CICU Severity Panel

Vasoactive-inotropic score (Gaies 2014, Box 1, verbatim)

Inotrope Score (IS) = dopamine (mcg/kg/min) + dobutamine (mcg/kg/min)
                    + 100 x epinephrine (mcg/kg/min)
VIS = IS + 10 x milrinone (mcg/kg/min)
         + 10,000 x vasopressin (units/kg/min)
         + 100 x norepinephrine (mcg/kg/min)

Vasopressin entered in milliunits/kg/min is divided by 1000 before the 10,000 multiplier (so 1 milliunit/kg/min = 10 points). Blank infusions count as 0.

VIS groups (Gaies 2014, Table 1; classification from Gaies 2010)

Group   max VIS, first 24 h   max VIS, 24-48 h
  1         <10                  <5
  2        10-14                 5-9
  3        15-19                10-14
  4        20-24                15-19
  5         ≥25                  ≥20
Patients are assigned to the highest group reached in either window.

Table 1 lists whole-number ranges; this page assigns non-integer values by continuous boundaries (for example 14.5 is group 2, 15.0 is group 3). That boundary rule is this page's interpretation.

Published associations shown as context (not targets, not cut-offs invented here)

• Gaies 2014 (4 centres, 391 infants <1 year after surgery with cardiopulmonary bypass, 2011–2012): maximum VIS in the first 24 h of ≥20 (groups 4–5) was defined as “high VIS”. High VIS was associated with the composite poor outcome (death, cardiac arrest, mechanical circulatory support, renal replacement therapy or neurologic injury), OR 6.5 (95% CI 2.9–14.6), and with mortality, OR 13.2 (3.7–47.6), after adjustment. At the group ≥4 cut-point sensitivity was 0.57 and specificity 0.82 (Table 5). The authors chose group 4 over group 3 to maximise specificity, and caution that the data do not show causation.
• Gaies 2010 (single centre, 174 infants 0–6 months after bypass): high maximum VIS in the first 48 h was associated with a poor outcome, adjusted OR 8.1 (3.4–19.2) (abstract).

Vasoactive-ventilation-renal score (Miletic 2015, Methods)

VVR = VIS + VI + (ΔCr x 10)
VI  = RR x (PIP - PEEP) x PaCO2 / 1000
ΔCr = postoperative creatinine - baseline preoperative creatinine
      (recorded as 0 when below baseline)
Extubated at the time of the gas: VI = 0.  No vasoactive support: VIS = 0.

• The paper does not print units. Units here (breaths/min, cmH₂O, mmHg, creatinine in mg/dL) follow the VVR calculator published by the senior author's institution (Indiana University). µmol/L is converted with 88.4 µmol/L = 1 mg/dL.
• The Indiana calculator does not show the “0 when below baseline” rule; this page follows the paper.
• VI is not defined on high-frequency oscillation, so no VVR is shown there.
• Context: in the derivation cohort (222 infants <1 year, single centre) the 48-hour VVR had the highest AUC for prolonged mechanical ventilation (0.935); the cut-off for VVR at 48 h was 22.5 and high VVR at 48 h (>22.5) was associated with prolonged ventilation. The authors warned of over-fitting and asked for confirmation in independent data before bedside use. A prospective validation (Miletic 2016, 92 children <18 years including single ventricles) reported AUC 0.980 for prolonged ventilation at 48 h. This page shows no VVR band.

Oxygenation index and oxygen saturation index (PALICC-2, Figure 1)

OI  = mean airway pressure (cmH2O) x FiO2 / PaO2 (mmHg)
OSI = mean airway pressure (cmH2O) x FiO2 / SpO2      (only when SpO2 ≤ 97%)
FiO2 entered as a percentage (21-100).

PALICC-2, invasive ventilation (apply ≥4 h after PARDS diagnosis):
  PARDS oxygenation criterion   OI ≥ 4  or OSI ≥ 5
  Mild/moderate                 OI < 16 or OSI < 12
  Severe                        OI ≥ 16 or OSI ≥ 12

• An OI or OSI band is not a PARDS diagnosis: PALICC-2 also requires new chest-imaging opacities, timing and exclusion of a primarily cardiac cause.
• Cyanotic congenital heart disease: PARDS can be diagnosed only with an acute deterioration in oxygenation not explained by the cardiac disease (statement 1.6.1), and such patients “should not be stratified by OI or OSI risk categories” (statement 1.6.4). With intracardiac mixing this page shows the number without a band.
• FiO₂ as a percentage is the convention under which the PALICC thresholds apply (OI = MAP × FiO₂ × 100 / PaO₂ with FiO₂ as a fraction).

Input checks

Doses outside these ranges give no result and a request to check units (these are plausibility limits, not dosing advice): dopamine and dobutamine 0–50, epinephrine, norepinephrine and milrinone 0–3 mcg/kg/min; vasopressin 0.01–10 milliunits/kg/min (0.00001–0.01 units/kg/min) or 0. Ventilator rate 1–150/min, PIP 1–80 and PEEP 0–30 cmH₂O with PIP > PEEP, PaCO₂ 10–200 and PaO₂ 10–700 mmHg, MAP 1–60 cmH₂O, FiO₂ 21–100%, SpO₂ 50–100%, creatinine 0.05–15 mg/dL (5–1300 µmol/L).

Limitations

• VIS measures treatment intensity, not cardiac output. Practice varies widely between centres (Gaies 2014, Table 3), so the same physiology can give different scores.
• The VIS associations come from infants after bypass surgery; their applicability to older children, non-bypass surgery or medical CICU patients is not established by these studies.
• VVR was derived and validated at one centre. No VVR threshold is applied here.
• None of these scores is a treatment target.

Verification

VIS, ventilation index, creatinine change and VVR were identical to Indiana University's published VVR calculator, running its own code on the same 6 test cases; the oxygenation index was identical to MDCalc's formula on 5 cases (October 2026). The oxygen saturation index has no official online calculator; it is implemented from the PALICC-2 formula.

References

• Gaies MG, Gurney JG, Yen AH, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 2010;11(2):234-238. doi:10.1097/PCC.0b013e3181b806fc (abstract checked; full text not retrieved).
• Gaies MG, Jeffries HE, Niebler RA, et al. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery: an analysis from the Pediatric Cardiac Critical Care Consortium and Virtual PICU System Registries. Pediatr Crit Care Med 2014;15(6):529-537. doi:10.1097/PCC.0000000000000153 (PMC4159673; Box 1, Tables 1, 5, 6 read).
• Miletic KG, Spiering TJ, Delius RE, Walters HL, Mastropietro CW. Use of a novel vasoactive-ventilation-renal score to predict outcomes after paediatric cardiac surgery. Interact Cardiovasc Thorac Surg 2015;20(3):289-295. doi:10.1093/icvts/ivu409
• Miletic KG, Delius RE, Walters HL, Mastropietro CW. Prospective validation of a novel vasoactive-ventilation-renal score as a predictor of outcomes after pediatric cardiac surgery. Ann Thorac Surg 2016;101(4):1558-1563. doi:10.1016/j.athoracsur.2015.11.006 (abstract).
• Indiana University School of Medicine. Vasoactive Ventilation Renal Score (VVR) calculator: medicine.iu.edu (units, October 2026).
• Emeriaud G, López-Fernández YM, Iyer NP, et al. Executive summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med 2023;24(2):143-168. doi:10.1097/PCC.0000000000003147 (PMC9848214; Figure 1, statements 1.4.1–1.6.4).