Derivation and Validation of Vasoactive Inotrope Score Trajectory Groups in Critically Ill Children With Shock.
Derivation and Validation of Vasoactive Inotrope Score Trajectory Groups in Critically Ill Children With Shock.
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DOI：
10.1097/pcc.0000000000003070
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发表时间：
2022-12-01
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确定危重病急性期休克患儿是否存在临床相关和可重复的血管活性-变力因子评分（维斯）轨迹。回顾性、观察性队列研究。两个三级学术儿科重症监护室。在进入PICU后24小时内需要血管活性药物输注的儿童（<18岁）。排除心脏手术后入院的患者。没有。在开始血管活性药物治疗后的前72小时内计算每小时维斯。基于组的轨迹建模（GBTM）被应用于推导集（75%的遭遇），并使用相同的参数与验证集（25%的遭遇）中的轨迹进行比较。主要结局是住院死亡率，次要结局是第7天的多器官功能障碍综合征（MODS）。共有1，828例患者符合入选标准，309例（16.9%）死亡。GBTM确定了验证集中可重现的四个亚组："轻度、快速缓解的休克"（n = 853 [47%]，死亡率9%），"中度，缓慢缓解性休克"（n = 422 [23%]，死亡率15%）、"中度、长期休克"（n = 312 [17%]，死亡率21%）和"重度、长期休克"（n = 241 [13%]，死亡率40%）。各组间死亡率、第7天的MODS和疑似感染有显著差异（p <0.001）。在最初24小时内可识别"轻度、快速缓解休克"和"重度、长期休克"组。"中度，缓慢解决"和"中度，长期休克"组在开始血管活性药物后的前24小时内无法区分，但在第7天的住院死亡率和MODS不同。氢化可的松给药与"轻度快速缓解休克"组的不良结局独立相关。我们发现了四个不同的和可重复的维斯轨迹组，这些轨迹组与休克儿童的不同风险因素、治疗反应和结局相关。在危重病的急性期描述维斯轨迹组可以实现更好的预测和更有针对性的管理。
To determine whether there are clinically relevant and reproducible vasoactive-inotrope score (VIS) trajectories in children with shock during the acute phase of critical illness. Retrospective, observational cohort study. Two tertiary, academic pediatric intensive care units. Children (<18 years old) who required vasoactive infusions within 24 hours of admission to the PICU. Those admitted post-cardiac surgery were excluded. None. An hourly VIS was calculated for the first 72 hours after initiation of vasoactives. Group-based trajectory modeling (GBTM) was applied to a derivation set (75% of encounters) and compared to the trajectories in a validation set (25% of encounters) using the same parameters. The primary outcome was in-hospital mortality and the secondary outcome was multiple organ dysfunction syndrome (MODS) on day 7. A total of 1,828 patients met inclusion criteria and 309 (16.9%) died. GBTM identified four subgroups that were reproducible in the validation set: “Mild, fast resolving shock” (n=853 [47%], mortality 9%), “Moderate, slow resolving shock” (n=422 [23%], mortality 15%), “Moderate, prolonged shock” (n=312 [17%], mortality 21%), and “Severe, prolonged shock” (n=241 [13%], mortality 40%). There was a significant difference in mortality, MODS on day 7, and suspected infection (p<0.001) across groups. The “Mild, fast resolving shock” and “Severe, prolonged shock” groups were identifiable within the first 24 hours. The “Moderate, slow resolving” and “Moderate, prolonged shock” groups were indistinguishable in the first 24 hours after initiation of vasoactives, but differed in in-hospital mortality and MODS on day 7. Hydrocortisone administration was independently associated with poor outcomes in the “Mild, fast resolving shock” group. We uncovered four distinct and reproducible VIS trajectory groups that were associated with different risk factors, response to therapy, and outcomes in children with shock. Characterizing VIS trajectory groups in the acute phase of critical illness may enable better prognostication and more targeted management.