
| | - Ali Al-Khafaji
- Departments of Critical Care Medicine and Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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van Rensen IHT, Hensgens KRC, Lekx AW, van Osch FHM, Knarren LHH, van Kampen-van den Boogaart VEM, Mehagnoul-Schipper JDJ, Wyers CE, van den Bergh JP, Barten DG. Early detection of hospitalized patients with COVID-19 at high risk of clinical deterioration: Utility of emergency department shock index. Am J Emerg Med 2021; 49:76-79. [PMID: 34087575 PMCID: PMC8137356 DOI: 10.1016/j.ajem.2021.05.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/02/2021] [Accepted: 05/16/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The COVID-19 outbreak has put an unprecedented strain on Emergency Departments (EDs) and other critical care resources. Early detection of patients that are at high risk of clinical deterioration and require intensive monitoring, is key in ED evaluation and disposition. A rapid and easy risk-stratification tool could aid clinicians in early decision making. The Shock Index (SI: heart rate/systolic blood pressure) proved useful in detecting hemodynamic instability in sepsis and myocardial infarction patients. In this study we aim to determine whether SI is discriminative for ICU admission and in-hospital mortality in COVID-19 patients. METHODS Retrospective, observational, single-center study. All patients ≥18 years old who were hospitalized with COVID-19 (defined as: positive result on reverse transcription polymerase chain reaction (PCR) test) between March 1, 2020 and December 31, 2020 were included for analysis. Data were collected from electronic medical patient records and stored in a protected database. ED shock index was calculated and analyzed for its discriminative value on in-hospital mortality and ICU admission by a ROC curve analysis. RESULTS In total, 411 patients were included. Of all patients 249 (61%) were male. ICU admission was observed in 92 patients (22%). Of these, 37 patients (40%) died in the ICU. Total in-hospital mortality was 28% (114 patients). For in-hospital mortality the optimal cut-off SI ≥ 0.86 was not discriminative (AUC 0.49 (95% CI: 0.43-0.56)), with a sensitivity of 12.3% and specificity of 93.6%. For ICU admission the optimal cut-off SI ≥ 0.57 was also not discriminative (AUC 0.56 (95% CI: 0.49-0.62)), with a sensitivity of 78.3% and a specificity of 34.2%. CONCLUSION In this cohort of patients hospitalized with COVID-19, SI measured at ED presentation was not discriminative for ICU admission and was not useful for early identification of patients at risk of clinical deterioration.
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Affiliation(s)
- Inge H T van Rensen
- VieCuri Medical Center, Department of Emergency Medicine, Venlo, the Netherlands.
| | - Kirsten R C Hensgens
- VieCuri Medical Center, Department of Emergency Medicine, Venlo, the Netherlands; VieCuri Medical Center, Intensive Care Unit, Venlo, the Netherlands.
| | - Anita W Lekx
- VieCuri Medical Center, Department of Emergency Medicine, Venlo, the Netherlands.
| | - Frits H M van Osch
- VieCuri Medical Center, Department of Epidemiology, Venlo, the Netherlands; Maastricht University Medical Center, School of Nutrition and Metabolism (NUTRIM), Maastricht, the Netherlands.
| | - Lieve H H Knarren
- VieCuri Medical Center, Department of Internal Medicine, Venlo, the Netherlands.
| | | | | | - Caroline E Wyers
- Maastricht University Medical Center, School of Nutrition and Metabolism (NUTRIM), Maastricht, the Netherlands; VieCuri Medical Center, Department of Internal Medicine, Venlo, the Netherlands; Maastricht University Medical Center, Department of Internal Medicine, Maastricht, the Netherlands.
| | - Joop P van den Bergh
- Maastricht University Medical Center, School of Nutrition and Metabolism (NUTRIM), Maastricht, the Netherlands; VieCuri Medical Center, Department of Internal Medicine, Venlo, the Netherlands; Maastricht University Medical Center, Department of Internal Medicine, Maastricht, the Netherlands.
| | - Dennis G Barten
- VieCuri Medical Center, Department of Emergency Medicine, Venlo, the Netherlands.
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22
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The Usefulness of Shock Index and Modified Shock Index in Predicting the Outcome of COVID-19 Patients. Disaster Med Public Health Prep 2021; 16:1558-1563. [PMID: 34099089 PMCID: PMC8376852 DOI: 10.1017/dmp.2021.187] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: The aim of this study is to investigate the accuracy of shock index (SI) and modified shock index (mSI) in predicting the intensive care unit (ICU) requirement and in-hospital mortality among coronavirus disease (COVID-19) patients who are admitted to the emergency department (ED). Likewise, the effects of patients’ conditions such as age, gender, and comorbidity on prognosis will be analyzed. Methods: The files were retrospectively scanned for all COVID-19 patients over the age of 18 years who were admitted to the ED and hospitalized between January 1, 2021, and March 15, 2021. The area under the receiver operating characteristic curve and the area under the curve (AUC) were used to assess each scoring system discriminatory for predicting in-hospital mortality and ICU admission. Results: There were 464 patients included in this study. The mean age of the patients was 62.4 ± 16.7, of which 245 were men and 219 were women. The most common comorbidity in patients was hypertension (200; 43.1%), followed by chronic obstructive pulmonary disease (174; 37.5%), and coronary artery disease (154; 33.2%). In terms of in-hospital mortality, the AUC of SI, and mSI were 0.719 and 0.739, respectively. In terms of an ICU requirement, the AUC of SI, and mSI were 0.704 and 0.729, respectively. Conclusion: In this study, it was concluded that SI and mSI are useful in predicting in-hospital mortality and ICU requirement in COVID-19 patients. In addition, another important result of the study is that advanced age, male gender, and hypertension may be associated with a poor prognosis.
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Dirks NPM, Mestrom M, van der Lugt M, van Osch F, Peters NALR, Elshof JWM, Barten DG. Utility of Shock Index for Suspected Rupture of Abdominal Aortic Aneurysms. PREHOSP EMERG CARE 2020; 25:496-503. [DOI: 10.1080/10903127.2020.1796184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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