Prediction of vasopressor requirement among hypotensive patients with suspected infection: usefulness of diastolic shock index and lactate

Abstract

Objective We evaluated the performance of diastolic shock index (DSI) and lactate in predicting vasopressor requirement among hypotensive patients with suspected infection in an emergency department.Methods This was a single-center, retrospective observational study for adult patients with suspected infection and hypotension in the emergency department from 2018 to 2019. The study population was split into derivation and validation cohorts (70/30). We derived a simple risk score to predict vasopressor requirement using DSI and lactate cutoff values determined by Youden index. We tested the score by the area under the receiver operating characteristic curve (AUC). We performed a multivariable regression analysis to evaluate the association between the timing of vasopressor treatment and 28-day mortality.Results A total of 1,917 patients were included. We developed a score, assigning 1 point each for the high DSI (≥2.0) and high lactate (≥2.5 mmol/L) criteria. The AUCs of the score were 0.741 (95% confidence interval [CI], 0.715–0.768) at hypotension and 0.736 (95% CI, 0.708–0.763) after initial fluid challenge in the derivation cohort and 0.676 (95% CI, 0.631–0.719) at hypotension and 0.688 (95% CI, 0.642–0.733) after initial fluid challenge in the validation cohort, respectively. In patients with scores of 2 points, early vasopressor therapy initiation was significantly associated with decreased 28-day mortality (adjusted odds ratio, 0.37; 95% CI, 0.14–0.94).Conclusion A prediction model with DSI and lactate levels might be useful to identify patients who are more likely to need vasopressor administration among hypotensive patients with suspected infection.

Using the diastolic shock index to determine when to promptly administer vasopressors in patients with septic shock

“…In a similar way, a recent retrospective study showed that DSI and lactate values identified patients who were more likely to require a vasopressor in the context of hypotension and suspected infection. 8 Even though these results are in line with previous reports, 7 the usefulness of DSI in clinical practice has not yet been demonstrated.…”

“…The patients subjected to very early vasopressor use in that cohort received a lower volume of resuscitation fluids, exhibited less net fluid accumulation, and had shorter hypotension times [ 9 ]. Similarly, in a recently published study, patients with simultaneous increases in their lactate and DSI levels had a lower 28-day mortality risk when vasopressors were initiated very early [ 8 ]. In contrast, others have reported opposite results when vasopressors were introduced very early during the resuscitation process [ 10 ], although it is not clear that this difference indicated an effect of the early start of vasopressors or simply reflected the presence of a more severe disease condition.…”

“…9 Similarly, in a recently published study, patients with simultaneous increases in their lactate and DSI levels had a lower 28-day mortality risk when vasopressors were initiated very early. 8 In contrast, others have reported opposite results when vasopressors were introduced very early during the resuscitation process, 10 although it is not clear that this difference indicated an effect of the early start of vasopressors or simply reflected the presence of a more severe disease condition. 10 Regardless of whether the immediate introduction of vasopressors was advantageous, it also remains to be determined which patients would benefit the most from this strategy.…”

“…Three important findings were noted: (1) higher DSI values calculated just before or at the start of vasopressor administration were associated with a gradual increase in the risk of death in patients with septic shock; (2) isolated low DAP or high HR values did not clearly identify such a risk; and (3) nonsurvivors evolved with persistently high DSI values and required higher doses of vasopressors and more resuscitation fluids than survivors. In a similar way, a recent retrospective study showed that DSI and lactate values identified patients who were more likely to require a vasopressor in the context of hypotension and suspected infection [ 8 ]. Even though these results are in line with previous reports [ 7 ], the usefulness of DSI in clinical practice has not yet been demonstrated.…”

Development of score system based on point-of-care ultrasound to predict vasopressor requirement for emergency patients with cardiopulmonary symptoms

“…Previously, vasopressor requirement prediction models were developed using the Acute Physiology and Chronic Health Evaluation III score, lactate level, acute kidney injury, intravenous crystalloid administration, and hypotension (<90 mm Hg) (30–32). To achieve a higher predictive performance, models usually select many components that require resources, including time and healthcare providers.…”