Shock Index Predicts Outcome in Patients with Suspected Sepsis or Community-Acquired Pneumonia: A Systematic Review

Unveiling the potential role of the shock index in maternal sepsis: reality or fantasy?

OBJECTIVE

Maternal sepsis continues to be a maternal health problem associated with 75,000 deaths per year worldwide, representing a greater burden in low- and middle-income countries (LMICs). Although the Shock Index (SI) has been widely studied in postpartum hemorrhage and in non-obstetric populations, it has not yet been widely studied in sepsis. We aimed to identify the relationship between Shock Index and suspected sepsis in pregnant and postpartum patients to explore the use of Shock index in the context of maternal sepsis and its relationship with sepsis-related outcomes.

METHODS

A single-center, retrospective, case-control study was conducted, including pregnant and postpartum patients attended between June 2015 and December 2020 in a high-complexity university hospital. This study was conducted in a High Obstetric Complexity Unit (UACO) in the southwest region of Colombia. Pregnant or postpartum women with infectious processes of obstetric or non-obstetric origins were included. Cases had sepsis diagnosis; controls showed infection process and systemic inflammatory response signs without confirmed sepsis. Those with unconfirmed infections and preterm conditions were excluded. A logistic regression model was conducted to examine the association between maternal factors and sepsis diagnosis, and significant variables were determined through univariate analysis and included in a multivariate model.

RESULTS

A total of 640 patients were included (343 cases and 297 controls), sepsis was significantly associated with a higher shock index at admission SI ≥ 0.9 (85.4% vs 75%, p = 0.001). No correlation was found between the Shock Index and C-reactive protein (CRP), leukocyte count, or ICU length of stay. The area under the receiver operating characteristic curve (AUROC) analysis identified a Shock Index of 1 as the optimal cutoff point, while the cutoff point of 0.9 demonstrated the highest sensitivity (85%). An SI ≥ 0.9 increased the risk of sepsis 1.94 times (95% CI 1.31-2.91, p = 0.001) and remained significant in the adjustment model (OR_adj 2.18, 95% CI 1.42-3,32, p < 0.001). Incidence of maternal sepsis, incidence of maternal complications, and perinatal outcomes were measured with a SI ≥ 0.9.

CONCLUSION

Our findings underscore the importance of using the Shock Index with a cutoff point of 0.9 as a predictive tool for sepsis in pregnant patients, emphasizing the need for timely intervention and continuous monitoring of patients.

Assessment of the shock index in septic shock: A systematic review

OBJECTIVE

To identify published research on the Shock Index (SI) in patients with septic shock or severe sepsis and to describe its main findings and conclusions.

DESIGN

Systematic review of the literature following the recommendations of the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

SETTINGS

The following databases were consulted: Pubmed, Embase, Library Cochrane and Lilacs.

PATIENTS

Patients older than 14 years with septic shock. Pregnant women and population with COVID-19 were excluded.

INTERVENTIONS

Studies reporting measurement of the shock index or its modified variants.

MAIN VARIABLES OF INTEREST

Absolute frequencies and relative frequencies were assessed with measures of central tendency and dispersion. Effect estimators (OR, RR and HR) were extracted according to the context of each study.

RESULTS

Seventeen articles were included, of which 11 investigated the SI as a predictor of mortality. Seven of them found significant differences in the SI when comparing survivors to non-survivors and observed a relationship between the SI evolution and clinical outcomes. Additional research evidenced a relation between the Modified Shock Index and myocardial depression, as well as mortality. Furthermore, they identified a relationship between the Diastolic Shock Index, the dose of administered dobutamine, and mortality.

CONCLUSIONS

The results suggest that both the SI and its modified versions, particularly in serial assessments, can be considered for evaluating patient prognosis. The SI can also aid in determining fluid management for patients.

The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings

Sepsis poses a significant global health challenge in low- and middle-income countries (LMICs). Several aspects of sepsis management recommended in international guidelines are often difficult or impossible to implement in resource-limited settings (RLS) due to issues related to cost, infrastructure, or lack of trained healthcare workers. The Indian Society of Critical Care Medicine (ISCCM) drafted a position statement for the management of sepsis in RLS focusing on India, facilitated by a task force of 18 intensivists using a Delphi process, to achieve consensus on various aspects of sepsis management which are challenging to implement in RLS. The process involved a comprehensive literature review, controlled feedback, and four iterative surveys conducted between 21 August 2023 and 21 September 2023. The domains addressed in the Delphi process included the need for a position statement, challenges in sepsis management, considerations for diagnosis, patient management while awaiting an intensive care unit (ICU) bed, and treatment of sepsis and septic shock in RLS. Consensus was achieved when 70% or more of the task force members voted either for or against statements using a Likert scale or a multiple-choice question (MCQ). The Delphi process with 100% participation of Task Force members in all rounds, generated consensus in 32 statements (91%) from which 20 clinical practice statements were drafted for the management of sepsis in RLS. The clinical practice statements will complement the existing international guidelines for the management of sepsis and provide valuable insights into tailoring sepsis interventions in the context of RLS, contributing to the global discourse on sepsis management. Future international guidelines should address the management of sepsis in RLS.

How to cite this article

Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, et al. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024;28(S2):S4-S19.

Shock Index and Physiological Stress Index for reestratifying patients with intermediate-high risk pulmonary embolism

OBJECTIVE

Study and Evaluation of Two Scores: Shock Index (SI) and Physiological Stress Index (PSI) as discriminators for proactive treatment (reperfusion before decompensated shock) in a population of intermediate-high risk pulmonary embolism (PE).

DESIGN

Using a database from a retrospective cohort with clinical variables and the outcome variable of "proactive treatment", a comparison of the populations was conducted. Optimal cut-off for "proactive treatment" points were obtained according to the SI and PSI. Comparisons were carried out based on the cut-off points of both indices.

SETTING

Patients admitted to a mixed ICU for PE.

PARTICIPANTS

Patients >18 years old admitted to the ICU with intermediate-high risk PE recruited from January 2015 to October 2022.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Population comparison and metrics regarding predictive capacity when determining proactive treatment.

RESULTS

SI and PSI independently have a substandard predictive capacity for discriminating patients who may benefit from an early reperfusion therapy. However, their combined use improves detection of sicker intermediate-high risk PE patients (Sensitivity = 0.66) in whom an early reperfusion therapy may improve outcomes (Specificity = 0.9).

CONCLUSIONS

The use of the SI and PSI in patients with intermediate-high risk PE could be useful for selecting patients who would benefit from proactive treatment.

Association between baseline hemodynamic indices, cardiotoxicity risk, and survival in women with breast cancer

BACKGROUND

The outcome of breast cancer (BrCa) women monitored by low-dose equilibrium radionuclide angiography (ERNA) remains challenging to predict.

AIM

This study aims to determine whether heart rate (HR)/blood pressure (BP) ratio-based indexes, previously confirmed to predict outcomes of various diseases, also predict BrCa-therapy-related cardiotoxicity and survival.

METHODS

Predictors of cardiotoxicity and survival were determined among pre-therapy variables, including shock index ([SI HR/systolic BP) and age-adjusted SI (ASI), in a female BrCa cohort with normal baseline ERNA-left ventricular ejection fraction (LVEF).

RESULTS

We included 274 women with a median age of 54.8 (interquartile range: 45.5-65.4) years, 271 treated with anthracyclines and 96 with trastuzumab. During a median follow-up of 25.9 (18.6-33.5) months, 31 women developed cardiotoxicity (LVEF: <50% and ≥10% drop from baseline), and 25 died. Baseline ASI was a multivariate predictor (p < 0.001) of (i) cardiotoxicity, in association with trastuzumab treatment (p = 0.010), and LV end-diastolic volume (p = 0.001) and (ii) survival, in association with metastasis (p < 0.001) and estimated glomerular filtration rate (p = 0.008). Cardiotoxicity poorly impacted survival (p = 0.064). The 36-month cardiotoxicity and mortality rates were markedly higher for patients in the upper half of baseline ASI values (ASI: >30 years min-1.mmHg-1, 16.5% and 20.7%, respectively) than in the lower half (7.6% and 4.5%, respectively, both p < 0.05).

CONCLUSIONS

In BrCa women with normal baseline ERNA-LVEF, HR/BP ratio-based indexes unmask hemodynamic profiles associated with increased cardiotoxicity risk and decreased survival, highlighting the need for a comprehensive assessment of cardiac- and vascular-related risks in BrCa women monitored by ERNA.

CONDENSED ABSTRACT

In a cohort of 274 women BrCa women who were monitored by ERNA for potentially cardiotoxic drugs (anthracyclines or trastuzumab) and who had no history of cardiac disease and a normal left ventricular ejection fraction before treatment, baseline indexes based on HR/BP ratios unmask hemodynamic profiles strongly associated with an increased risk of cardiotoxicity and subsequently decreased survival. Although further validations in other cohorts are needed, these findings highlight the need for a more comprehensive assessment of the cardiac- and vascular-related risk in BrCa women monitored by ERNA.

Reverse shock index multiplied by simplified motor score as a predictor of clinical outcomes for patients with COVID-19

BACKGROUND

The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM).

METHODS

All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden's index.

RESULTS

After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33-60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively.

CONCLUSIONS

Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.

The new combination of oxygen saturation with age shock index predicts the outcome of COVID-19 pneumonia

Introduction

Emergency departments around the world have been struggling to deal with patients with COVID-19 and presumed COVID-19. Triaging patients who need further medical support is the key matter to emergency physicians as the delay of proper treatment may worsen the results. The aim of this study was to validate the ability of age shock index and hypoxia-age-shock index at the time of presentation to the emergency department to predict case fatality in patients with COVID-19 pneumonia.

Methods

We only included patients who had COVID-19-associated pneumonia who needed in-hospital treatment. The vital signs and oxygen saturation used in the study were collected, especially from the triage sector, before patients were given supplemental oxygen.

Results

A total of 241 patients enrolled in the study. The case fatality rate was 27%. The median age of the study samples was 78 (66-86) years with 133 male and 108 female patients. Hypoxia-age-shock index showed the best performance in analysis (odds ratio 15.1, 95% confidence interval: 5.1-44.4; adjusted odds ratio 8.6, 95% confidence interval: 2.8-26.8).

Conclusion

The hypoxia-age-shock index was a strong predictor for in-hospital mortality of COVID-19 pneumonia. Furthermore, when it was compared with age shock index, hypoxia-age-shock index showed better performance in predicting fatality of the disease.

The reverse shock index multiplied by the Glasgow Coma Scale score can predict the need for initial resuscitation in patients suspected of sepsis

For patients suspected of sepsis, early recognition of the need for initial resuscitation is key in management. This study evaluated the ability of a modified shock index - the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) - to predict the need for initial resuscitation in patients with sepsis. This retrospective study involved adults with infection who were admitted to a Japanese tertiary care hospital from an emergency department between January and November 2020. The rSIG, modified Early Warning Score (MEWS), quick Sequential Organ Failure Assessment (qSOFA), and original shock index (SI) values were recorded using initial vital signs. The primary outcome was the area under the receiver-operating characteristic curve (AUROC) for the composite outcome consisting of vasopressor use, mechanical ventilation, and 72-h mortality. Secondary outcomes were the AUROCs for each component of the primary outcome and 28-day mortality. As a result, the primary outcome was met by 67 of the 724 patients (9%). The AUROC was significantly higher for the rSIG than for the other tools (rSIG 0.84 [0.78 - 0.88]; MEWS 0.78 [0.71 - 0.84]; qSOFA 0.72 [0.65 - 0.79]; SI 0.80 [0.74 - 0.85]). Compared with MEWS and qSOFA, the rSIG also had a higher AUROC for vasopressor use and mechanical ventilation, but not for 72-h mortality or in-hospital mortality. The rSIG could be a simple and reliable predictor of the need for initial resuscitation in patients suspected of sepsis.

Shock index in the emergency department as a predictor for mortality in COVID-19 patients: A systematic review and meta-analysis

Background

The shock index (SI) ratio serves as a straightforward predictor to identify patients who are either at risk of or experiencing shock. COVID-19 patients with shock face increased mortality risk and reduced chances of recovery. This review aims to determine the role of SI in the emergency department (ED) to predict COVID-19 patient outcomes.

Methods

The systematic search was conducted in PubMed, ProQuest, Scopus, and ScienceDirect on June 16, 2023. We included observational studies evaluating SI in ED and COVID-19 patient outcomes. Random-effect meta-analysis was done to generate odds ratios of SI as the predictor of intensive care unit (ICU) admission and mortality. The sensitivity and specificity of SI in predicting these outcomes were also pooled, and a summary receiver operating characteristics (sROC) curve was generated.

Results

A total of eight studies involving 4557 participants were included in the pooled analysis. High SI was found to be associated with an increased risk of ICU admission (OR 5.81 [95%CI: 1.18-28.58], p = 0.03). Regarding mortality, high SI was linked to higher rates of in-hospital (OR 7.45 [95%CI: 2.44-22.74], p = 0.0004), within 30-day (OR 7.34 [95%CI: 5.27-10.21], p < 0.00001), and overall (OR 7.52 [95%CI: 3.72-15.19], p < 0.00001) mortality. The sensitivity and specificity of SI for predicting ICU admission were 76.2% [95%CI: 54.6%-89.5%] and 64.3% [95%CI: 19.6%-93.0%], respectively. In terms of overall mortality, the sensitivity and specificity were 54.0% (95%CI: 34.3%-72.6%) and 85.9% (95%CI: 75.8%-92.3%), respectively, with only subtle changes for in-hospital and within 30-day mortality. Adjustment of SI cut-off to >0.7 yielded improved sensitivity (95%CI: 78.0% [59.7%-89.4%]) and specificity (95%CI: 76.8% [41.7%-93.9%]) in predicting overall mortality.

Conclusion

SI in emergency room may be a simple and useful triage instrument for predicting ICU admission and mortality in COVID-19 patients. Future well-conducted studies are still needed to corroborate the findings of this study.

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

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.

Shock Index Is a Validated Prediction Tool for the Short-Term Survival of Advanced Cancer Patients Presenting to the Emergency Department

Advanced cancer patients who are not expected to survive past the short term can benefit from early initiation of palliative care in the emergency department (ED). This discussion, however, requires accurate prognostication of their short-term survival. We previously found in our retrospective study that shock index (SI) is an ideal risk stratification tool in predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. This study is a follow-up prospective validation study conducted from January 2019 to April 2021. A total of 410 advanced cancer patients who presented to the ED of a medical centre and could be followed-up feasibly were recruited. Univariate and multivariable logistic regression analyses were performed with receiver operator calibrating (ROC) curve analysis. Non-survivors had significantly lower body temperatures, higher pulse rates, higher respiratory rates, lower blood pressures, and higher SI. Each 0.1 increment of SI increased the odds of 60-day mortality by 1.591. Area under ROC curve was 0.7819. At optimal cut-off of 0.94, SI had 66.10% accuracy. These results were similar to our previous study, thus validating the use of SI in predicting the 60-day mortality of advanced cancer patients presenting to the ED. Identified patients may be offered palliative care.

Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis

PURPOSE

The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1.

METHODS

This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa.

RESULTS

We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low.

CONCLUSIONS

This systematic review found a fourfold increased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Improving the EHMRG Prognostic Evaluation of Acute Heart Failure with TAPSE/PASp: A Sequential Approach

The Emergency Heart Failure Mortality Risk Grade (EHMRG) can predict short-term mortality in patients admitted for acute heart failure (AHF) in the emergency department (ED). This paper aimed to evaluate if TAPSE/PASp, an echocardiographic marker of ventricular desynchronization, can improve in-hospital death prediction in patients at moderate-to-high risk, according to EHMRG score classification. From 1 January 2018 to 30 December 2019, we retrospectively enrolled all the consecutive subjects admitted to our Internal Medicine Department for AHF from the ED. We performed bedside echocardiography within the first 24 h of admission. We evaluated EHMRG and NYHA in the ED, days of admission in Internal Medicine, and in-hospital mortality. We assessed cutoffs with ROC curve analysis and survival with Kaplan–Meier and Cox regression. We obtained a cohort of 439 subjects; 10.3% underwent in-hospital death. Patients with normal TAPSE/PASp in EHMRG Classes 4, 5a, and 5b had higher survival rates (100%, 100%, and 94.3%, respectively), while subjects with pathologic TAPSE/PASp had lower survival rates (81.8%, 78.3%, and 43.4%, respectively) (p < 0.0001, log-rank test). TAPSE/PASp, an echocardiographic marker of ventricular desynchronization, can further stratify the risk of in-hospital death evaluated by EHMRG.

Shock index predicts up to 90-day mortality risk after intracerebral haemorrhage

BACKGROUND

Shock index (SI - heart rate/systolic blood pressure) has been studied as a measure of haemodynamic status. We aimed to determine whether SI measures within 72 h of admission were associated with adverse outcomes in intracerebral haemorrhage (ICH).

METHODS

Patients were drawn from the Virtual International Stroke Trials Archive-Intracerebral Haemorrhage (VISTA-ICH). Multivariable Cox regressions modelled the relationship between SI (on admission, 24, 48, 72 h) and mortality (at 3-, 7-, and 90-days), 90-day incident pneumonia and cardiovascular events (MACE). Ordinal logistic regressions modelled the relationship between SI and 90-day modified Rankin Scale (mRS).

RESULTS

979 patients were included. Baseline SI was not associated with mortality. 24 h SI > 0.7 was associated with 7-day mortality (hazard ratio (95% confidence interval) = 3.14 (1.37-7.19)). 48 h and 72 h SI > 0.7 were associated with 7-day (4.23 (2.07-8.66) and 3.24 (1.41-7.42) respectively) and 90-day mortality (2.97 (1.82-4.85) and 2.05 (1.26-3.61) respectively). SI < 0.5 at baseline, 48 h and 72 h was associated with decreased pneumonia risk. 24 h and 48 h SI > 0.7was associated with increased MACE risk. 48 h and 72 h SI > 0.7 was associated with increased odds of higher 90-day mRS.

CONCLUSION

Higher-than-normal SI subsequent to initial encounter was associated with higher post-ICH mortality at 3, 7, and 90 days. Lower-than-normal SI was associated with a decreased risk of incident pneumonia.

Non reducible inguinal hernias in Malawi: an occupational hazard

PURPOSE

Inguinal hernias are one of the most common surgical conditions worldwide. Due to limited surgical access in low- and middle-income countries, many hernias present emergently; however, data on the resultant outcome disparities is limited. We, therefore, sought to describe the epidemiology, clinical features, and outcomes of incarcerated inguinal hernias at a tertiary center in Malawi.

METHODS

This is a retrospective analysis of the acute care surgery registry at Kamuzu Central Hospital in Lilongwe, Malawi. All patients > 13 years admitted with a non-reducible inguinal hernia from 2013 to 2019 were included. The primary outcome was in-hospital mortality. A Poisson multivariable regression determined factors associated with increased risk of mortality.

RESULTS

A total of 297 patients presented with non-reducible inguinal hernias, the majority of which were young (median age 38), male (93.6%), farmers (47.8%). Of the 81% who underwent surgery, 55% were delayed ≥ 24 h. 19.5% of hernias were strangulated. Overall mortality was 5.4%. Increased age (RR 1.06, 95% CI 1.01-1.12), shock index ≥ 1 (RR 4.82, 95% CI 1.45-16.09), and delay ≥ 24 h from presentation to operative intervention (RR 11.24, 95% CI 1.55-81.34) resulted in an increase in relative risk of mortality.

CONCLUSION

Non-reducible inguinal hernias largely affect young male farmers in Malawi. Delays to care can limit economic productivity for this rural population, as well as, yield considerable risk of mortality. While specific patient and institutional factors must be further elucidated, increased awareness, public health prioritization, and surgical capacity building is needed to reduce further hernia-related morbidity and mortality.

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

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.

Shock Index-C: An Updated and Simple Risk-Stratifying Tool in ST-Segment Elevation Myocardial Infarction

Background: Shock index (heart rate/systolic blood pressure, SI) is a simple scale with prognostic value in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). The present study introduces an updated version of SI that includes renal function.

Methods: A total of 1,851 consecutive patients with STEMI undergoing PCI were retrospectively included at Cardiac Care Unit in Guangdong Provincial People's Hospital and divided into two groups according to their admission time: derivation database (from January 2010 to December 2013, n = 1,145) and validation database (from January 2014 to April 2016, n = 706). Shock Index-C (SIC) was calculated as (SI × 100)–estimated CCr. Calibration was evaluated using the Hosmer-Lemeshow statistic. The predictive power of SIC was evaluated using receiver operating characteristic (ROC) curve analysis.

Results: The predictive value and calibration of SIC for in-hospital death was excellent in derivation [area under the curve (AUC) = 0.877, p < 0.001; Hosmer-Lemeshow chi-square = 3.95, p = 0.861] and validation cohort (AUC = 0.868, p < 0.001; Hosmer-Lemeshow chi-square = 5.01, p = 0.756). SIC exhibited better predictive power for in-hospital events than SI (AUC: 0.874 vs. 0.759 for death; 0.837 vs. 0.651 for major adverse clinical events [MACEs]; 0.707 vs. 0.577 for contrast-induced acute kidney injury [CI-AKI]; and 0.732 vs. 0.590 for bleeding, all p < 0.001). Cumulative 1-year mortality was significantly higher in the upper SIC tertile (log-rank = 131.89, p < 0.001).

Conclusion: SIC was an effective predictor of poor prognosis and may have potential as a novel and simple risk stratification tool for patients with STEMI undergoing PCI.

The Development and Validation of a Machine Learning Model to Predict Bacteremia and Fungemia in Hospitalized Patients Using Electronic Health Record Data

OBJECTIVES

Bacteremia and fungemia can cause life-threatening illness with high mortality rates, which increase with delays in antimicrobial therapy. The objective of this study is to develop machine learning models to predict blood culture results at the time of the blood culture order using routine data in the electronic health record.

DESIGN

Retrospective analysis of a large, multicenter inpatient data.

SETTING

Two academic tertiary medical centers between the years 2007 and 2018.

SUBJECTS

All hospitalized patients who received a blood culture during hospitalization.

INTERVENTIONS

The dataset was partitioned temporally into development and validation cohorts: the logistic regression and gradient boosting machine models were trained on the earliest 80% of hospital admissions and validated on the most recent 20%.

MEASUREMENTS AND MAIN RESULTS

There were 252,569 blood culture days-defined as nonoverlapping 24-hour periods in which one or more blood cultures were ordered. In the validation cohort, there were 50,514 blood culture days, with 3,762 cases of bacteremia (7.5%) and 370 cases of fungemia (0.7%). The gradient boosting machine model for bacteremia had significantly higher area under the receiver operating characteristic curve (0.78 [95% CI 0.77-0.78]) than the logistic regression model (0.73 [0.72-0.74]) (p < 0.001). The model identified a high-risk group with over 30 times the occurrence rate of bacteremia in the low-risk group (27.4% vs 0.9%; p < 0.001). Using the low-risk cut-off, the model identifies bacteremia with 98.7% sensitivity. The gradient boosting machine model for fungemia had high discrimination (area under the receiver operating characteristic curve 0.88 [95% CI 0.86-0.90]). The high-risk fungemia group had 252 fungemic cultures compared with one fungemic culture in the low-risk group (5.0% vs 0.02%; p < 0.001). Further, the high-risk group had a mortality rate 60 times higher than the low-risk group (28.2% vs 0.4%; p < 0.001).

CONCLUSIONS

Our novel models identified patients at low and high-risk for bacteremia and fungemia using routinely collected electronic health record data. Further research is needed to evaluate the cost-effectiveness and impact of model implementation in clinical practice.

Appendicitis Mortality in a Resource-Limited Setting: Issues of Access and Failure to Rescue

BACKGROUND

Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi.

METHODS

We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality.

RESULTS

We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation.

CONCLUSIONS

Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Prognostic performance of peripheral perfusion index and shock index combined with ESI to predict hospital outcome

INTRODUCTION

Peripheral perfusion index (PPI) and shock index (SI) are considered valuable predictors of hospital outcome and mortality in various operative and intensive care settings. In the present study, we evaluated the prognostic capabilities of these parameters for performing emergency department (ED) triage, as represented by the emergency severity index (ESI).

METHODS

This prospective cross-sectional study included 367 patients aged older than 18 years who visited the ED of a tertiary referral hospital. The ESI triage levels with PPI, SI, and other basic vital sign parameters were recorded for each patient. The hospital outcome of the patients at the end of the ED period, such as discharge, admission to the hospital and death were recorded.

RESULTS

A total of 367 patients (M/F: 178/189) admitted to the ED were categorized according to ESI and included in the study. A decrease in diastolic BP, SpO2 and PPI increased the likelihood of hospitalization and 30-day mortality. Based on univariate analysis, a significant improvement in performance was found by using age, diastolic BP, mean arterial pressure, SpO2, SI and PPI in terms of predicting high acuity level patients (ESI < 3). In the multivariable analysis only SpO2 and PPI were found to predict ESI < 3 patients.

CONCLUSION

Peripheral perfusion index and SI as novel triage instruments might provide useful information for predicting hospital admission and mortality in ED patients. The addition of these parameters to existing triage instruments such as ESI could enhance the triage specificity in unselected patients admitted to ED.

Equivalency between the shock index and subtracting the systolic blood pressure from the heart rate: an observational cohort study

Background

Although the shock index is known to predict mortality and other severe outcomes, deriving it requires complex calculations. Subtracting the systolic blood pressure from the heart rate may produce a simple shock index that would be a clinically useful substitute for the shock index. In this study, we investigated whether the simple shock index was equivalent to the shock index.

Methods

This observational cohort study was conducted at 2 tertiary care hospitals. Patients who were transported by ambulance were recruited for this study and were excluded if they were aged < 15 years, had experienced prehospital cardiopulmonary arrest, or had undergone inter-hospital transfer. Pearson’s product-moment correlation coefficient and regression equation were calculated, and two one-sided tests were performed to examine their equivalency.

Results

Among 5429 eligible patients, the correlation coefficient between the shock index and simple shock index was extremely high (0.917, 95% confidence interval 0.912 to 0.921, P < .001). The regression equation was estimated as sSI = 258.55 log SI. The two one-sided tests revealed a very strong equivalency between the shock index and the index estimated by the above equation using the simple shock index (mean difference was 0.004, 90% confidence interval 0.003 to 0.005).

Conclusion

The simple shock index strongly correlated with the shock index.