Reply to “Is the Shock Index a Dynamic Index?”

Abstract Introduction Acute lower gastrointestinal bleeding (LGIB) tends to occur in elderly patients with complex comorbidities. At North Middlesex University Hospital (NMUH), LGIB patients are primarily managed by the surgical department. We amended local policies by integrating aspects of new guidelines published by the British Society of Gastroenterology (BSG). Method Handover documentation between November 2019 and January 2020 established patients admitted with LGIB (n = 45). Further data regarding the management of these patients was collated from clinical software and compared to standards set from BSG guidelines. Results We found NMUH to be efficient in ruling out upper GI bleeds via 24-hour OGDs and had low surgical intervention rates (0.02%). 40% of patients were transfused with an admission haemoglobin above suggested NICE thresholds, accounting for cardiovascular comorbidities. 56% of patients were discharged without a documented anticoagulation plan. Over 50% of patients did not have BSG recommended inpatient investigations. Conclusions Updated Trust guidelines aim to uphold areas that NMUH were shown to excel in, while reiterating NICE transfusion thresholds and include guidance regarding anticoagulant and antiplatelet medications. The Oakland score and shock index have been integrated into local protocols and will aid clinicians in making safe decisions in the management of LGIB patients.

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888 Challenges in The Management of Lower Gastrointestinal Bleeding in General Surgery: Developing Consistent Practice and Application of BSG Guidelines

British Journal of Surgery ◽

10.1093/bjs/znab134.587 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

A Bhojwani ◽

M Ahmed ◽

F Mahmood ◽

C Sellahewa ◽

C Desai

Keyword(s):

Risk Stratification ◽

Gastrointestinal Bleeding ◽

District Hospital ◽

Hospital Setting ◽

Lower Gastrointestinal Bleeding ◽

Shock Index ◽

Retrospective Audit ◽

Ct Angiogram ◽

Sensitive Tool ◽

The Uk

Abstract Introduction Lower gastrointestinal bleeding (LGIB) accounts for 3% of all surgical referrals in the UK, with an in-hospital mortality of 3.4%. The BSG 2019 guidelines recommend risk stratification as per Oakland scoring, inpatient lower GI endoscopy for admissions and CT-angiography for unstable patients. This study evaluates the delivery of these outcomes in a district hospital setting. Method Retrospective audit assessing all acute LGI bleed admissions from 01-07-2019 to 28-02-2020 at Russells Hall Hospital. Shock Index (SI) and Oakland score used to stratify patients into unstable, stable-major and stable-minor LGIB. Compliance with BSG standards was assessed by review of investigations and emergent patient management. Results 143 patients (Median age = 70years) evaluated, with 64 admissions having no formal risk stratification (OAKLAND-score) documented. Only 12 admissions underwent inpatient LGI endoscopy with sigmoid diverticulosis the most common pathology (39.3%). CT-angiogram was the initial investigation for 75% of patients admitted with unstable LGIB. Conclusions OAKLAND-scoring is a sensitive tool to stratify LGIB patients based on clinical parameters. Application of BSG-2019 guidelines and developing consistency in management is challenged by the lack of routine access to LGI endoscopy and tools to manage bleeding endoscopically.

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Small animal Review

Companion Animal ◽

10.12968/coan.2021.0008 ◽

2021 ◽

Vol 26 (3) ◽

pp. 5-5

Author(s):

Alex Gough

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Pulmonary Oedema ◽

Potential Role ◽

Lung Ultrasound ◽

Small Animal ◽

Shock Index ◽

Cardiogenic Pulmonary Oedema ◽

The Impact

Summary In this month's Small Animal Review, we summarise three recently published papers from other veterinary journals. The papers for this issue explore the impact of open registries on inbreeding, in the working Australian Kelpie population particularly, and the impact of vehicle trauma on the canine shock index, as well as the potential role for lung ultrasound in monitoring for cardiogenic pulmonary oedema in dogs being treated for left-sided congestive heart failure.

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Shock index as a predictor of mortality among the Covid-19 patients

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2020.12.053 ◽

2021 ◽

Vol 40 ◽

pp. 106-109

Author(s):

Fatih Doğanay ◽

Fuat Elkonca ◽

Avni Uygar Seyhan ◽

Erdal Yılmaz ◽

Ayşe Batırel ◽

...

Keyword(s):

Shock Index

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Prehospital shock index outperforms hypotension alone in predicting significant injury in trauma patients

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000712 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000712

Author(s):

Tareq Kheirbek ◽

Thomas J Martin ◽

Jessica Cao ◽

Benjamin M Hall ◽

Stephanie Lueckel ◽

...

Keyword(s):

Blood Pressure ◽

Missing Values ◽

Injured Patient ◽

Injury Pattern ◽

Long Bone ◽

Shock Index ◽

Level Of Evidence ◽

Emergent Operation ◽

Serious Injury ◽

Significant Injury

BackgroundThe American College of Surgeons Resources for Optimal Care of the Injured Patient recommends using hypotension, defined as systolic blood pressure ≤90 mm Hg, as an indicator of a full team trauma activation. We hypothesized that an elevated shock index (SI) predicts significant traumatic injuries better than hypotension alone.MethodsThis is a retrospective cohort study analyzing full team trauma activations between February 2018 and January 2020, excluding transfers and those who had missing values for prehospital blood pressure or heart rate. We reviewed patients’ demographics, prehospital and emergency department vitals, injury pattern, need for operation, and clinical outcomes. The primary outcome was rate of significant injury defined as identified injured liver, spleen, or kidney, pelvis fracture, long bone fracture, significant extremity soft tissue damage, hemothorax, or pneumothorax.ResultsAmong 544 patients, 82 (15.1%) had prehospital hypotension and 492 had normal blood pressure. Of the patients with prehospital hypotension, 34 (41.5%) had a significant injury. There was no difference in age, gender, medical history, or injury pattern between the two groups. There was no difference between the two groups in rate of serious injury (41.5% vs. 46.1%, NS), need for emergent operation (31.7% vs. 28.1%, NS) or death (20.7% vs. 18.8%, NS). On the other hand, SI ≥1 was associated with increased rate of serious injury (54.6% vs. 43.4%, p=0.04). On a logistic regression analysis, prehospital hypotension was not associated with significant injury or need for emergent operation (OR 0.83, 95% CI 0.51 to 1.33 and OR 1.32, 95% CI 0.79 to 2.25, respectively). SI ≥1 was associated with both increased odds of significant injury and need for emergent operation (OR 1.57, 95% CI 1.01 to 2.44 and OR 1.64, 95% CI 1.01 to 2.66).DiscussionSI was a better indicator and could replace hypotension to better categorize and triage patients in need of higher level of care.Level of evidencePrognostic and epidemiologic, level III.

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