From the Guidelines
Management of a patient with a shock index greater than 0.9 requires immediate resuscitation and identification of the underlying cause, with a focus on securing the airway, ensuring adequate breathing, and restoring circulation, as well as initiating fluid resuscitation and vasopressors as needed, according to the most recent guidelines 1. The initial management should include establishing intravenous access with two large-bore peripheral catheters or a central venous catheter, and starting fluid resuscitation with crystalloids, such as Lactated Ringer's or Plasma-Lyte, administered as rapid boluses with reassessment after each bolus. If the patient remains hypotensive after adequate fluid resuscitation, vasopressors should be initiated, with norepinephrine (starting at 0.01-0.5 μg/kg/min, titrated to maintain MAP ≥65 mmHg) as the first-line agent, as recommended by the Surviving Sepsis Campaign Guidelines 1. Concurrent diagnostic workup should include blood cultures, lactate levels, complete blood count, coagulation studies, and imaging as appropriate to identify the shock etiology. Specific interventions depend on the type of shock: antibiotics for septic shock (within one hour of recognition), blood products for hemorrhagic shock, cardiac interventions for cardiogenic shock, or treatment of obstructive causes. Continuous monitoring of vital signs, urine output, mental status, and serial lactate measurements helps assess response to treatment. The shock index (heart rate divided by systolic blood pressure) exceeding 0.9 indicates significant hemodynamic compromise and correlates with higher mortality, making rapid intervention crucial for improving outcomes. It is essential to use an individualized mean arterial pressure (MAP) target based on frequent assessment of end-organ perfusion, including mental status, capillary refill, urine output, extremity perfusion, lactate, central venous oxygen saturation, and end-organ function, as suggested by the guidelines 1. Invasive monitoring with an arterial line should be considered, and norepinephrine is recommended as the first-line vasopressor agent to maintain adequate organ perfusion pressure in patients with septic shock 1. The optimal approach is to use a combination of fluid resuscitation, vasopressors, and other interventions, such as cardiac interventions for cardiogenic shock, to improve outcomes in patients with a shock index greater than 0.9. Overall, the management of a patient with a shock index greater than 0.9 requires a comprehensive and individualized approach, with a focus on rapid intervention and close monitoring to improve outcomes.
From the FDA Drug Label
2.2 Hypotension associated with Septic Shock To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).
The management approach for a patient with a shock index greater than 0.9 indicating significant shock may involve administering epinephrine (IV) at a suggested dosing infusion rate of 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min, to achieve the desired blood pressure goal 2.
- Key considerations:
- Administer epinephrine into a large vein.
- Avoid using a catheter tie-in technique.
- Avoid the veins of the leg in elderly patients or in those suffering from occlusive vascular diseases.
From the Research
Management Approach for Shock Index Greater Than 0.9
The management approach for a patient with a shock index greater than 0.9 indicating significant shock involves several key considerations:
- Identifying and addressing the underlying pathophysiology mechanisms operating in the patient 3
- Initiating circulatory support therapy to restore adequate tissue perfusion, which may include fluid resuscitation, vasopressors, and inotropes 3, 4
- Choosing the appropriate vasopressor and inotrope therapy, with norepinephrine being a common first-line choice for vasodilatory shock 3, 4
- Considering the addition of other agents, such as vasopressin or angiotensin II, if norepinephrine alone is inadequate 3, 4
Utility of Shock Index in Emergency Department
The shock index has been studied in various settings, including the emergency department, as a potential tool for identifying patients at risk of shock or critical illness:
- A shock index greater than 1.0 has been associated with increased risk of mortality and morbidity 5
- The shock index may be useful in evaluating acute critical illness in the emergency department, particularly in patients with apparently stable vital signs 6
- Variants of the shock index, such as the adjusted shock index and age-modified shock index, may also have prognostic value in certain patient populations 7
Key Considerations for Patient Management
When managing a patient with a shock index greater than 0.9, it is essential to: