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Derivation and Validation of Vasoactive Inotrope Score Trajectory Groups in Critically Ill Children With Shock
Elitsa N Perizes1,2, Grace Chong3,4, L Nelson Sanchez-Pinto1,2,5
1Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
Insights
Researchers identified four distinct Vasoactive Inotrope Score (VIS) trajectories in critically ill children with shock, offering insights into prognosis and targeted management. These reproducible shock trajectories impact patient outcomes and guide clinical decision-making.
Area of Science:
- Pediatric Critical Care Medicine
- Hemodynamic Monitoring
- Shock Management
Background:
- Children experiencing shock in the intensive care unit often require vasoactive infusions.
- Understanding the progression of shock and response to treatment is crucial for improving outcomes.
- The Vasoactive Inotrope Score (VIS) is a tool used to quantify vasoactive support.
Purpose of the Study:
- To identify clinically relevant and reproducible Vasoactive Inotrope Score (VIS) trajectories in pediatric patients with shock during critical illness.
- To determine if these trajectories correlate with patient outcomes such as mortality and organ dysfunction.
Main Methods:
- Retrospective observational cohort study of children (<18 years) requiring vasoactive infusions in two tertiary PICUs.
- Hourly VIS was calculated for the initial 72 hours post-vasoactive initiation.
- Group-based trajectory modeling (GBTM) was used to identify distinct VIS trajectories, validated on separate patient cohorts.
Main Results:
- Four reproducible VIS trajectory groups were identified: 'Mild, fast resolving shock' (9% mortality), 'Moderate, slow resolving shock' (15% mortality), 'Moderate, prolonged shock' (21% mortality), and 'Severe, prolonged shock' (40% mortality).
- Significant differences in in-hospital mortality, multiple organ dysfunction syndrome (MODS) on day 7, and suspected infection were observed across the groups.
- Certain groups were identifiable within 24 hours, while others required longer observation; hydrocortisone use was linked to poorer outcomes in the 'Mild, fast resolving shock' group.
Conclusions:
- Distinct and reproducible VIS trajectory groups exist in children with shock, associated with varying risk factors, treatment responses, and outcomes.
- Characterizing these trajectories in the acute phase of critical illness can aid in better prognostication.
- Identifying VIS trajectory groups may facilitate more targeted and personalized management strategies for pediatric shock.
Objectives:
To determine whether there are clinically relevant and reproducible Vasoactive Inotrope Score (VIS) trajectories in children with shock during the acute phase of critical illness.
Design:
Retrospective, observational cohort study.
Setting:
Two tertiary, academic PICUs.
Patients:
Children (< 18 yr old) who required vasoactive infusions within 24 hours of admission to the PICU. Those admitted post cardiac surgery were excluded.
Interventions:
None.
Measurements And Main Results:
An hourly VIS was calculated for the first 72 hours after initiation of vasoactives. Group-based trajectory modeling (GBTM) was applied to a derivation set (75% of encounters) and compared with the trajectories in a validation set (25% of encounters) using the same variables. The primary outcome was in-hospital mortality, and the secondary outcome was multiple organ dysfunction syndrome (MODS) on day 7. A total of 1,828 patients met inclusion criteria, and 309 (16.9%) died. GBTM identified four subgroups that were reproducible in the validation set: "Mild, fast resolving shock" ( n = 853 [47%]; mortality 9%), "Moderate, slow resolving shock" ( n = 422 [23%]; mortality 15%), "Moderate, prolonged shock" ( n = 312 [17%]; mortality 21%), and "Severe, prolonged shock" ( n = 241 [13%]; mortality 40%). There was a significant difference in mortality, MODS on day 7, and suspected infection ( p < 0.001) across groups. The "Mild, fast resolving shock" and "Severe, prolonged shock" groups were identifiable within the first 24 hours. The "Moderate, slow resolving" and "Moderate, prolonged shock" groups were indistinguishable in the first 24 hours after initiation of vasoactives but differed in in-hospital mortality and MODS on day 7. Hydrocortisone administration was independently associated with poor outcomes in the "Mild, fast resolving shock" group.
Conclusions:
We uncovered four distinct and reproducible VIS trajectory groups that were associated with different risk factors, response to therapy, and outcomes in children with shock. Characterizing VIS trajectory groups in the acute phase of critical illness may enable better prognostication and more targeted management.
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