Analysis of risk factors for acute moderate to high risk pulmonary thromboembolism in adults / 中国医师杂志

Objective:To investigate the risk factors according to the clinical data of the adult patients with acute moderate to high risk pulmonary thromboembolism (PTE).Methods:The clinical data of 100 adult patients with acute moderate-risk PTE in Hunan Provincial People′s Hospital from June 2019 to March 2022 were analyzed retrospectively. According to the risk stratification, they were divided into moderate to low risk group (34 cases) and moderate to high risk group (66 cases). The laboratory data and clinical data of all adult patients were collected, and the independent risk factors of acute moderate to high risk PTE in adults were analyzed by binary logistic regression; Receiver operating characteristic (ROC) curve was used to analyze the predictive ability of independent risk factors for acute moderate to high risk PTE.Results:There were 34 patients with moderate to low risk PTE, 20 males and 14 females, aged 16-86 (60.2±15.5)years, 66 patients with moderate to high risk PTE, 36 males and 30 females, aged 34-82(63.6±9.6)years. There was no significant difference in age, gender and risk factors between the two groups (all P>0.05). The tumor history of concomitant diseases in moderate to high risk group was significantly higher than that in moderate to low risk group, and the symptoms of dyspnea and shortness of breath in moderate to high risk group were significantly higher than those in moderate to low risk group (all P>0.05). The levels of troponin I, shock index (SI) and N-terminal B-type brain natriuretic peptide precursor (NT-proBNP) in moderate to high risk group were significantly higher than those in moderate to low risk group, while the levels of PaO 2 and oxygenation index in moderate to high risk group were significantly lower than those in moderate to low risk group, with statistical significant difference (all P<0.05). Echocardiographic results showed that there were significant differences in right ventricular inner diameter (RV), left ventricular inner diameter (LV), RV/LV, tricuspid regurgitation velocity and pulmonary systolic pressure between moderate to high risk PTE patients and moderate to low risk PTE patients (all P>0.05). CTPA results showed that RV, RV/LV, main pulmonary artery diameter and thrombus load in moderate to high risk PTE patients were significantly higher than those in moderate to low risk PTE patients (all P<0.05). Multivariate binary logistic regression analysis showed that SI, NT-proBNP and RV were independent predictors of moderate to high risk PTE (all P<0.05). The combined detection of SI, NT-proBNP and RV had a good predictive value for moderate to high risk PTE. The area under ROC curve (AUC) was 0.984, the sensitivity and specificity were 90.32% and 97.73%, respectively. The negative predictive value was 87.8%, and the positive predictive value was 98.2%. Conclusions:SI, NT-proBNP, RV of echocardiography and RV of CTPA are the predictors of acute moderate to high risk PTE in adults, which provided a strong supplement for the risk stratification of acute moderate risk PTE in adults.

Caracterización del índice de choque como variable al ingreso en una Unidad de Cuidados Intensivos Polivalente

Introducción: El índice de choque ha sido propuesto como un parámetro eficaz, barato y fácilmente realizable para la determinación del pronóstico del desarrollo de complicaciones e incluso la muerte. Objetivo: Describir los valores del índice de choque al ingreso, de los pacientes ingresados en la en la Unidad de Cuidados Intensivos del Hospital General Docente "Vladimir Ilich Lenin" de Holguín, Cuba, entre junio-diciembre de 2019. Método: Se realizó un estudio transversal descriptivo, donde de un universo de 98 pacientes ingresados en dicha unidad (N=98) la muestra quedó conformada por 77 pacientes (n=77) a través de un muestreo no probabilístico. Las variables evaluadas fueron: APACHE II, índice de choque, diagnóstico etiológico presuntivo, qSOFA y lactato sérico. Como instrumento de la investigación se implantó un formulario de recolección de datos. Se utilizó el paquete estadístico SPSS versión 24. Para el procesamiento de las variables cuantitativas se empleó la media y la desviación estándar. Resultados: Las enfermedades predominantes fueron la hemorragia puerperal, el posoperatorio complicado y la preeclampsia. El 54,5 % presentó valores normales de lactato sérico y el 59,7 % presentó valores de qSOFA normales o bajos. El 84,2 % mostró valores bajos de APACHE II al ingreso. El 58,5 % de los pacientes presentó un índice de choque mayor de 0,7. Conclusiones: Los pacientes ingresados en la UCI muestran mayor alteración del índice de choque que de variables más conocidas y ampliamente utilizadas (APACHE II, qSOFA y lactato sérico).

Introduction: The shock index has been proposed as an effective, cheap and easily achievable parameter for the prognosis of possible complications and even death. Objective: To describe the shock index values in patients admitted to Intensive Care Unit at the Hospital General Docente "Vladimir Ilich Lenin" de Holguín, Cuba, throughout June to December 2019. Method: A descriptive cross-sectional study was performed in which 98 patients (N=98) admitted to ICU were selected as universe, the sample consisted of 77 patients (n=77) through non-probabilistic sampling. Variables evaluated were as follow: APACHE II system, shock index, presumptive etiologic diagnosis, qSOFA score and serum lactate level. A data collection form was used as a research instrument. The SPSS version 24 statistical package was used. The mean and standard deviation were used to process the quantitative variables. Results: The predominant diseases found were postpartum hemorrhage, the postoperative complication and pre-eclampsia disorder. Serum lactate values were normal in 54.5% of studied patients and normal or low qSOFA values in 59.7%. The 84.2% showed low APACHE II values on admission and 58.5% had a shock index greater than 0.7. Conclusions: Patients admitted to the ICU show greater alterations in the shock index than in better known and widely used variables like (APACHE II, qSOFA and serum lactate).

Introdução: O índice de choque tem sido proposto como um parâmetro eficaz, barato e facilmente alcançável para determinar o prognóstico para o desenvolvimento de complicações e até morte. Objetivo: Descrever os valores do índice de choque na admissão, dos pacientes internados na Unidade de Terapia Intensiva do Hospital General Docente "Vladimir Ilich Lenin" em Holguín, Cuba, entre junho e dezembro de 2019. Método: Um cruzamento descritivo -estudo seccional, onde de um universo de 98 doentes internados na referida unidade (N=98) a amostra foi constituída por 77 doentes (n=77) através de uma amostragem não probabilística. As variáveisavaliadas foram: APACHE II, índice de choque, diagnóstico etiológico presuntivo, qSOFA e lactato sérico. Como instrumento de pesquisa, implementou-se um formulário de coleta de dados. Foi utilizado o pacote estatístico SPSS versão 24. Para o processamento das variáveis quantitativas foram utilizados a média e o desvio padrão. Resultados: As doenças predominantes foram hemorragia pós-parto, pós-operatório complicado e pré-eclâmpsia. 54,5% tinham valores de lactato sérico normais e 59,7% tinham valores de qSOFA normais ou baixos. 84,2% apresentaram baixos valores de APACHE II na admissão. 58,5% dos pacientes apresentaram índice de choque maior que 0,7. Conclusões: Os pacientes internados na UTI apresentam maiores alterações no índice de choque do que em variáveis mais conhecidas e amplamente utilizadas (APACHE II, qSOFA e lactato sérico).

The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study

ABSTRACT BACKGROUND: Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients. OBJECTIVE: To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding. DESIGN AND SETTING: Prospective cohort study in an emergency department in Bursa, Turkey. METHODS: Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated. RESULTS: A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001). CONCLUSION: The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.

Déficit de base, lactato e índice de shock como predictores de mortalidad en lesionados múltiples / Base Deficit, Lactate and Shock Index as Mortality Predictors in Trauma Patients

Introducción: Las respuestas fisiológicas a la hemorragia, como hipotensión y taquicardia, no siempre son proporcionales al estado de choque, lo cual ha llevado a la necesidad de usar otros predictores. Objetivo: Analizar el comportamiento del déficit de base, lactato e índice de shock severo como predictores de mortalidad en pacientes lesionados múltiples. Métodos: Se realizó un estudio analítico, observacional y retrospectivo en el Servicio de Anestesiología y Reanimación del Hospital Universitario "General Calixto García", entre agosto de 2018 y agosto de 2020. La muestra fue de 50 pacientes, según criterio de selección no probabilístico del investigador. Resultados: Los pacientes que sufrieron trauma craneal tuvieron siete veces más riesgo de morir. El índice de shock severo, a las tres horas triplicó el riesgo de morir. El lactato y el déficit de base se correlacionaron con un índice de shock mayor de uno, de forma significativa. La transfusión sanguínea duplicó el riesgo de morir, mientras que los requerimientos de aminas, no mostraron ser factores de mal pronóstico. Dentro de las complicaciones la respuesta inflamatoria sistémica mostró tener nueve veces mayor riesgo de morir y la disfunción múltiple de órgano siete veces, pero la presencia de neumonía no influyó en la muerte. Conclusiones: El índice de shock severo se consideró un factor pronóstico de mortalidad en pacientes politraumatizados al triplicar el riesgo de morir y guardó relación con el lactato elevado y la alteración de los valores del déficit de bases(AU)

Introduction: Physiological responses to hemorrhage, such as hypotension and tachycardia, are not always proportional to the state of shock, which has led to the need to use other predictors. Objective: To analyze the characteristics of base deficit, lactate and severe shock index as predictors of mortality in multiply injured patients. Methods: An analytical, observational and retrospective study was carried out in the anesthesiology and resuscitation service of General Calixto García University Hospital, between August 2018 and August 2020. The sample was made up of 50 patients, according to nonprobabilistic selection criteria of the researcher. Results: Patients who suffered cranial trauma were seven times more likely to die. The index of severe shock at three hours tripled the risk of death. Lactate and baseline deficit correlated significantly with shock index greater than one. Blood transfusion doubled the risk of death, while amine requirements were not shown to be poor prognostic factors. Among complications, systemic inflammatory response was shown to have nine times higher risk of dying and multiple organ dysfunction seven times, but the presence of pneumonia did not influence death. Conclusions: The severe shock index was considered a prognostic factor for mortality in polytraumatized patients, as far as it tripled the risk of dying and was related to elevated lactate and altered base deficit values(AU)

Transfusão maciça em pacientes vítimas de trauma: uma coorte não concorrente / Massive transfusion in trauma patients: a non-concurrent cohort study

As causas externas estão entre os principais motivos de óbito no mundo e, dentre elas, o trauma se destaca por causar óbitos e incapacitações permanentes. A perda sanguínea maciça é a principal causa de morte evitável no trauma. Nos casos de hemorragias volumosas, a transfusão maciça de hemocomponentes pode ser necessária; entretanto aspectos sobre o procedimento são controversos na literatura. No Brasil, estudos sobre a transfusão maciça, ainda que escassos, ressaltam a elevada mortalidade e a necessidade de maior conhecimento de enfermeiros e equipes sobre a transfusão. Assim, este estudo objetivou analisar os aspectos epidemiológicos das transfusões maciças em pacientes vítimas de trauma, em um hospital referência neste tipo de atendimento em Belo Horizonte, Minas Gerais. Trata-se de um estudo de coorte não concorrente, em que foram analisados os registros de transfusão maciça de 110 pacientes vítimas de trauma, com idade superior a 18 anos, admitidos no período compreendido entre janeiro de 2019 e junho de 2020. Os dados foram obtidos por meio dos registros da agência transfusional do hospital e dos prontuários dos pacientes. Para a análise, foi empregada a estatística descritiva e inferencial, utilizando frequência simples e acumulada, medidas de tendência central e dispersão, análise de perdas de informações, bem como estatística Kappa, estimativa de incidência, estatística de Kaplan-Meier e teste log-rank. Em 78,18% dos casos houve a ocorrência de trauma contuso, provocado por colisões (40,00%) e atropelamentos (18,18%). O maior número de pacientes era do sexo masculino com mediana da idade de 36,5 anos. As Unidades de Suporte Avançado do Serviço de Atendimento Móvel de Urgência conduziram 45,37% das vítimas ao hospital. À admissão, a mediana dos dados dos pacientes indicava alteração do sensório (Escala de Coma de Glasgow 13), pressão arterial sistólica limítrofe (90 mmHg) e taquicardia (110 BPM). Ocorreram 45 óbitos, sendo 19,09% em até 6 horas após a admissão, 12,73% entre 6 e 24 horas e 9,09% após 24 horas da admissão. Infecção, sepse e insuficiência renal aguda foram complicações mais relatadas na internação, sendo os mais acometidos os pacientes vítimas de trauma contuso com traumatismo cranioencefálico. No momento da alta, os pacientes apresentavam alguma limitação, demanda de cuidado ou recomendação de acompanhamento ou nova cirurgia. Em 77,27% dos casos o protocolo de transfusão de emergências foi acionado, e a mediana do tempo entre a admissão e a primeira dispensação de hemocomponente foi de 19 minutos. Índice de choque (com ponto de corte de 0,9) e a escala Assessment of Blood Consumption (com ponto de corte de 2,0) tiveram uma concordância moderada (42,77%/ p<0,001), pelo Teste de Kappa, para predizer a necessidade de transfusão maciça. A incidência de óbitos foi de 40,90%, sendo a densidade para esse grupo de pacientes de 13,57 (10,13-18,17 IC95%) por mil pessoas-dia. A probabilidade de óbitos foi maior entre pacientes que não fizeram uso de plaquetas e ácido tranexâmico, não havendo diferença estatisticamente significativa em relação aos que não usaram tais substâncias. Identificou-se que a probabilidade de óbito dentre os pacientes que fizeram uso de volumes iguais ou superiores a 10 unidades de concentrado de hemácias foi superior àqueles pacientes que usaram volumes menores deste hemocomponente (p <0,05). A análise evidenciou que as vítimas de trauma submetidas à transfusão maciça são homens jovens, com quadro grave e com maior probabilidade de evoluir à óbito quando recebem volumes de concentrado de hemácias superiores a 3000ml. Os resultados fornecem informações que contribuem para a avaliação e acompanhamento destes pacientes, tais como sinais de gravidade e fatores a serem observados em sua evolução e que podem determinar maior probabilidade de óbito. Os dados reforçam, ainda, a importância do cuidado do ambiente pré-hospitalar após a alta.

External causes are among the main reasons off mortality in the world, with trauma accounting for a great number of deaths and permanent disability. Massive blood loss is the leading cause of preventable death in trauma. In cases of massive hemorrhages, massive transfusion of blood components may be necessary, however aspects about this procedure are controversial in the literature. Thus, this study aimed to analyze the epidemiological aspects of massive transfusions in trauma patients admitted in a hospital that is recognized for trauma care in Belo Horizonte, Minas Gerais. This is a non-concurrent cohort study, in which records of massive transfusions of 110 trauma patients aged over 18 years, admitted between january 2019 and june 2020, were analyzed. Data were obtained through the records of the hospital's transfusion agency and the patients' charts. For data analysis, descriptive and inferencial statistics were used, using simple and accumulated frequency, measures of central tendency and dispersion, analysis of information loss, as well as Kappa statistics, incidence estimation and Kaplan-Meier statistics and log-test. rank. In 78.18% of the cases there was the occurrence of blunt trauma, caused by most of the time by collisions (40.00%) and being run over (18.18%). The largest number of patients was male with a median age of 36.5 years. The Advanced Support Units of the Serviço de Atendimento Móvel de Urgência, was responsible for 45.37% of transport of the victims to the hospital. At admission, the median of patient data indicated sensory alteration (Glasgow Coma Scale 13), hypotension (90 mmHg) and tachycardia (110 BPM). There were 45 deaths, 19.09% within 6 hours of admission, 12.73% between 6 and 24 hours after admission, and 9.09% after 24 hours of admission. Infection, sepsis, and acute renal failure were the most reported complications during hospitalization, with patients suffering from blunt trauma with traumatic brain injury being the most affected. At the time of discharge, the patients had some limitation, demand for care or recommendation for follow-up or new surgery. In 77.27% of the cases, the emergency transfusion protocol was activated, and the median time between admission and the first dispensing of blood components was 19 minutes. Shock Index (with a cutoff point of 0.9) and the Assessment of Blood Consumption score (with a cutoff point of 2.0) had moderate agreement (42.77%/p<0.001), by the Kappa test, to predict the need for massive transfusion. The incidence density of deaths for this group of patients was 13.57 (10.13-18.17 95%CI) per thousand person-day. The probability of death was higher among patients who did not use platelets and tranexamic acid, with no statistically significant difference compared to those who did not use these substances. It was identified that the probability of death among patients who used volumes equal to or greater than 10 units of packed red blood cells was higher than for those patients who used smaller volumes of this blood component (p < 0.05). The analysis showed that trauma victims submitted to massive transfusiosns are young men, with severe condition and who are more likely to progress to deth when they receive volume of red blood cells greater than 3000ml. The results provide information that contributes to the assessment and follow-up of these patients, as signs of severity and factors to be observed in its evolution, as well as whic can determine a greater probability of death. They reinforce the importance of caring in pre-hospital environment, during hospital care and after discharge.

Early identification value of shock index and platelet count in patients with grade 3 acute cholangitis / 中国医师杂志

Objective:To evaluate the value of shock index and platelet count in early identification of grade 3 acute cholangitis.Methods:This study is a retrospective case-control study. A total of 750 patients who met the diagnostic criteria of acute cholangitis were treated in Beijing Friendship Hospital Affiliated to Capital Medical University from January 2018 to December 2020. They were divided into grade 1, grade 2 and grade 3 groups according to the 2018 Tokyo Guidelines. The age, gender, etiology, complications, Charlson comorbidity index (CCI), vital signs, blood routine indexes, C-reactive protein, lactic acid and consciousness of patients in each group were compared, and the effective indexes for differentiating grade 3 cholangitis were selected. Logistic regression and receiver operating characteristic curve (ROC) analysis were used to screen the indexes with high specificity and sensitivity for early identification of acute cholangitis.Results:There were significant differences in age, CCI score, incidence of acute cholecystitis, all-cause mortality, shock index, heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, respiration, lactic acid, white blood cell count, neutrophil count, lymphocyte count, granulocyte ratio, C-reactive protein, hematocrit, platelet count, thrombocytocrit and platelet distribution width among the three groups ( P<0.05). ROC curve analysis showed that platelet count and thrombocytocrit were more effective in predicting grade 3 cholangitis ( P<0.05). Logistic regression analysis showed that shock index and platelet were significantly correlated with grade 3 cholangitis ( P<0.05). For patients without unconsciousness, the area under curve (AUC) value of shock index alone was 0.621 for differentiating grade 3 cholangitis; The sensitivity was 47.6%, and the specificity was 71.3%. The AUC value of combined shock index and platelet for differentiating grade 3 cholangitis was 0.861, with a specificity of 95.6% and sensitivity of 71%. Conclusions:Shock index combined with platelet can be used as a good indicator for early differentiation of severe acute cholangitis without conscious disorder.

Clinical profile of maternal deaths due to postpartum haemorrhage

Background: Postpartum haemorrhage is one of the dreadful complications that occur during delivery. It is often un-anticipated and occurs suddenly and un-expectedly. It is responsible for 20 percent of maternal deaths in developing countries. These deaths are largely preventable. The objective of the study was to find out the clinical profile, associated co-morbid conditions and contributory factors and treatment modalities used in the management.Methods: Retrospective observational study of maternal deaths due to postpartum haemorrhage (PPH) was carried out at tertiary care hospital. The data of maternal deaths for seven years from year 2013 to 2019 was reviewed, compiled and analyzed to draw conclusions.Results: There were 18 maternal deaths (19%) due to PPH out of total 86 maternal deaths. The average age of the woman who died due to PPH was 24 years. Ninety five percent of the cases of PPH were due to atonic uterus. Seventy percent of the cases had reported in advanced stage of shock with average blood loss of more than two to three litres. Poor general condition due to delay in reaching to tertiary care hospital was predominant feature. Sixty percent women underwent obstetric hysterectomy. Massive blood transfusion was given in fifty percent cases. Severe pregnancy induced hypertension, severe anaemia and severe concealed accidental haemorrhage were common associated factors in sixty percent of maternal deaths.Conclusions: Postpartum haemorrhage is still a common cause of maternal death. Early detection, prompt aggressive management, adequate blood replacement, use of uterine balloon tamponade and non-pneumatic anti-shock garment, timely transfer to higher centre and timely decision for surgical interventions can prevent maternal deaths.

Confusion, blood urea, respiration and blood pressure 65, pneumonia severity index and shock index and hypoxemia scores in community acquired pneumonia and outcome prediction: a descriptive study from Dr B R Ambedkar Memorial Hospital Raipur, India

Background: According to WHO, pneumonia is the third important cause of death worldwide despite various advances in medical science. Incidence of Community acquired pneumonia is about 20% to 30% in developing countries compared to 3% to 4 % in developed countries. Incidence of CAP is much higher in the very young and the elderly individuals. Objectives of the study was to compare CURB 65, PSI (Pneumonia severity index) and SIPF (shock index and hypoxemia) scores with respect to outcome prediction in community acquired pneumonia (CAP).Methods: The present hospital based descriptive observational study was conducted in the Dept of medicine, Pt. J.N.M. Medical College and Dr B. R. A. M. Hospital, Raipur, during 2016-2018 involving a total of 98 patients of community acquired pneumonia.Results: Majority of them i.e. 22 (22.4%) subjects belonged to age group 41-50 years. 34 (34.7%) subjects were found to have CURB65 score 1. 28(28.6%) subjects PSI score was noted to be class I. 89 (90.8%) subjects were discharged while, there was death of 9 (9.2%) subjects. The difference in the mean score was statistically significant (p<0.001). PSI score was found to have diagnostic sensitivity of 94.4% and specificity of 100% while CURB 65 score having 83.1% sensitivity and 100 % specificity. SIPF score had least AUC 0.88.Conclusions: Maximum diagnostic ability was noted with PSI score followed by CURB 65 and SIPF score.

Utility of the Pediatric Shock Index as a predictor of outcomes in cases of Dengue in a pediatric tertiary children's hospital

@#<p><strong>BACKGROUND:</strong> Despite extensive studies on dengue fever, there is still limited knowledge about factors associated with poor outcomes in cases of dengue fever. The shock index (SI) is a bedside tool previously used in the adult population, adopted as a marker for poor outcomes in many shock states. There are limited studies applying the SI in children. There are also no known local studies applying an age-adjusted version as a marker or predictor of poor outcomes in severe acute illness, such as dengue.</p><p><strong>OBJECTIVES:</strong> To determine the diagnostic ability of the age-adjusted pediatric shock index in predicting outcomes in cases of dengue admitted at a tertiary children's hospital.</p><p><strong>METHODS:</strong> This is a prospective cohort study performed in a pediatric tertiary hospital over a period of 30 days. Admitting heart rate (HR) and systolic blood pressure (SBP) were taken to determine their shock index. This was then grouped according to age groups based on known literature and corresponding acceptable age-adjusted shock indices (ASI), and compared with outcomes such as final dengue classification (non-severe vs severe), use of inotropes, and mortality.</p><p><strong>RESULTS:</strong> A total of 90 patients were identified for the study. Three were excluded due to exclusion criteria. 87 cases were followed up after admission from the ER. Unadjusted Shock Index (USI) was found not to be associated with both final dengue classification (as severe dengue) and use of inotropic support. In contrast, ASI was associated with both final dengue classification (p < 0.001) and use of inotropes (p < 0.039). The ASI had a fairly accurate capability of predicting poor outcomes for both final dengue classifications, with an area under the ROC curve of 0.7122, and eventual use of inotropes, with an area under the ROC curve of 0.6435.</p><p><strong>CONCLUSIONS AND RECOMMENDATIONS:</strong> SI was found to be a helpful tool in predicting poor outcomes, but only when the Age-adjusted Shock Index (ASI) was used. A longer data collection period is recommended to be able to include mortality as an outcome. The predictive value of the tool can be tested against various other markers of poor outcome to widen the application of this non-invasive measure of hemodynamic status.</p>

Shock index as a predictor of vasopressor use in patients with sepsis

Background: Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis and septic shock are major healthcare problems affecting millions of people around the world each year and killing as many as one in four. The documented incidence of sepsis worldwide is 1.8 million each year with mortality rate of almost 30%. Sepsis is the 10th leading cause of death in the United States. Shock index (SI) is defined as “Heart rate divided by Systolic blood pressure (HR/SBP)”. Normal range is 0.5 to 0.7 in healthy adults.Methods: A Prospective study was conducted between August 2018 to March 2019 comprising of 100 consecutive patients presenting to emergency department and ICU with sepsis. Subjects were identified by having evidence of infection presenting with cardiovascular collapse or organ failure with help of q-SOFA(quick- sepsis related organ failure assessment ) and SOFA scores (sequential organ failure assessment score).Cases with clear alternative diagnosis were excluded. Vital signs were recorded, and Shock index was calculated. Primary outcome, which was use of Vasopressor therapy was analysed. Results : A Total of 100 cases were studied, of which 70 patients were males and 30 females with mean age of 48.5 ±16.2 yrs. Most of the cases were between 35 to 60 years. Patients were classified into 3 categories based on shock index:1. <0.8 (normal, n=16) 2. 0.8 to <1.2 (n=29) 3. >1.2 (n=55). The use of vasopressor therapy within first 24 hours for each group was 18%, 34%, and 78%. This difference was statistically significant (p=<0.05).Conclusion : In patients with sepsis an elevated shock index was indicator of early vasopressor therapy in the first 24hours. It is a simple bedside tool to identify septic patients in need for early vasopressor therapy thereby preventing further clinical deterioration.

Índice de choque como marcador inicial de choque hipovolémico en hemorragia obstétrica de primer trimestre / Shock index as initial marker of hypovolemic shock in obstetric hemorrhage of the first trimester / Índice de choque como marcador inicial do choque hipovolémico na hemorragia obstétrica do primeiro trimestre

Resumen: La hemorragia obstétrica continúa siendo la principal causa de morbilidad y mortalidad materna a nivel mundial siendo mayor en países en vías de desarrollo. Estudios realizados por la Organización Mundial de la Salud (OMS) revelan que entre 25-30% de muertes maternas se deben a hemorragia obstétrica, tales muertes inician usualmente al relacionarse con el desarrollo de choque hemorrágico y sus consecuencias, especialmente la disfunción orgánica múltiple. La hemorragia obstétrica se define como la pérdida sanguínea mayor o igual a 500 mL. El índice de choque (IC) se define como la frecuencia cardiaca dividida por la presión arterial sistólica, fue introducida por primera vez en 1967 por Allgöwer y Burri. Se ha estudiado en pacientes con y sin trauma y se usa en la práctica clínica para evaluar el choque hipovolémico o la gravedad del choque no hipovolémico y para ayudar al tratamiento agudo en este contexto. En la población normal no embarazada, el rango del IC normal es 0.5-0.7 y un IC > 0.9 se ha asociado con una mayor mortalidad. En el presente trabajo se realizó la correlación del índice de choque como marcador inicial de choque hipovolémico en pacientes con hemorragia obstétrica del primer trimestre. Se realizó un estudio observacional, prospectivo, transversal y analítico en pacientes de todas las edades con hemorragia obstétrica del primer trimestre. Se observó que el índice de choque en las pacientes con diagnóstico de hemorragia obstétrica de primer trimestre se asocia significativamente con inestabilidad hemodinámica y mayor probabilidad de requerir productos sanguíneos.

Abstract: Obstetric hemorrhage continues to be the main cause of maternal morbidity and mortality worldwide, being higher in developing countries. Studies conducted by the World Health Organization (WHO) reveal that between 25 and 30% of maternal deaths are due to obstetric hemorrhage, such deaths usually begin when related to the development of hemorrhagic shock and its consequences, especially multiple organ dysfunction. Obstetric hemorrhage is defined as blood loss greater than or equal to 500 mL. The shock index (CI) is defined as the heart rate divided by the systolic blood pressure, it was first introduced in 1967 by Allgöwer and Burri. It has been studied in patients with and without trauma and is used in clinical practice to evaluate hypovolemic shock or the severity of non-hypovolemic shock and to help acute treatment in this context. In the normal non-pregnant population, the range of the normal CI is 0.5-0.7 and an IC of > 0.9 has been associated with a higher mortality. In the present work, the correlation of the shock index was made as an initial marker of hypovolemic shock in patients with obstetric hemorrhage in the first trimester. An observational, prospective, cross-sectional and analytical study was conducted in patients of all ages with first-trimester obstetric hemorrhage. It was observed that HF in patients with a diagnosis of first-trimester obstetric hemorrhage is significantly associated with hemodynamic instability and a higher probability of requiring blood products.

Resumo: A hemorragia obstétrica continua sendo a principal causa de morbidade e mortalidade materna a nível mundial, sendo maior nos países em desenvolvimento. Estudos realizados pela Organização Mundial da Saúde (OMS) revelam que entre 25 e 30% dos óbitos maternos são decorrentes de hemorragia obstétrica, tais óbitos começam usualmete quando relacionados ao desenvolvimento do choque hemorrágico e suas conseqüências, especialmente disfunção de múltiplos órgãos. A hemorragia obstétrica é definida como perda de sangue maior ou igual a 500 mL. O índice de choque (IC) é definido como a freqüência cardíaca dividida pela pressão arterial sistólica, que foi introduzida pela primeira vez em 1967 por Allgöwer e Burri. Tem sido estudado em pacientes com e sem trauma e é usado na prática clínica para avaliar o choque hipovolêmico ou a gravidade do choque não-hipovolêmico e para auxiliar no tratamento agudo nesse contexto. Na população normal não gestante, o intervalo do IC normal é de 0.5-0.7 e um IC > 0.9 foi associado a uma mortalidade mais elevada. No presente trabalho foi realizada a correlação do índice de choque como um marcador inicial de choque hipovolêmico em pacientes com hemorragia obstétrica no primeiro trimestre. Foi realizado um estudo observacional, prospectivo, transversal e analítico em pacientes de todas as idades com hemorragia obstétrica no primeiro trimestre. Observou-se que a IC em pacientes com diagnóstico de hemorragia obstétrica no primeiro trimestre está significativamente associada à instabilidade hemodinâmica e maior probabilidade de necessidade de hemoderivados.

Hemorragia posparto: nuevas evidencias / Postpartum hemorrhage: new evidence

Introducción: la hemorragia posparto (HPP) es toda pérdida sanguínea mayor de 500 ml luego de un parto vaginal o mayor de 1000 mililitros luego de una cesárea, o cualquier pérdida sanguínea luego del parto que provoque inestabilidad hemodinámica, independiente del tipo de parto. Puede provocar signos y síntomas de choque que si no se maneja adecuadamente podría comprometer la vida de la paciente. Objetivo: realizar una revisión bibliográfica sobre HPP. Métodos: se realizó una exhaustiva revisión bibliográfica de la literatura médica más actualizada sobre HPP. Resultados y discusión: 32 artículos médicos en idioma español y en idioma inglés de los últimos años se incluyen en el presente trabajo, lo que incluye guías clínicas. La HPP se clasifica en hemorragia postparto primaria, temprana o inmediata y en hemorragia postparto secundaria o tardía. Dentro de las principales causas de hemorragia postparto primaria tenemos como nemotecnia las 4 T que incluyen: Tono, Trauma, Tejido y Trombina, siendo la más frecuente la relacionada con el tono que representa el 70% de los casos. La clave del manejo de la HPP es reconocer el sangrado excesivo en el posparto, identificar la causa, e iniciar una intervención adecuada según el caso. Conclusión: la HPP es la segunda causa de muerte materna a nivel mundial, por lo tanto, es muy importante conocer sus causas, manejo y la prevención de la misma.

Introduction: postpartum hemorrhage (PPH) is any blood loss greater than 500 ml after a vaginal birth or more than 1000 milliliters after a cesarean, or any blood loss after delivery that causes hemodynamic instability regardless of the type of delivery. It can cause signs and symptoms of shock, which if not properly handled could compromise the patient life. Objective: we performed an exhaustive review of the most recent medical literature about PPH. Methods: an exhaustive bibliographic review of the most recent medical literature on PHP was carried out. Results and discussion: 32 medical articles in Spanish and in English language of the last years were included in the present work including clinical guidelines. PPH is classified as primary, early or immediate postpartum hemorrhage and secondary or late postpartum hemorrhage. Among the main causes of primary postpartum hemorrhage, we have as mnemonic the 4 T that include: Tone, Trauma, Tissue and Thrombin, the most frequent being the one related to the tone that represents 70% of the cases. The key of the management is to recognize hemorrhage after the delivery, identify the cause and start an opportune and adequate treatment. Conclusion: PPH is the second cause of maternal death worldwide, therefore, it is very important to know its causes, management and prevention.

Papel del índice de choque en embarazadas del tercer trimestre con hemorragia obstétrica para requerimiento transfusional atendidas en el Hospital General «Las Américas¼ / Role of the shock index in pregnancy of the third quarter with obstetric hemorrhage for transfusion requirement attended at the «Las Americas¼ General Hospital / Papel do índice de choque em gestantes no terceiro trimestre com hemorragia obstétrica com indicação para transfusão atendidas no Hospital ISEM «Las Americas¼

Resumen: La hemorragia obstétrica sigue siendo la causa más importante de muertes maternas en todo el mundo. Una mujer en el tercer trimestre puede perder hasta 30% del volumen sanguíneo antes de que disminuya la presión arterial sistólica, lo que lleva a suponer una estabilidad hemodinámica y retraso en la atención. El índice de choque (IC), calculado como la frecuencia cardiaca dividida por la presión arterial sistólica, se ha propuesto para predecir la hipovolemia temprana. En las poblaciones no embarazadas, el IC normal se ha sugerido como 0.5-0.7 y el IC ≥ 0.9 corresponde con mayor mortalidad y morbilidad. Hasta el momento, sólo un pequeño estudio obstétrico ha definido IC normal como 0.7-0.9. Diseño del estudio: Se calculó el índice de choque en pacientes gestantes en el tercer trimestre que llegaron con hemorragia obstétrica, las cuales llegaron a choque hipovolémico grado III. Se evaluó el efecto del ajuste de los factores de confusión en la relación entre los umbrales del IC y el resultado, utilizando métodos de regresión logística. Resultados: Nuestro estudio es el primero en evaluar la capacidad predictiva de índice de choque en mujeres gestantes con antecedente de hemorragia en el tercer trimestre, demostrando que no ayuda a la toma de decisiones sobre tratamiento final y eventos adversos, ya que los cambios hemodinámicos del embarazo y el postparto pueden retrasar el reconocimiento de la hipovolemia, subestimando la reanimación y derivación tempranas. Conclusiones: El índice de choque no es un valioso predictor del deterioro materno, pero sí impacta sobre la necesidad de transfusión o la intervención quirúrgica en el contexto de hemorragia del tercer trimestre. Proponemos un umbral de IC ≥ 0.9 para identificar mujeres que requieren atención urgente de alto nivel. Esto es más alto que el límite superior de la normalidad en las poblaciones no embarazadas, lo que refleja los cambios hemodinámicos del embarazo y el periodo postparto.

Abstract: Obstetric hemorrhage remains the most important cause of maternal deaths worldwide. A woman in the third trimester may lose up to 30% of the blood volume before the SBP falls, leading to hemodynamic stability and delayed attention. The shock index (SI), calculated as a heart rate divided by systolic blood pressure, has been proposed to predict early hypovolemia. In non-pregnant population, normal SI has been suggested as 0.5-0.7 and SI ≥ 0.9 corresponds with higher mortality and morbidity. So far, only a small obstetric study has defined normal SI, such as 0.7-0.9. Study design: The shock index was calculated in pregnant patients in the third trimester who arrived with obstetric hemorrhage in the third trimester, of which they reached grade III hypovolemic shock. The effect of the adjustment of the confounding factors on the relationship between the SI thresholds and the result was evaluated, using logistic regression methods. Results: Our study is the first to evaluate the predictive capacity of shock rate in pregnant women with a history of hemorrhage in the third trimester demonstrating that it does not help to make decisions about final treatment and adverse events, since the hemodynamic changes of pregnancy and postpartum may delay the recognition of hypovolemia by underestimating early resuscitation and referral. Conclusion: The shock index is not a valuable predictor of maternal deterioration, but it does impact on the need for transfusion or surgical intervention in the context of third trimester hemorrhage. We propose an SI threshold ≥ 0.9 to identify women who require urgent high-level care. This is higher than the upper limit of normality in non-pregnant populations, reflecting the hemodynamic changes of pregnancy and the postpartum period.

Resumo: A hemorragia obstétrica continua sendo a causa mais importante de mortes maternas no mundo. Uma mulher no terceiro trimestre pode perder até 30% do volume de sangue antes que a PAS descenda, levando à supor uma estabilidade hemodinâmica e ao atraso da atenção. O índice de choque (IC), calculado como uma freqüência cardíaca dividida pela pressão arterial sistólica, foi proposto para prever a hipovolemia precoce. Nas populações não gestantes, o IC normal foi sugerido como 0.5-0.7 e o IC ≥ 0.9 corresponde a maior mortalidade e morbidade. Até agora, apenas um pequeno estudo obstétrico definiu o IC normal, como 0.7-0.9. Desenho do estudo: A taxa de choque foi calculada em pacientes gestantes no terceiro trimestre que chegaram com hemorragia obstétrica, das quais atingiram o choque hipovolêmico grau III. Avaliou-se o efeito do ajuste dos fatores de confusão na relação entre os limiares do IC e o resultado, utilizando métodos de regressão logística. Resultados: Nosso estudo é o primeiro a avaliar a capacidade preditiva da taxa de choque em mulheres gestantes com história de hemorragia no terceiro trimestre, demonstrando que não ajuda a tomar decisões sobre o tratamento final e eventos adversos, já que as alterações hemodinâmicas da gestacão e o pós-parto podem retardar o reconhecimento da hipovolemia subestimando a ressuscitação e o encaminhamento precoces. Conclusão: O índice de choque não é um preditor valioso da deterioração materna, mas tem impacto sobre a necessidade de transfusão ou intervenção cirúrgica no contexto da hemorragia no terceiro trimestre. Propomos um limiar de IS ≥ 0.9 para identificar mulheres que necessitam de cuidados urgentes de alto nível. Isso é mais alto que o limite superior da normalidade nas populações não gestantes, refletindo as alterações hemodinâmicas da gestação e do período pós-parto.

The relationship between the reverse shock index multiplied by GlasgowComa scale score and serum translocator protein and prognosis in patients with severe traumatic brain injury / 中华急诊医学杂志

Objective To investigate the value of the reverse shock index multiplied by GlasgowComa scale score (rSIG) and serum translocator protein 18000 in the prognosis of patients with severe traumatic brain injury. Methods One hundred and fifteen patients with severe traumatic brain injury were divided into the survival group and death group. SPSS 20.0 software was used to compare the vital signs, rSIG and TSPO between the two groups, and the relationship between rSIG and TSPO was analyzed. Receiver operating characteristic (ROC) curve was used to predict the value of rSIG and TSPO and their combination in the prognosis of patients with severe traumatic brain injury. According to the best cut-off value of rSIG and TSPO of ROC curve, patients were divided into the rSIG ≤ 14.8 group and rSIG>14.8 group, and the TSPO ≤ 1.84 ng/mL group and TSPO>1.84 ng/mL group, and the mortality between the groups was compared. Results In 115 patients, rSIG of the survival group was significantly higher than that of the death group, and TSPO was significantly lower than that of the death group [(10.5±4.4) vs. (6.4±4.1), 1.0(0.3,1.9) ng/mL vs.3.4 (2.0, 4.6) ng/mL, P<0.01]. The ability of rSIG combined with TSPO to forecast the mortality of patients with severe traumatic brain injury is not superior to the predictive power of these two indicators alone. The serum TSPO value and 28-day mortality in the rSIG > 4.15 group were significantly higher than those in the rSIG ≤ 4.15 group. The rSIG value of the TSPO ≤ 1.84 ng/mL group was significantly higher than that of the TSPO>1.84 ng/mL group; the 28-day mortality was significantly lower than that in the TSPO>1.84 ng/mL group. The rSIG value was negatively correlated with serum TSPO value (r=-0.611, P<0.01). Conclusions rSIG value and serum TSPO value have good predictive value for the prognosis of patients with severe traumatic brain injury, and can provide certain guiding significance in clinical practice.

Preliminary study on the value of the new community acquired pneumonia severity index / 中华急诊医学杂志

Objective To explore the value of a new community-acquired pneumonia severity index(CPSI) in predicting the severity and mortality of patients with community-acquired pneumonia(CAP).Methods A retrospective analysis was conducted.Patients with CAP in critical care medicine of the First People's Hospital of Chenzhou were enrolled in this study.According to whether the patients died within 28 days,patients were divided into the survival group and the death group.The difference of sex,age,vital signs,blood test,the lowest Glasgow coma score (GCS) and acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sepsis related organ failure assessment (SOFA)score,CURB-65 (confusion,uremia,respiratory rate,BP,age 65 years) score,pneumonia severity index (PSI) score and community-acquired pneumonia severity index (CPSI) score were compared between the two groups.Logistic regression analysis was performed for the scoring systems with statistical significance in univariate analysis.The receiver operating characteristic (ROC) was drawn to analyze the prognostic value of each scoring system.Results Totally 283 patients were enrolled in this study (184 survivals and 99 deaths,mortality rate 35％).Univariate analysis showed that age,mechanical ventilation (MV) ratio,the fastest heart beat rate (HR),the lowest systolic blood pressure (SBP),the lowest mean blood pressure (MAP),pressure adjusted shock index (PASI),inspired oxygen concentration (FiO2),arterial oxygen partial pressure (PaO2),and oxygenation index (PO2/FiO2),blood urea nitrogen concentration (BUN),serum creatinine concentration (Scr),urine output,length of ICU stay,the lowest GCS,and APACHE Ⅱ score were significantly different between the two groups (P＜0.05).Multivariate regression analysis showed that CPSI score and SOFA score were independent risk factors for patients with CAP.The ROC curve of CAP patients was predicted in each scoring system,and the area under the ROC curve of CPSI score (0.728),SOFA and age score (0.708),PSI score (0.701),APACHE Ⅱ score (0.690),CURB-65 score (0.687) and SOFA score (0.683) gradually decreased.The sensitivity and specificity of the area under curve prediction showed that CPSI score was superior to the other scores.Conclusions The CPSI score can evaluate the severity of CAP patients,efficiently predict the outcome of patients with CAP,and can be widely used in clinical practice.

Comparación de una escala, un indice y un biomarcador como predictores de mortalidad en niños con choque séptico que ingresan a la unidad de terapia intensiva del hospital Dr. José Renán Esquivel. Agosto 2015- marzo 2016 / Comparison of a scale, an index and a biomarker as predictors of mortality in children with septic shock admitted to the intensive care unit of the Dr. José Renán Esquivel hospital. August 2015- March 2016

Resumen El choque séptico es una entidad que en la población pediátrica se ve asociado a altas tasas de morbilidad y mortalidad. En las unidades de terapia intensiva es importante estimar el riesgo de muerte en los pacientes ingresados para así redirigir metas en el manejo de los mismos. Sin embargo, la falta de consistencia y la subjetividad del clínico han sido factores determinantes para el desarrollo de escalas de mortalidad con el fin de lograr mediciones cuantitativas certeras. Existen muchas escalas, índices y biomarcadores desarrollados con el fin de predecir mortalidad. Entre estos se encuentra la escala PIM-2, el índice de choque y el lactato. Objetivo: Comparar la escala PIM-2, el índice de choque y el lactato como marcadores precoces de mortalidad en los niños con choque séptico. Metodología: Se realizó un estudio de cohorte prospectivo, en el cual se incluyeron todos los pacientes con criterios de choque séptico que ingresaron a la Unidad de Terapia intensiva del Hospital del Niño entre agosto del 2015 y marzo del 2016. Se realizaron los cálculos de PIM-2, índice de choque y valor de lactato al ingreso en los pacientes sobrevivientes y fallecidos y se compararon los resultados de estos marcadores como predictores de mortalidad. Resultados: La escala PIM-2 resultó un excelente predictor de mortalidad con un área bajo la curva de 94% comparada con el índice de choque que osciló entre 53% a 61% y el valor de lactato que fue de 77%. Conclusión: El PIM-2, resultó una prueba sencilla, gratuita y fácil de calcular, con una excelente sensibilidad para la predicción de mortalidad en niños críticos con diagnóstico de choque séptico. A pesar de la facilidad de cálculo del índice de choque, este resultó ser un pobre predictor de mortalidad. El lactato es un marcador aceptable para predecir mortalidad, sin embargo, debe correlacionarse con otras escalas ya que puede ser sesgado por otras causas que produzcan su aumento o disminución.

Summary: In the pediatric population, septic shock is an entity associated with high mortality and morbidity rates. In the intensive care unit, it is important to estimate the risk of death of the patients admitted in order to re-direct the goals of treatment. However, the lack of consistency and the subjectivity of the clinician have been determinant factors for the development of mortality scales with the purpose of achieving accurate quantitative measurements. Many scales, indexes and biomarkers exist which have been developed to predict mortality. Among these are the PIM-2 scale, the shock index and serum lactate. Objective: To compare the PIM-2 scale, the shock index and serum lactate as early markers of mortality in children with septic shock. Methods: A prospective cohort study was performed in which all patients with septic shock criteria admitted to the intensive care unit of the Hospital del Niño between August 2015 and March 2016 were included. Calculations of PIM-2, shock index and serum lactate value at admission of the surviving and the deceased patients were performed, and the results of these markers were compared as predictors of mortality. Results: The PIM-2 scale resulted in an excellent mortality predictor with an under the curve area of 94% compared to the shock index which oscillated between 53 and 61%, and the value of lactate which was of 77%. Conclusion: The PIM-2 scale turned out to be a simple, free and easy to calculate test, with an excellent sensibility to predict mortality in critically ill children with septic shock. Despite the ease of use of the shock index, it resulted to be a poor predictor of mortality. However, it should be correlated with other scales since it can be biased by other causes which produce its increase or decrease.

Utilidad del índice de choque para predecir la mortalidad en pacientes pediátricos con sepsis grave o choque séptico / Shock index utility to predict mortality in pediatric patients with septic shock or severe sepsis

Resumen Introducción: La sepsis en pediatría es la principal causa de muerte hospitalaria. Se han intentado crear herramientas que faciliten su identificación, como el índice de choque (IC), definido como el cociente entre frecuencia cardíaca y tensión arterial sistólica. El objetivo de este trabajo fue identificar el mejor momento del IC para predecir la mortalidad en pacientes pediátricos con sepsis grave y choque séptico. Métodos: Cohorte retrospectiva con 165 pacientes pediátricos que desarrollaron sepsis grave y choque séptico en la Unidad de Terapia Intensiva Pediatrica. Se calculó el IC al diagnóstico (IC0), a las dos, cuatro y seis horas posteriores al mismo (IC2, IC4 e IC6). Se crearon dos grupos según el desenlace (sobrevivientes/muertos). La comparación estadística se realizó con prueba U-Mann Whitney y χ2. Se compararon los factores de riesgo entre los sobrevivientes y muertos, calculando la razón de momios (RM). Resultados: Se comparó el valor del IC entre grupos; en el grupo de choque séptico, el IC se encontró más elevado en IC4 e IC6 (p = 0.010 y p = 0.005). Se encontró que, en los pacientes muertos, el IC incrementó progresivamente su valor en IC4 e IC6 (p < 0.05). Los valores de IC4 e IC6 elevados incrementaron el riesgo de muerte en los pacientes (IC4, RM: 442.1; IC 95% [intervalo de confianza al 95%]: 54.2-3,601.7; p < 0.001; e IC6, RM: 81,951.3; IC 95%: 427.1-15,700,000; p < 0.001). Conclusiones: La elevación del valor del IC se asocia con mayor mortalidad de la sepsis. El valor de IC6 es el más útil para predecir mortalidad.

Abstract Background: Pediatric sepsis is considered the main cause of hospital death around the world. Many groups have tried to create tools that facilitate its early identification, as the shock index (SI) defined as the ratio between cardiac frequency and systolic blood pressure. The objective of this study was to determine the utility of SI to predict mortality in pediatric patients with severe sepsis and septic shock. Methods: Retrospective cohort with 165 pediatric patients with severe sepsis or septic shock in the Pediatric Intensive Care Unit. SI was calculated at diagnosis, 2, 4 and 6 hours after (SI2, SI4 and SI6). We divided the population in two groups depending their outcome: survivors and non-survivors. The statistical analysis was performed with U Mann-Whitney and chi squared tests. The risk factors were compared between the survivors and the dead, and we calculated the odds ratio (OR). Results: The median value of SI was compared between groups; in the group of septic shock, SI showed a tendency to remain high in SI4 and SI6 (p = 0.010 and p = 0.005, respectively). Among the survivors and the non-survivors, we found that in the latter, SI was progressively increased in SI4 and SI6 (p < 0.05). High values of SI4 and SI6 increased the risk of death in patients (SI4: OR: 442.1; CI 95% [confidence interval 95%]: 54.2-3,601.7; p < 0.001 and SI6: OR: 81,951.3; CI 95%: 427.1-15,700,000]; p < 0.001). Conclusions: High values of SI are associated with increased mortality. The IS6 value is the most useful to predict mortality.

Correlation between shock index and diastolic blood pressure in patients with postpartum hemorrhage and early warning of postpartum hemorrhage risk: an analysis of numerous cases in 4 years / 中华危重病急救医学

Objective To observe the changes of shock index (SI) and diastolic blood pressure (DBP) in postpartum hemorrhage patients, and the explore their relationship with postpartum hemorrhage and the clinical significance of early warning of hemorrhage risk. Methods 402 patients with postpartum hemorrhage (within 24 hours after delivery, the amount of bleeding in vaginal delivery≥500 mL, and the amount of bleeding in caesarean delivery≥1 000 mL) admitted to the obstetrics ward of Affiliated Hospital of Hangzhou Normal University from January 2014 to December 2017 were selected as the objective group and 416 without complications during delivery were selected as the control group in the same hospital at the same period. Clinical data in the two groups before and after childbirth was collected, including age, pregnancy week, 24-hour blood loss, and hemoglobin (Hb), whole blood cell parameters, heart rate (HR), systolic blood pressure (SBP), DBP, SI, blood urea nitrogen (BUN), serum creatinine (SCr) within 24 hours before and after delivery, and postpartum 24 hours and prenatal DBP difference (ΔDBP). The differences of indicators were compared between the two groups. Pearson method was used to analyze the correlation between the postpartum DBP and SI in the objective group. Ordinal regression model was used to analyze the early warning risk factors of each index to postpartum hemorrhage. Results Compared with the control group, older age (years: 29.29±5.01 vs. 28.05±4.46), more pregnancies (times: 2.68±1.42 vs. 2.33±1.28), shorter gestation weeks (weeks: 38.33±3.57 vs. 39.05±1.40), more 24-hour blood loss (mL: 726.57±467.66 vs. 244.49±50.25) in the objective group were significant differences (all P﹤0.01). Postpartum hemorrhage patients were successfully hemostatic, no maternal and perinatal death was found in the two groups. Compared with the control group, DBP was significantly decreased at 24 hours after delivery in the objective group [mmHg (1 mmHg = 0.133 kPa): 71.19±12.55 vs. 75.68±8.96, P < 0.05], and ΔDBP was significantly increased (mmHg: 5.39±3.93 vs. 0.67±0.33, P < 0.01). In addition, compared with the control group, SI and HR were significantly increased in the objective group [SI:0.80±0.15 vs. 0.72±0.11, HR (bpm): 91.56±13.37 vs. 82.96±11.76, both P < 0.05], Hb, red blood cell count (RBC), platelet count (PLT) and SBP were significantly decreased [Hb (g/L): 91.30±13.41 vs. 112.30±13.41, RBC (×1012/L): 3.74±0.38 vs. 4.59±0.45, PLT (×109/L): 173.02±59.08 vs. 182.09±54.76, SBP (mmHg):115.13±9.27 vs. 117.94±11.66, all P﹤0.05]. Correlation analysis showed that postpartum DBP was negatively correlated with SI, 24-hour blood loss, ΔDBP, BUN and SCr (r value was -0.419, -0.268, -0.490, -0.108, -0.163, respectively, all P < 0.05), and positively correlated with SBP, Hb and RBC (r value was 0.739, 0.125, 0.096, respectively, all P < 0.05). It was shown by Ordinal regression analysis that the risk of postpartum hemorrhage was significantly increased when ΔDBP≥9.32 mmHg [relative risk (RR) = 2.64, 95% confidence interval (95%CI) =1.94-3.34, P = 0.000], SI≥0.95 (RR = 1.78, 95%CI = 1.01-2.55, P = 0.000), DBP≤59.64 mmHg (RR = 0.86, 95%CI = 0.31-1.41, P = 0.000), SBP≤105.86 mmHg (RR = 0.63, 95%CI = 0.18-1.07, P = 0.000), Hb≤77.89 g/L (RR = 1.68, 95%CI = 0.99-2.38, P = 0.000), and ΔDBP≥9.32 mmHg was the most effective early warning effect. Conclusions Combined with clinical manifestations of patients with postpartum hemorrhage, SI and DBP can be used as an important reference indicator for the observation of postpartum hemorrhage conditions. ΔDBP≥9.32 mmHg can be used as the risk factors of the patient with postpartum hemorrhage.

Correlation between shock index and severity of septic shock and its prognostic value / 中华危重病急救医学

Objective To discuss the correlation between shock index (SI) and severity and the values to forecast the prognosis in patients with septic shock. Methods 127 patients with septic shock admitted to intensive care unit (ICU) of Zhejiang Provincial People's Hospital from January 1st, 2016 to October 31st, 2017 were enrolled, and they were divided into survival group and death group according to the outcomes after 28-day hospitalized. The vital signs, laboratory indexes, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ), sequential organ failure assessment (SOFA), lactate clearance rate (LCR) of 3 hours after fluid resuscitation, and shock index on admission (SI1) and shock index of 3 hours after fluid resuscitation (SI2) were compared between the two groups. The correlation among SI and APACHE Ⅱ, SOFA, LCR was analyzed. The receiver operating characteristic curve (ROC) was drawn to evaluate the prognostic value of SI in patients with septic shock. Results A total of 127 patients were included, 52 in survival group (40.9%) and 75 in death group (59.1%). The SI1, SI2, APACHE Ⅱ and SOFA in the death group were significantly higher than those in the survival group (SI1: 1.62±0.46 vs. 1.35±0.32, SI2: 1.36±0.24 vs. 0.93±0.15, APACHEⅡ:17.5±4.0 vs. 13.6±3.5,SOFA: 9.5±2.3 vs. 6.3±1.5), and LCR was significantly lower than that in the survival group [(14.4±5.2)% vs. (28.6±8.6)%], with statistically significant differences (all P < 0.01). The correlation analysis showed that SI1was significantly positively correlated with APACHEⅡ (r = 0.458, P = 0.000) and SOFA (r = 0.535, P = 0.000), SI2was also significantly positively correlated with APACHEⅡ (r = 0.624, P = 0.000) and SOFA (r = 0.656, P = 0.000), while SI1and SI2were significantly negatively correlated with LCR (r values were -0.348, -0.435, both P = 0.000), and the SI2were more remarkable. ROC curve analysis showed that the area under ROC curve (AUC) of SI1for predicting the prognosis of septic shock was 0.720 [95% confidence interval (95%CI) = 0.620-0.831, P < 0.05]; when SI1= 1.68, the sensitivity, specificity, Yoden index, positive predictive value and negative predictive value were 79.5%, 65.6%, 0.451, 0.759 and 0.636, respectively. The AUC of the SI2to predict prognosis of septic shock was 0.826 (95%CI =0.739-0.826, P < 0.05); when SI2= 1.37, the sensitivity, specificity, Yoden index, positive predictive value and negative predictive value were 85.7%, 87.6%, 0.733, 0.893 and 0.902, respectively. Conclusion Compared with SI1, SI2was more correlated with the severity in patients with septic shock and it had more values to predict prognosis.

Utilidad del índice de choque como valor predictivo para el requerimiento de trasfusión en hemorragia obstétrica / Utility of the shock index in obstetric hemorrhage as a predictive value for the transfusion requirement

Resumen Objetivo: Determinar el punto de corte del índice de choque obstétrico asociado con trasfusión masiva en mujeres con hemorragia obstétrica. Materiales y métodos: Estudio retrospectivo, transversal y analítico efectuado con base en la revisión de los expedientes clínicos de pacientes que ingresaron a la unidad de cuidados intensivos. Cálculo del índice de choque obstétrico al momento del diagnóstico de hemorragia obstétrica. Análisis de los signos vitales, gasometría, tipo de componentes sanguíneos trasfundidos y cantidad de líquidos administrados. Resultados: Se incluyeron 105 pacientes con hemorragia obstétrica; en 65 (61%) el resultado del índice de choque fue ≥ 0.9, de éstas 38 (58%) requirieron trasfusión masiva. El índice de choque obstétrico ≥ 0.9 se asoció, significativamente, con trasfusión masiva (p < 0.001). La pérdida sanguínea fue de 3000 mL (RIC 2000 mL) en pacientes con índice de choque obstétrico ≥ 0.9 vs 2500 mL (RIC 1000 mL) en pacientes con índice de choque obstétrico < 0.9 (p = 0.04). Las mujeres con índice de choque obstétrico ≥ 0.9 mostraron mayor requerimiento de trasfusión de concentrados globulares (p = 0.03) y plaquetarios (p = 0.01). Conclusiones: Un índice de choque obstétrico ≥ 0.9 se asoció con altos requerimientos de trasfusión sanguínea y mayor incidencia de eventos adversos graves, por lo que se recomienda este valor como el punto de corte para predicción de la necesidad de trasfusión masiva.

Abstract Objective: To determine the cut-off point of obstetric shock index associated with massive transfusion in women with obstetric hemorrhage. Materials and methods: We designed a cross-sectional study in women who were admitted to the intensive care unit. The obstetric shock index was calculated at the time of the diagnosis of obstetric hemorrhage. We analyzed vital signs, arterial blood gas, loss of blood, fluid replacement and transfused blood products. Results: One hundred and five women with obstetric bleeding were included, in 65 (61%) the obstetric shock index was ≥ 0.9, of whom 38 (58%) needed massive transfusion. Obstetric shock index ≥ 0.9 was significantly associated with massive transfusion (p < 0.001). The blood loss was of 3000 mL (RIC 2000 mL) in the patients with obstetric shock index ≥ 0.9 compared to 2500 mL (RIC 1000 mL) in patients with obstetric shock index < 0.9 (p = 0.04). Women with obstetric shock index ≥ 0.9 showed more significant requirement of transfusion of package red blood (p = 0.03) and platelets (p = 0.01). Conclusions: An obstetric shock index ≥0.9 was associated with high transfusión requirements and a higher incidence of serious adverse events, this value is recommended as the cut-off point for predicting the need for massive transfusion.