Abstract
BackgroundClinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores.MethodsThis multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score’s performance was compared to that of the previous severity scores.ResultsNew scoring system for 28-day mortality was based on six variables (score range, 0–8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%).ConclusionsThe VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.
Highlights
Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging
We aimed to develop a new prognostic model for stage IV cancer patients who present with septic shock available at ED and compare its performance to existing scoring systems including Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, quick SOFA score, National Early Warning Score, and Modified Early Warning Score
The C-static for the VitaL CLASS score was superior to that of the existing scoring systems such as the SOFA (0.713; 95% Confidence interval (CI), 0.664–0.762; p = 0.001) and APACHE II (0.692; 95% CI, 0.643–0.741; p < 0.001)
Summary
Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. Recent advances in cancer treatment have improved the overall survival rates; they have increased the possibility of developing a critical illness requiring intensive care unit (ICU) management [1, 2]. The clinical decision-making for advanced cancer patients with septic shock in the ED comprises more than 3 of health care specialties: critical care medicine, emergency medicine, oncology, and surgery. Treatment recommendations for these patients could be different depending on the specialties [6, 7]. The patient-physician communication in such situations frequently leads to overutilization of invasive ICU treatments, which can produce more costly and invasive care without improving outcomes [8,9,10]
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