Document Type : Research articles


Emergency Department, Weifang Traditional Chinese Hospital, Weifang, P. R. China


Background: The changes before and after fluid resuscitation in patients with septic shock and their relationship with prognosis have rarely been reported.
Objectives: We aimed to observe the correlation between pulmonary vascular permeability index (PVPI), shock index (SI), and severity of septic shock.
Methods: This case-control study retrospectively analyzed the clinical data of 154 patients with septic shock treated at our hospital (Weifang, China) from October 2016 to October 2018. They were divided into a survival group or a death group according to the 28-day prognosis. Univariate analysis was performed for vital signs, the acute physiology and chronic health evaluation II (APACHE-II) score, the sequential organ failure assessment (SOFA) score at admission, SI at admission (SI1), SI at 3 h after fluid resuscitation (SI2), PVPI at admission (PVPI1), PVPI at 3 h after fluid resuscitation (PVPI2), and lactate clearance rate (LCR). The correlations of PVPI and SI with the APACHE-II score, SOFA score, and LCR were analyzed by plotting the receiver operating characteristic curves.
Results: Among the 154 cases, 70 survived after 28 days and 84 died. We observed that SI1, SI2, PVPI1, PVPI2, APACHE-II score, and SOFA score were significantly lower in the survival group than in the death group, while LCR was significantly higher (P < 0.05). Also, SI1, SI2, PVPI1, and PVPI2 were positively correlated with APSCHE-II and SOFA scores of patients with septic shock, but negatively correlated with LCR (P < 0.05). Moreover, SI2 predicted the prognosis of patients with septic shock significantly better than SI1, PVPI1, and PVPI2 did. When SI2 was 1.22, the Youden index was 0.822, the sensitivity was 91.23%, the specificity was 89.47%, the positive predictive value was 0.912, and the negative predictive value was 0.924. The positive and negative likelihood ratios were 0.897 and 0.375, respectively.
Conclusions: Based on the study, SI after fluid resuscitation was more valuable for evaluating the prognosis of patients with septic shock than SI at admission, as well as PVPI values at admission and after fluid resuscitation.


  1. Ghosh S, Li J, Cao L, Ramamohanarao K. Septic shock prediction for ICU patients via coupled HMM walking on sequential contrast patterns. J Biomed Inform. 2017;66:19-31. doi: 10.1016/j.jbi.2016.12.010. [PubMed: 28011233].
  2. Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R; Prism Investigators, et al. Early, goal-directed therapy for septic shock - a patient-level meta-analysis. N Engl J Med. 2017;376(23):2223-34. doi: 10.1056/NEJMoa1701380. [PubMed: 28320242].
  3. Lee SM, An WS. New clinical criteria for septic shock: Serum lactate level as new emerging vital sign. J Thorac Dis. 2016;8(7):1388-90. doi: 10.21037/jtd.2016.05.55. [PubMed: 27501243]. [PubMed Central: PMC4958885].
  4. Zangrillo A, Putzu A, Monaco F, Oriani A, Frau G, De Luca M, et al. Levosimendan reduces mortality in patients with severe sepsis and septic shock: A meta-analysis of randomized trials. J Crit Care. 2015;30(5):908-13. doi: 10.1016/j.jcrc.2015.05.017. [PubMed: 26093802].
  5. Tseng J, Nugent K. Utility of the shock index in patients with sepsis. Am J Med Sci. 2015;349(6):531-5. doi: 10.1097/MAJ.0000000000000444. [PubMed: 25782337].
  6. Truwit JD, Bernard GR, Steingrub J, Matthay MA; National Heart, Lung, and Blood Institute Ards Clinical Trials NetworkBlood Institute Ards Clinical Trials Network, et al. Rosuvastatin for sepsis-associated acute respiratory distress syndrome. N Engl J Med. 2014;370(23):2191-200. doi: 10.1056/NEJMoa1401520. [PubMed: 24835849]. [PubMed Central: PMC4241052].
  7. Shigemitsu K, Rinka H, Morimoto T, Morooka T, Ishikawa J, Fuke A, et al. 1041: Pulmonary vascular permeability index not predicting systemic vascular permeability in septic shock. Crit Care Med. 2015;43:262. doi: 10.1097/01.ccm.0000474872.50302.db.
  8. Coccolini F, Sartelli M, Catena F, Ceresoli M, Montori G, Ansaloni L. Early goal-directed treatment versus standard care in management of early septic shock: Meta-analysis of randomized trials. J Trauma Acute Care Surg. 2016;81(5):971-8. doi: 10.1097/TA.0000000000001246. [PubMed: 27602898].
  9. Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock. 2015;43(1):68-73. doi: 10.1097/SHK.0000000000000268. [PubMed: 25247784]. [PubMed Central: PMC4269557].
  10. Garnacho-Montero J, Gutierrez-Pizarraya A, Escoresca-Ortega A, Corcia-Palomo Y, Fernandez-Delgado E, Herrera-Melero I, et al. De-escalation of empirical therapy is associated with lower mortality in patients with severe sepsis and septic shock. Intensive Care Med. 2014;40(1):32-40. doi: 10.1007/s00134-013-3077-7. [PubMed: 24026297].
  11. Wang H, Guo S, Wan C, Yang T, Zeng N, Wu Y, et al. Tumor necrosis factor-alpha -308 G/A polymorphism and risk of sepsis, septic shock, and mortality: An updated meta-analysis. Oncotarget. 2017;8(55):94910-9. doi: 10.18632/oncotarget.20862. [PubMed: 29212277]. [PubMed Central: PMC5706923].
  12. Tarui T, Yamaguchi Y, Suzuki K, Tsuruta R, Ikeda H, Ogura H, et al. Early evaluation of severity in patients with severe sepsis: A comparison with "septic shock" - subgroup analysis of the Japanese Association for Acute Medicine Sepsis Registry (JAAM-SR). Acute Med Surg. 2017;4(4):426-31. doi: 10.1002/ams2.299. [PubMed: 29123903]. [PubMed Central: PMC5649294].
  13. Hohn A, Balfer N, Heising B, Hertel S, Wiemer JC, Hochreiter M, et al. Adherence to a procalcitonin-guided antibiotic treatment protocol in patients with severe sepsis and septic shock. Ann Intensive Care. 2018;8(1):68. doi: 10.1186/s13613-018-0415-5. [PubMed: 29869120]. [PubMed Central: PMC5986690].
  14. Potter DR, Miyazawa BY, Gibb SL, Deng X, Togaratti PP, Croze RH, et al. Mesenchymal stem cell-derived extracellular vesicles attenuate pulmonary vascular permeability and lung injury induced by hemorrhagic shock and trauma. J Trauma Acute Care Surg. 2018;84(2):245-56. doi: 10.1097/TA.0000000000001744. [PubMed: 29251710]. [PubMed Central: PMC6378956].
  15. Song M, Zhang Y, Guo Y, Xia F, Yanqing WU, Shi Z, et al. Test of Sepsis 3.0 for diagnosis and prognosis of the septic patients in the Intensive Care Unit. Chin J Integr Tradit West Med Intensive Crit Care. 2017;24(1):6-9.
  16. Sadaka F, Juarez M, Naydenov S, O'Brien J. Fluid resuscitation in septic shock: The effect of increasing fluid balance on mortality. J Intensive Care Med. 2014;29(4):213-7. doi: 10.1177/0885066613478899. [PubMed: 23753235].
  17. Lanspa MJ, Brown SM, Hirshberg EL, Jones JP, Grissom CK. Central venous pressure and shock index predict lack of hemodynamic response to volume expansion in septic shock: A prospective, observational study. J Crit Care. 2012;27(6):609-15. doi: 10.1016/j.jcrc.2012.07.021. [PubMed: 23084132]. [PubMed Central: PMC3621131].
  18. Cerro L, Valencia J, Calle P, Leon A, Jaimes F. [Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units]. Rev Esp Anestesiol Reanim. 2014;61(3):125-32. Spanish. doi: 10.1016/j.redar.2013.11.014. [PubMed: 24468009].
  19. Johansson PI, Stensballe J, Ostrowski SR. Shock induced endotheliopathy (SHINE) in acute critical illness - a unifying pathophysiologic mechanism. Crit Care. 2017;21(1):25. doi: 10.1186/s13054-017-1605-5. [PubMed: 28179016]. [PubMed Central: PMC5299749].
  20. Pisano SRR, Howard J, Posthaus H, Kovacevic A, Yozova ID. Hydrocortisone therapy in a cat with vasopressor-refractory septic shock and suspected critical illness-related corticosteroid insufficiency. Clin Case Rep. 2017;5(7):1123-9. doi: 10.1002/ccr3.1018. [PubMed: 28680609]. [PubMed Central: PMC5494402].
  21. Rady MY, Smithline HA, Blake H, Nowak R, Rivers E. A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med. 1994;24(4):685-90. doi: 10.1016/s0196-0644(94)70279-9. [PubMed: 8092595].
  22. Liu M. Correlation of insulin resistance extent with systemic inflammatory response and target organ damage in children with sepsis. J Hainan Med Univ. 2017;23(11):128-31.
  23. Kobayashi A, Misumida N, Luger D, Kanei Y. Shock Index as a predictor for In-hospital mortality in patients with non-ST-segment elevation myocardial infarction. Cardiovasc Revasc Med. 2016;17(4):225-8. doi: 10.1016/j.carrev.2016.02.015. [PubMed: 26973283].
  24. Yussof SJ, Zakaria MI, Mohamed FL, Bujang MA, Lakshmanan S, Asaari AH. Value of Shock index in prognosticating the short-term outcome of death for patients presenting with severe sepsis and septic shock in the emergency department. Med J Malaysia. 2012;67(4):406-11. [PubMed: 23082451].