What is the management approach for a patient with a shock index greater than 0.9, indicating shock?

From the Guidelines

Patients with a shock index greater than 0.9 require immediate resuscitation and management focused on identifying and treating the underlying cause of shock. Initial management includes establishing large-bore intravenous access (two 16-18 gauge IVs), administering crystalloid fluids (typically 30 mL/kg of balanced crystalloids like Lactated Ringer's or Plasma-Lyte) within the first hour, and initiating continuous vital sign monitoring including cardiac monitoring, pulse oximetry, and frequent blood pressure checks 1. Supplemental oxygen should be provided to maintain oxygen saturation above 94%. Laboratory studies should be obtained promptly, including complete blood count, comprehensive metabolic panel, lactate level, coagulation studies, and blood cultures if infection is suspected. If the patient remains hypotensive (systolic BP <90 mmHg) after initial fluid resuscitation, vasopressors should be started, with norepinephrine (starting at 0.01-0.5 μg/kg/min, titrated to maintain MAP >65 mmHg) as the first-line agent 1. Concurrent diagnostic workup should identify the shock etiology (hypovolemic, cardiogenic, distributive, or obstructive) to guide specific interventions. For septic shock, early broad-spectrum antibiotics should be administered within one hour. For cardiogenic shock, inotropic support with dobutamine (2-20 mcg/kg/min) may be needed 1. Hemorrhagic shock requires blood product transfusion and hemorrhage control. This aggressive approach is necessary because shock represents inadequate tissue perfusion that can rapidly lead to multi-organ dysfunction if not promptly addressed. The optimal approach is to use an individualized MAP target based on frequent assessment of end-organ perfusion (mental status, capillary refill, urine output, extremity perfusion, lactate, central venous oxygen saturation, and end-organ function) 1. Surviving Sepsis Campaign Guidelines suggest invasive arterial monitoring as soon as practical and suggest starting vasopressors peripherally to restore MAP rather than delaying until central venous access is secured 1. Norepinephrine is recommended as the first-line vasopressor agent to maintain adequate organ perfusion pressure in patients with septic shock 1. Management by a multidisciplinary team experienced in shock is reasonable for patients with cardiogenic shock 1. Placement of a PA line may be considered to define hemodynamic subsets and appropriate management strategies 1. Triage to centers that can provide temporary mechanical circulatory support (MCS) may be considered to optimize management for patients who are not rapidly responding to initial shock measures 1.

Some key points to consider:

• The use of vasopressors and inotropes should be guided by the patient's hemodynamic status and response to treatment.
• The goal of treatment is to restore adequate organ perfusion and prevent multi-organ dysfunction.
• Early recognition and treatment of shock are critical to improving outcomes.
• A multidisciplinary approach to management is recommended for patients with cardiogenic shock.
• The most recent guidelines from 2022 support the use of norepinephrine as the first-line vasopressor agent and recommend management by a multidisciplinary team experienced in shock 1.

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 shock, involves 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 shock, involves several key considerations:

• Fluid resuscitation is a critical component, with crystalloids being the preferred initial fluid solution of choice 3
• The choice between balanced crystalloids and normal saline may depend on the specific patient population, with some studies suggesting balanced crystalloids may reduce mortality in non-traumatic brain injury patients 4, 5
• However, other studies have found no significant difference in mortality between balanced crystalloids and normal saline 4, 5
• The shock index has been shown to be a valid predictor of mortality in emergency department patients, including those with hypertension, diabetes, and high age, or those receiving β- or calcium channel blockers 6
• Resuscitation with normal saline vs. lactated Ringer's solution has been studied, with lactated Ringer's solution showing more favorable effects on extravascular lung water and haemodynamics 7

Key Considerations

• The primary goal of fluid resuscitation is to restore adequate circulation and oxygen delivery to tissues
• The choice of fluid and the volume administered should be tailored to the individual patient's needs and response
• Close monitoring of the patient's hemodynamic status, oxygenation, and other vital signs is essential to guide management decisions
• The use of balanced crystalloids, such as lactated Ringer's solution, may be preferred in certain patient populations due to their more favorable effects on acid-base balance and haemodynamics 7