• Sejin Heo, Daun Jeong, Minyoung Choi, Inkyu Kim, Minha Kim, Ye Rim Lee, Sung KoByukBDepartment of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea., Mok RyooSeungSDepartment of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea., Eunah Han, Hyunglan Chang, June YuneChangCDepartment of Critical Care Medicine, Anyang Sam Hospital, An Yang, Korea., Jai LeeHuiHDepartment of Emergency Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea. Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea., Joon SuhGilGDepartment of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea., Sung-Hyuk Choi, Phil ChungSungSDepartment of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea., Ho LimTaeTDepartment of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea., Young KimWonWDepartment of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea., Kyuseok Kim, Yeon HwangSungSDepartment of Emergency Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea., Eun ParkJongJDepartment of Emergency Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea., Tak LeeGunGDepartment of Emergency Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea., Gun ShinTaeTDepartment of Emergency Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea., and Korean Shock Society.
• Department of Emergency Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea.
• Emergencias. 2025 Feb 1; 37 (1): 152215-22.

ObjectiveTo develop a scale to predict refractory septic shock (SS) based on clinical variables recorded during initial evaluations of patients.MethodsMulticenter retrospective study of data for patients with suspected infection registered in the Marketplace for Medical Information in Intensive Care (MIMIC-IV). These data were used for the development and internal validation of the refractory SS scale (RSSS). For external validation, we used retrospective data for 2 cohorts: 1) patients diagnosed with SS in an emergency department (ED cohort) whose data were registered in a Korean SS registry, and 2) patients diagnosed with SS in 6 hospital intensive care units (ICU cohort). A machine-learning automatic clinical scoring system (AutoScore) was used in the development phase. The performance of the RSSS in the validation cohorts was assessed with the area under the receiver operating characteristic curve (AUROC) for each. The primary outcome was the development of refractory SS within 24 hours of ICU admission. Refractory SS was defined by the need for a norepinephrine-equivalent dose greater than 0.5 µg/kg/min.ResultsWe collected data for 29 618 patients from the MIMIC-IV registry, 3113 patients for the ED cohort, and 1015 for the ICU cohort. The RSSS had 6 predictors: serum lactate level, systolic blood pressure, heart rate, temperature, arterial pH, and leukocyte count. The scale's AUROCs were as follows: 0.873 (95% CI, 0.846-0.900) in the internal validation, 0.705 (95% CI, 0.678-0.733) in the ED cohort on arrival, 0.781 (95% CI, 0.757-0.805) in the ED cohort at the moment of diagnosing hypoperfusion or hypotension, and 0.822 (95% CI, 0.787-0.857) in the ICU cohort. Calibration was acceptable in all the cohorts.ConclusionsThe RSSS had adequate diagnostic accuracy in multiple cohorts of patients diagnosed in the ED and ICU.

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