Introduction: Scoring systems were developed for risk-stratification of septic shock (SS) patients but their performance is poor in the prehospital setting.
Objective: The aim of this study was to evaluate the ability of the shock index (SI) in prehospital triage of SS patients to predict their admission in intensive care unit (ICU).
Methods: We performed a two months retrospective study of call records received by the Paris SAMU 75 regulation centerconcerning patients with presumed SS. The outcome was the in-ICU admission.
Results: Among the 30 642 calls received, 140 concerned patients with presumed SS were included. Twenty-two patients (16%) were admitted to ICU and 118 (84%) to the emergency department. The area under the curve (AUC) of the SI was 0.76 [0.65-0.86]. Using a threshold for SI > 0.9, the sensitivity was 82%, the specificity was 67%, the positive predictive value was 32% and the negative predictive value was 95%. After logistic regression analysis, the OR for SI > 0.9 reached 7.65 [2.33- 35.00]. Using propensity score analysis, the odd-ratio (OR) for SI > 0.9 was 1.34 [1.15-1.52]. Results are expressed by OR with 95 percent confidence interval [95 CI].
Conclusion: Shock index is a reliable tool for risk stratification of SS patients managed in the prehospital setting. Using a threshold of one for the SI helps the screening of patients requiring ICU admission by the SAMU 15 regulation call centre. Prospective studies including SI in the decision-making process in the prehospital triage of SS patients are needed to validate these results.
Ferrer R, Artigas A, Levy MM, Blanco J, Gonzalez-Diaz G, Garnacho- Montero J, et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008; 299:2294-303.
Nguyen HB, Van Ginkel C, Batech M, Banta J, Corbett SW. Comparison of predisposition, insult/infection, response, and organ dysfunction, acute physiology and chronic health evaluation II, and mortality in emergency department sepsis in patients meeting criteria for early goal- directed therapy and the severe sepsis resuscitation bundle. J Crit Care 2012; 27:362-9.
Brun-Buisson C. The epidemiology of the systemic inflammatory response. Intensive Care Med 2000; 26:S64-74.
Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014; 312:90-2.
Epstein L, Dantes R, Magill S, Fiore A. Varying estimates of sepsis mortality using death certificates and administrative codes - United States, 1999-2014. Morb Mortal Wkly Rep 2016; 65:342-5.
Blanco J, Muriel-Bombin A, Sagredo V, Taboada F, Gandia F, Tamayo L, et al. Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study. Crit Care 2008; 12:R158.
Finfer S, Bellomo R, Lipman J, French C, Dobb G, Myburgh J. Adult- population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Med 2004; 30:589-96.
Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34:1589-96.
Leisman DE, Doerfler ME, Ward MF, Masick KD, Wie BJ, Gribben JL, et al. Survival Benefit and cost savings from compliance with a simplified 3-hour sepsis bundle in a series of prospective, multisite, observational cohorts. Crit Care Med 2017; 45:395-406.
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31:1250-6.
Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-77.
Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017; 376:2235-44.
Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, et al. Assessment of clinical criteria for sepsis: for the third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315:762-74.
Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther 2014; 46:361-80.
Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified early warning score in medical admissions. QJM 2001; 94:521-6.
Robson W, Nutbeam T, Daniels R. Sepsis: a need for prehospital intervention? Emerg Med J 2009; 26:535-8.
Bayer O, Schwarzkopf D, Stumme C, Stacke A, Hartog CS, Hohenstein C, et al. An early warning scoring system to identify septic patients in the prehospital setting: The PRESEP score. Acad Emerg Med 2015; 22:868-71.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315:801-10.
Jouffroy R, Saade A, Carpentier A, Ellouze S, Philippe P, Idialisoa R, et al. Triage of septic patients using qSOFA criteria at the SAMU regulation: A retrospective analysis. Prehosp Emerg Care 2018; 22:84-90.
Jouffroy R, Saade A, Ellouze S, Carpentier A, Michaloux M, Carli P, et al. Prehospital triage of septic patients at the SAMU regulation: Comparison of qSOFA, MRST, MEWS and PRESEP scores. Am J Emerg Med 2018; 36:820-4.
Koyama S, Yamaguchi Y, Gibo K, Nakayama I, Ueda S. Use of prehospital qSOFA in predicting in-hospital mortality in patients with suspected infection: A retrospective cohort study. PLoS One 2019; 14:e0216560.
Tusgul S, Carron PN, Yersin B, Calandra T, Dami F. Low sensitivity of qSOFA, SIRS criteria and sepsis definition to identify infected patients at risk of complication in the prehospital setting and at the emergency department triage. Scand J Trauma Resusc Emerg Med 2017; 25:108.
Rady MY, Nightingale P, Little RA, Edwards JD. Shock index: a re- evaluation in acute circulatory failure. Resuscitation 1992; 23:227-34.
Jouffroy R, Saade A, Tourtier JP, Gueye P, Bloch-Laine E, Ecollan P, et al. Skin mottling score and capillary refill time to assess mortality of septic shock since pre-hospital setting. Am J Emerg Med 2019; 37:664-71.
Jouffroy R, Vivien B. Prehospital emergency care in sepsis: from the
«door-to-antibiotic» to the «antibiotic-at-door» concept? Ann Am Thorac
Soc 2019; 16:775-6.
Adnet F, Lapostolle F. International EMS systems: France. Resuscitation 2004; 63:7-9.
Allgöwer M BC. Schock index. Deutsche Medizinische Wodenschrift 1967; 46:1-10.
Berger T, Green J, Horeczko T, Hagar Y, Garg N, Suarez A, et al. Shock index and early recognition of sepsis in the emergency department: pilot study. West J Emerg Med 2013; 14:168-74.
Tseng J, Nugent K. Utility of the shock index in patients with sepsis. Am J Med Sci 2015; 349:531-5.
Yussof SJ, Zakaria MI, Mohamed FL, Bujang MA, Lakshmanan S, Asaari AH. Value of Shock Index in prognosticating the short-term outcome of death for patients presenting with severe sepsis and septic shock in the emergency department. Med J Malaysia 2012; 67:406-11.
Austin PC. Goodness-of-fit diagnostics for the propensity score model when estimating treatment effects using covariate adjustment with the propensity score. Pharmacoepidemiol Drug Saf 2008; 17:1202-17.
Churpek MM, Snyder A, Han X, Sokol S, Pettit N, Howell MD, et al. Quick sepsis-related organ failure assessment, systemic inflammatory response syndrome, and early warning scores for detecting clinical deterioration in infected patients outside the intensive care unit. Am J Respir Crit Care Med 2017; 195:906-11.
Dorsett M, Kroll M, Smith CS, Asaro P, Liang SY, Moy HP. qSOFA has poor sensitivity for prehospital identification of severe sepsis and septic shock. Prehosp Emerg Care 2017; 21:489-97.
Innocenti F, Tozzi C, Donnini C, De Villa E, Conti A, Zanobetti M, et al. SOFA score in septic patients: incremental prognostic value over age, comorbidities, and parameters of sepsis severity. Intern Emerg Med 2018; 13:405-12.