Original Article

Utility of the Shock Index for Risk Stratification in Patients with Acute Upper Gastrointestinal Bleeding

Authors: Supannee Rassameehiran, MD, Jirapat Teerakanok, MD, Sakolwan Suchartlikitwong, MD, Kenneth Nugent, MD

Abstract

Objectives: Patients with upper gastrointestinal bleeding (UGIB) frequently require hospitalization, and a small but significant percentage of these patients have adverse outcomes. Risk-scoring tools can help clinicians organize care and make predictions about outcomes. The shock index (heart rate divided by systolic blood pressure) has been used in multiple acute disorders and has the potential to identify patients with UGIB who are at risk for adverse outcomes.

Methods: We retrospectively reviewed the electronic medical records of patients admitted with UGIB between January 1, 2012 and December 31, 2015. We collected information about patient demographics, presenting symptoms, underlying clinical disorders, endoscopic results, and outcomes. We calculated risk scores using the Glasgow-Blatchford score, the pre-endoscopy Rockall score, the full Rockall score, the AIMS65 (albumin, international normalized ratio, mental status, systolic blood pressure, age older than 65 years) score, and the shock index.

Results: This study included 214 admissions for acute UGIB. The mean age was 59.0 ± 15.9 years, 64.5% were men, the mean hemoglobin was 9.2 ± 3.1 g/dL, and the mean shock index was 0.78 ± 0.21 bpm/mm Hg. The mean shock index was significantly increased in patients requiring endoscopic therapy, admission to the intensive care unit, blood component transfusion, and red blood cell transfusion. Classification of patients by a shock index >0.7 preferentially selected patients with these adverse short-term outcomes. Among the scoring tools evaluated in this study, the shock index was the best predictor of the need for endoscopic therapy.

Conclusions: The shock index is a good tool to identify patients with the potential for short-term adverse outcomes when they present with UGIB. It performs as well as other risk-scoring tools for GI bleeding and has the potential for serial use during hospitalization to identify changes in the clinical course.

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References

1. Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc 2015;81:882-888.e1.
 
2. Laine L, Yang H, Chang SC, et al. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012;107:1190-1196.
 
3. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-113.
 
4. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107:345-361.
 
5. Barkun A, Bardou M, Marshall JK, et al. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2003;139:843-857.
 
6. Brasel KJ, Guse C, Gentilello LM, et al. Heart rate: is it truly a vital sign? J Trauma 2007;62:812-817.
 
7. Zarzaur BL, Croce MA, Fischer PE, et al. New vitals after injury: shock index for the young and age x shock index for the old. J Surg Res 2008;147:229-236.
 
8. Cannon CM, Braxton CC, Kling-Smith M, et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma 2009;67:1426-1430.
 
9. Chen IC, Hung MS, Chiu TF, et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med 2007;25:774-779.
 
10. Robertson M, Majumdar A, Boyapati R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc 2016;83:1151-1160.
 
11. Allgower M, Burri C."Shock index" [in German]. Dtsch Med Wochenschr 1967;92:1947–1950.
12. Birkhahn RH, Gaeta TJ, Terry D, et al. Shock index in diagnosing early acute hypovolemia. Am J Emerg Med 2005;23:323-326.
 
13. Zarzaur BL, Croce MA, Magnotti LJ, et al. Identifying life-threatening shock in the older injured patient: an analysis of the National Trauma Data Bank. J Trauma 2010;68:1134-1138.
 
14. Baraff LJ, Schriger DL. Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss. Am J Emerg Med 1992;10:99-103.
 
15. Mutschler M, Nienaber U, Munzberg M, et al. The Shock Index revisited-a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Crit Care 2013;17:R172.
 
16. Birkhahn RH, Gaeta TJ, Van Deusen SK, et al. The ability of traditional vital signs and shock index to identify ruptured ectopic pregnancy. Am J Obstet Gynecol 2003;189:1293-1296.
 
17. Schulz F, Hanusch J, Starlinger M, et al. Significance of emergency endoscopy in severe upper gastrointestinal hemorrhage
18. Tseng J, Nugent K. Utility of the shock index in patients with sepsis. Am J Med Sci 2015;349:531-535.
 
19. Ratra A, Rassameehiran S, Parupudi S, et al. Utility of the shock index and other risk-scoring tools in patients with gastrointestinal bleeding. South Med J 2016;109:178-184.
 
20. Hwang JK, Jang WJ, Song YB, et al. Shock index as a predictor of myocardial injury in ST-segment elevation myocardial infarction. Am J Med Sci 2016;352:574-581.
 
21. Vandromme MJ, Griffin RL, Kerby JD, et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma 2011;70:384-390.
 
22. Sohn CH, Kim WY, Kim SR, et al. An increase in initial shock index is associated with the requirement for massive transfusion in emergency department patients with primary postpartum hemorrhage. Shock 2013;40:101-105.
 
23. DeMuro JP, Simmons S, Jax J, et al. Application of the shock index to the prediction of need for hemostasis intervention. Am J Emerg Med 2013;31:1260-1263.
 
24. Berger T, Green J, Horeczko T, et al. Shock index and early recognition of sepsis in the emergency department: pilot study. West J Emerg Med 2013;14:168-174.
 
25. Pandit V, Rhee P, Hashmi A, et al. Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2014;76:1111-1115.
 
26. Mitra B, Fitzgerald M, Chan J. The utility of a shock index > 1 as an indication for pre-hospital oxygen carrier administration in major trauma. Injury 2014;45:61-65.
 
27. Nakasone Y, Ikeda O, Yamashita Y, et al. Shock index correlates with extravasation on angiographs of gastrointestinal hemorrhage: a logistics regression analysis. Cardiovasc Intervent Radiol 2007;30:861-865.
 
28. El Ayadi AM, Nathan HL, Seed PT, et al. Vital sign prediction of adverse maternal outcomes in women with hypovolemic shock: the role of shock index. PLoS One 2016;11:e0148729.
 
29. Joseph B, Haider A, Ibraheem K, et al. Revitalizing vital signs: the role of delta shock index. Shock 2016;46(3 suppl 1):50-54.