Vital Sign Prediction of Adverse Maternal Outcomes in Women with Hypovolemic Shock: The Role of Shock Index.
Vital Sign Prediction of Adverse Maternal Outcomes in Women with Hypovolemic Shock: The Role of Shock Index.
复制标题
DOI：
10.1371/journal.pone.0148729
复制
发表时间：
2016
期刊：
影响因子：
3.7
通讯作者：
Miller S
中科院分区：
文献类型：
--
作者：
El Ayadi AM;Nathan HL;Seed PT;Butrick EA;Hezelgrave NL;Shennan AH;Miller S
确定因产科出血继发低血容量休克的妇女不良产妇结局的最佳生命体征预测因子，并制定转诊/强化监测的阈值以及紧急干预的需要，以通知资源匮乏地区的生命体征警报装置。我们对资源匮乏地区发生低血容量休克的孕妇/产后妇女的数据集进行了二次分析 (n = 958)。使用受试者工作曲线分析，我们评估了脉搏、收缩压、舒张压、休克指数、平均动脉压和脉压对三种不良孕产妇结局的预测能力：(1) 死亡，(2) 严重孕产妇结局（死亡或严重终末器官功能障碍发病率）； (3) 合并严重孕产妇和危重干预结果，包括死亡、严重终末器官功能障碍发病率、重症监护入院、输血≥5单位或紧急子宫切除术。根据敏感性、特异性以及阳性和阴性预测值，选择具有最佳排除和排除特征的两个阈值参数。休克指数一直是孕产妇不良结局的前两个预测因素之一。其对孕产妇死亡的区分能力显着优于脉搏和脉压（分别为p<0.05和p<0.01），对于严重孕产妇结局的舒张压和脉压（p<0.01），对于严重孕产妇结局和关键干预的收缩压和舒张压、平均动脉压和脉压（p<0.01）。 ≥ 0.9的休克指数阈值保持了较高的敏感性（100.0）和临床实用性，≥ 1.4平衡了特异性（范围70.0-74.8）和阴性预测值（范围93.2-99.2），≥ 1.7进一步提高了特异性（范围80.7-90.8）而不影响阴性预测值（范围88.8-98.5）。对于因产科出血而发生低血容量休克的女性，休克指数始终是所有不良后果的有力预测因子。在资源匮乏的较低级别设施中，我们建议冲击指数阈值≥0.9表明需要转诊，≥1.4表明在三级设施中迫切需要干预，≥1.7表明不良结果的可能性很高。生命体征警报装置包含值 0.9 和 1.7；然而，所有阈值都将进行前瞻性验证，并在临床实施之前建立适合设定的临床行动路径。
To determine the optimal vital sign predictor of adverse maternal outcomes in women with hypovolemic shock secondary to obstetric hemorrhage and to develop thresholds for referral/intensive monitoring and need for urgent intervention to inform a vital sign alert device for low-resource settings. We conducted secondary analyses of a dataset of pregnant/postpartum women with hypovolemic shock in low-resource settings (n = 958). Using receiver-operating curve analysis, we evaluated the predictive ability of pulse, systolic blood pressure, diastolic blood pressure, shock index, mean arterial pressure, and pulse pressure for three adverse maternal outcomes: (1) death, (2) severe maternal outcome (death or severe end organ dysfunction morbidity); and (3) a combined severe maternal and critical interventions outcome comprising death, severe end organ dysfunction morbidity, intensive care admission, blood transfusion ≥ 5 units, or emergency hysterectomy. Two threshold parameters with optimal rule-in and rule-out characteristics were selected based on sensitivities, specificities, and positive and negative predictive values. Shock index was consistently among the top two predictors across adverse maternal outcomes. Its discriminatory ability was significantly better than pulse and pulse pressure for maternal death (p<0.05 and p<0.01, respectively), diastolic blood pressure and pulse pressure for severe maternal outcome (p<0.01), and systolic and diastolic blood pressure, mean arterial pressure and pulse pressure for severe maternal outcome and critical interventions (p<0.01). A shock index threshold of ≥ 0.9 maintained high sensitivity (100.0) with clinical practicality, ≥ 1.4 balanced specificity (range 70.0–74.8) with negative predictive value (range 93.2–99.2), and ≥ 1.7 further improved specificity (range 80.7–90.8) without compromising negative predictive value (range 88.8–98.5). For women with hypovolemic shock from obstetric hemorrhage, shock index was consistently a strong predictor of all adverse outcomes. In lower-level facilities in low resource settings, we recommend a shock index threshold of ≥ 0.9 indicating need for referral, ≥ 1.4 indicating urgent need for intervention in tertiary facilities and ≥ 1.7 indicating high chance of adverse outcome. The vital sign alert device incorporated values 0.9 and 1.7; however, all thresholds will be prospectively validated and clinical pathways for action appropriate to setting established prior to clinical implementation.