Determinants of fatal outcome in septic shock patients with euthyroid sick syndrome

doi:10.5492/wjccm.v15.i1.115599

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World Journal of Critical Care Medicine

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©Author(s) (or their employer(s)) 2026. No commercial re-use. See Permissions. Published by Baishideng Publishing Group Inc.

World J Crit Care Med. Mar 9, 2026; 15(1): 115599
Published online Mar 9, 2026. doi: 10.5492/wjccm.v15.i1.115599

Determinants of fatal outcome in septic shock patients with euthyroid sick syndrome

Mirza Kovacevic, Visnja Nesek-Adam, Semir Klokic, Mehmet Yilmaz

Mirza Kovacevic, Department of Anesthesiology, Resuscitation and Intensive Care, Cantonal Hospital, Zenica 72000, Bosnia and Herzegovina

Mirza Kovacevic, Faculty of Medicine, University of Zenica, Zenica 72000, Bosnia and Herzegovina

Visnja Nesek-Adam, Department of Anesthesiology, Resuscitation and Intensive Care, Clinical Hospital Sveti Duh, Zagreb 10000, Croatia

Visnja Nesek-Adam, Faculty of Medicine, University of Osijek, Osijek 31000, Osjecko-Baranjska Zupanija, Croatia

Visnja Nesek-Adam, Faculty of Dental Medicine and Health, University of Josip Juraj Strossmayer, Osijek 31000, Osjecko-Baranjska Zupanija, Croatia

Semir Klokic, General Practitioner’s Office, Laufen 4242, Switzerland

Mehmet Yilmaz, Department of Internal Medicine, Kantonsspital Baselland, Liestal 4410, Baselland, Switzerland

Author contributions: Kovacevic M contributed to study conception and design, statistical analysis, manuscript drafting; Nesek-Adam V contributed to patient management; Klokic S contributed to data interpretation, literature review, manuscript editing. Yilmaz M contributed to study supervision, methodology; Kovacevic M and Nesek-Adam V contributed to data collection; Nesek-Adam V and Yilmaz M contributed to critical revision of the manuscript.

Institutional review board statement: The study protocol was reviewed and approved by the Institutional Review Board of the Cantonal Hospital Zenica, Bosnia and Herzegovina (approval No. 00-03-35-38-14/22) on January 31, 2022.

Clinical trial registration statement: This prospective observational study was not registered as a clinical trial.

Informed consent statement: Informed consent was not required for this study because the analysis was performed on anonymized data, which were collected after each patient had provided written consent for participation in the original study.

Conflict-of-interest statement: All authors declare that they have no conflicts of interest relevant to this study.

CONSORT 2010 statement: The authors have read the CONSORT 2010 statement, and the manuscript was prepared and revised according to the CONSORT 2010 statement.

Data sharing statement: Due to patient confidentiality, the datasets supporting the conclusions of this study are not publicly available. Anonymized data may be provided by the corresponding author upon reasonable request.

Corresponding author: Mirza Kovacevic, MD, PhD, Assistant Professor, Department of Anesthesiology, Resuscitation and Intensive Care, Cantonal Hospital, Crkvice 48e, Zenica 72000, Bosnia and Herzegovina. kovacevic.mirza@hotmail.com

Received: October 22, 2025
Revised: November 7, 2025
Accepted: January 4, 2026
Published online: March 9, 2026
Processing time: 129 Days and 19.5 Hours

Abstract

BACKGROUND

Septic shock is a leading cause of mortality in intensive care, and euthyroid sick syndrome (ESS) may influence outcomes. Identifying predictors of fatal outcome in this population is crucial for guiding management.

AIM

To identify clinical and laboratory predictors of 28-day mortality in patients with septic shock and ESS, and to evaluate the prognostic value of markers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), prognostic index (PI), and modified Glasgow prognostic score (mGPS), the vasoactive drug-dependent index (VDI), and shock index (SI).

METHODS

In this prospective observational study, 95 patients with septic shock and ESS admitted between May 2024 and August 2025 were analyzed. Demographic, clinical, and laboratory data were collected at admission and on days 1, 3, and 7. Prognostic markers - NLR, PLR, PI, and mGPS, VDI, and SI were analyzed. Associations with 28-day mortality were evaluated using standard statistical tests.

RESULTS

Of the 95 patients (mean age 61 ± 14.6 years; female/male ratio 52/43), 53 (52%) died. Duration of mechanical ventilation (P = 0.013) and intensive care unit (ICU) length of stay (P = 0.005) were significantly associated with mortality. Acute Physiology and Chronic Health Evaluation II (P = 0.014) and Simplified Acute Physiology Score II (P = 0.001) scores correlated positively with fatal outcome. Predictive laboratory parameters included base excess and free thyroxine (FT4) at admission (P = 0.013, P < 0.001); free triiodothyronine and FT4 on day 1 (P = 0.007, P < 0.001); red blood cells (RBC) and lymphocytes on day 2 (P = 0.027, P = 0.049); and white blood cells, pO₂, thyroid-stimulating hormone, and FT4 on day 3 (all P < 0.05). Variables positively correlated with mortality included neutrophils, lactate, C-reactive protein, and albumin, while pH, pO₂, bicarbonate, RBC, platelets, and thyroid hormones were negatively correlated. SI on day 3 (P = 0.027) and mGPS on day 1 (P = 0.030) were significant prognostic indices.

CONCLUSION

The 28-day mortality among patients with septic shock and ESS was 52%. Duration of mechanical ventilation, ICU stay, severity scores, laboratory parameters, and indices such as SI and mGPS were significantly associated with outcome. The presence of ESS may contribute to adverse prognosis, and combined evaluation of clinical and laboratory factors can improve risk stratification in this high-risk population.

Keywords: Septic shock; Euthyroid sick syndrome; Vasoactive drug index; Inflammatory prognostic scores; Mortality

Core Tip: This prospective observational study identifies clinical and laboratory determinants of fatal outcome in septic shock patients with euthyroid sick syndrome. Recognizing these predictors may help clinicians improve risk stratification and optimize management strategies in critically ill patients.