High-frequency oscillatory ventilation for patients during exudative phase of severe ARDS.

BACKGROUND: High frequency oscillatory ventilation (HFOV) is theoretically ideal for lung protective strategy ventilation (LPSV) in acute respiratory distress syndrome (ARDS). However, recent studies revealed unsatisfactory outcomes. The authors conducted a study to examine this phenomenon in patients with early phase of moderate to severe ARDS. OBJECTIVE: To evaluate the effectiveness of HFOV in patients with early phase of moderate to severe ARDS. The primary outcome was 30 days all-cause mortality. MATERIAL AND METHOD: The study was a matched-case controlled clinical trial performed in the medical intensive care units, Faculty of Medicine, Siriraj Hospital. The authors compared HFOV with LPSV in adult patients with the early phase of ARDS who received mechanical ventilation less than 72 hours and had moderate to severe hypoxemia (PaO/FiO2 ratio less than or equal 150). RESULTS: Between June 2010 and February 2014, 49 patients with moderate to severe ARDS were included. Fourteen patients who received HFOV were matched with 16 patients who received LPSV. The 30-day mortality in HFOV group was 61.5%; while in control group, 50% (p = 0.53). The authors found use of higher doses of sedative drugs and muscle relaxants in HFOV group. In addition, this group had high-level of mean airway pressure (mPaw). The presence of hemodynamic instability was not different in both groups. CONCLUSION: In adult patients in the early phase of moderate to severe ARDS who received mechanical ventilation for less than 72 hours, HFOV did not decrease the 30-day mortality. Thus, this support should be only a rescue therapy for refractory hypoxemia cases and in highly selected patients.

Evaluation of correlation between vascular pedicle width and intravascular volume status in Thai critically ill patients.

OBJECTIVE: To evaluate the correlation between vascular pedicle widths (VPW) measured from portable chest roentgenogram (CXR) and intravascular volume status in Thai critically ill patients. MATERIAL AND METHOD: A prospective cohort study included the critically ill patients in whom pulmonary artery catheter was placed in the Medical Intensive Care Units of Siriraj Hospital, Mahidol University between June 2009 and January 2010. The patient's baseline characteristics, hemodynamic data measured from pulmonary artery catheter (PAC) and CXR parameters were collected. RESULTS: From thirty-four patients, thirteen (38.2%) had high pulmonary artery occlusive pressure (PAOP > or =18 mmHg). The patients with high PAOP were older (69.8 +/- 8.8 years vs. 59.2 +/- 15.4 years, p = 0.02), taller (163.2 +/- 5.3 cm vs. 157.0 +/- 10.4 cm, p = 0.03) and higher weight (67.4 +/- 12.9 kg vs. 57.1 +/- 7.8 kg, p = 0.007) than the low PAOP group. The correlations between PAOP and VPW (r = 0.68, p < 0.001) as well as between PAOP and cardiothoracic ratio (CTR) (r = 0.23, p = 0.03) were significant. From the receiver operating characteristic (ROC) curve, VPW > 68 mm is the best parameter to predict PAOP > or =18 mmHg (the area under the curve (AUC) = 0.853, p < 0.001, sensitivity = 92.3%, specificity = 85.7%). The CTR > 0.58 can be used to predict elevated PAOP > or =18 mmHg with acceptable sensitivity = 85.74% and specificity = 76.9% (AUC = 0.727, p = 0.03). The peribronchial cuffing (PBC) was detected at a higher percentage among high PAOP group than in the low PAOP group (76.9% vs. 33.3%, p = 0.03). CONCLUSION: The VPW >68 mm, CTR >0.58 and the present of PBC can be used together to predict elevation of PAOP > or =18 mmHg among the Thai critically ill patients. By using these CXR parameters, the PAC insertion may be avoided especially in patients with contraindication.

Right ventricular dysfunction in septic shock.

BACKGROUND: Right ventricular dysfunction (RVD) is common in critically ill patients and the presence of this condition affects patients' outcomes. Improving the knowledge background and establishing the incidence of RVD in septic shock patients would render the management more efficacious. This study was performed to evaluate the incidence and outcomes of RVD in septic shock patients. MATERIAL AND METHOD: A single center retrospective observational study was performed in the Medical ICU, Siriraj Hospital, Mahidol University between January 2007 and October 2009. Patients with septic shock in whom pulmonary artery catheter (PAC) was inserted were included in the study. RESULTS: The PAC was placed in 118 patients during the study period. The patients' mean age was 58.0 +/- 18.5 years and 71 of them (59.3%) were male. The mean body mass index was 25.0 +/- 6.6 Kg/m2 and the mean APACHE II score was 26.1 +/- 7.7. The admission diagnoses were severe sepsis or septic shock (70%), severe pneumonia (38%), acute respiratory distress syndrome (21%). Twenty one patients (17.8%) meet the diagnosis criteria of RVD. The hospital mortality in RVD patients tended to be higher than the non-RVD patients (81.0% vs. 60.8%, p 0.06). Although similar proportions of both group received ventilatory support, the RVD patients had lower tidal volume and had higher peak airway pressure. Also the RVD group had lower PaO2/FiO2 ratio. In addition, the RVD group had lower cardiac output and more frequently underwent renal replacement therapy. CONCLUSION: In patients with septic shock, the incidence of RVD is substantial. The significant factors associated with RVD include low tidal volume and high peak airway pressure. Measures to prevent the alteration in lung compliance in septic shock patients may prevent RVD and improve patients' outcomes.

Stress hyperglycemia in patients with sepsis.

BACKGROUND: Patients with acute stress from stroke or myocardial infarction may develop hyperglycemia, even in the absence of diabetes mellitus. Stress hyperglycemia increases morbidity and mortality in these patients. There has been no study to evaluate stress hyperglycemia in patients with sepsis. MATERIAL AND METHOD: A prospective cohort study in patients with sepsis admitted in the Department of Medicine of Siriraj Hospital during 2006-2007 was done. Data were collected on admission blood glucose, HbA1c and other factors which may predict the outcomes of sepsis. RESULTS: Data were collected from 70 patients with sepsis. The prevalence of stress hyperglycemia was 42.3% in this study. We found no differences in clinical findings, laboratories, interventions and outcomes between groups of stress and non-stress hyperglycemia. Multivariate analysis showed that only APACHE II score and use of a mechanical ventilator were associated with mortality. CONCLUSION: The prevalence of stress hyperglycemia in patients with sepsis was high. We cannot conclude that stress hyperglycemia did not affect the mortality and morbidity outcome mainly because of the small number of subjects which may be not enough to detect statistical significance.

An outbreak of botulism in Thailand: clinical manifestations and management of severe respiratory failure.

BACKGROUND: Northern Thailand's biggest botulism outbreak to date occurred on 14 March 2006 and affected 209 people. Of these, 42 developed respiratory failure, and 25 of those who developed respiratory failure were referred to 9 high facility hospitals for treatment of severe respiratory failure and autonomic nervous system involvement. Among these patients, we aimed to assess the relationship between the rate of ventilator dependence and the occurrence of treatment by day 4 versus day 6 after exposure to bamboo shoots (the source of the botulism outbreak), as well as the relationship between ventilator dependence and negative inspiratory pressure. METHODS: We reviewed the circumstances and timing of symptoms following exposure. Mobile teams treated patients with botulinum antitoxin on day 4 or day 6 after exposure in Nan Hospital (Nan, Thailand). Eighteen patients (in 7 high facility hospitals) with severe respiratory failure received a low- and high-rate repetitive nerve stimulation test, and negative inspiratory pressure was measured. RESULTS: Within 1-65 h after exposure, 18 of the patients with severe respiratory failure had become ill. The typical clinical sequence was abdominal pain, nausea and/or vomiting, diarrhea, dysphagia and/or dysarthria, ptosis, diplopia, generalized weakness, urinary retention, and respiratory failure. Most patients exhibited fluctuating pulse and blood pressure. Repetitive nerve stimulation test showed no response in the most severe stage. In the moderately severe stage, there was a low-amplitude compound muscle action potential with a low-rate incremented/high-rate decremented response. In the early recovery phase, there was a low-amplitude compound muscle action potential with low- and high-rate incremented response. In the ventilator-weaning stage, there was a normal-amplitude compound muscle action potential. Negative inspiratory pressure variation among 14 patients undergoing weaning from mechanical ventilation was observed. Kaplan-Meier survival analysis identified a shorter period of ventilator dependency among patients receiving botulinum antitoxin on day 4 (P=.02). CONCLUSIONS: Patients receiving botulinum antitoxin on day 4 had decreased ventilator dependency. In addition, for patients with foodborne botulism, an effective referral system and team of specialists are needed.

The effect of lateral position on oxygenation in ARDS patients: a pilot study.

BACKGROUND: The effect of body position on oxygenation in acute respiratory distress syndrome (ARDS) patients has long been known. Prone position improves the PaO2 in 60-70% of ARDS patients. However the effect of the lateral positions, which are used in routine critical care, has never been reported. OBJECTIVE: To determine whether placing the patient in a lateral position has any effect on oxygenation in ARDS. MATERIAL AND METHOD: Prospective observational study, comparing oxygenation in ARDS patients between supine, right and left lateral positions (> or = 60 degree). RESULTS: We included 18 ARDS patients, their mean aged was 52.2 +/- 19.6 years, 14 were men and the ICU mortality rate was 61.1%. There was no significant change in the mean PaO2, arterial blood gas parameters, respiratory mechanics and hemodynamic parameters between the supine and decubitus positions in the overall group. However there was a trend toward increasing the mean PaO2 during right lateral position compared with the supine position (90.3 +/- 29.0 vs 84.6 +/- 20.4, p = 0.23). Nine patients who responded to the right lateral position had significantly higher mean PaO2 during the right lateral position than in the supine position (107.8 +/- 29.0 vs 85.6 +/- 21.8, p < 0.0001). In this group, four patients had predominant left pulmonary infiltration and five patients had equally bilateral pulmonary infiltration on chest X-ray. Unfortunately, the PaO2 in three patients decreased more than 10 mmHg during right lateral decubitus. CONCLUSION: The PaO2 increased while in the right lateral position in patients with predominant left pulmonary infiltration or bilateral infiltration. This effect may be due to the small sample size. A further large-sized randomized controlled study is needed.

Prediction of mortality by using the standard scoring systems in a medical intensive care unit in Thailand.

In order to evaluate and compare the predictive ability of the APACHE II (Acute Physiology and Chronic Health Evaluation II) and the SAPS (Simplified Acute Physiology Score) scoring systems in relation to outcome in a medical intensive care unit (ICU). The authors reviewed consecutive medical ICU admissions (n = 482) at a tertiary hospital over a 2-year period. For each patient, demographic data, diagnosis, APACHE II score, SAPS score and ICU outcome complied during the first 24 hrs of the ICU stay were obtained. The comparison of predictive ability between APACHE II and SAPS was assessed by forward stepwise logistic regression and area under the receiver operating characteristic (ROC) curves. Overall ICU mortality was 36.93%. Mean APACHE II and SAPS scores were 21.17 +/- 9.35 and 14.61 +/- 6.47, respectively. APACHE II and SAPS scores of nonsurvivors (26.97 +/- 8.27 and 18.01 +/- 5.84 respectively) were significantly higher than those of survivors (17.77 +/- 8.22 and 12.62 +/- 5.99 respectively) (p < 0. 001). Correlation between both systems was excellent (Pearson correlation coefficient, r = 0.825: p < 0.001). The predicted risk of death calculated by using the APACHE II risk of death equation was 38.98%. The predictive ability to discriminate between survivors and nonsurvivors of APACHE II was higher than SAPS according to forward stepwise logistic regression and area under the ROC curves (APACHE II was 0.788 while SAPS was 0.746). In conclusion, the APACHE II scoring system is an efficient predictor for monitoring the hospital outcome and has more predictive ability than the SAPS in the medical ICU patients.

Streptococcus suis infection in Thailand.

This is a retrospective study of Streptococcus suis infection in humans submitted to the National Streptococcal Referrence Center of Thailand from 1994 to 2001. There were 11 men and 6 women whose mean age was 46.24 years (range 1 month to 75 years). Among the men, two had known occupational and behavioral exposure to pork or meat products. Among the women, one was a butcher and three were housewives. Half of the patients had underlying diseases. One patient had congenital hydrocephalus, three patients had rheumatic heart disease and three were alcoholics. Two of these patients had a history of skin injury before infection. Nine patients had evidence of acute bacterial meningitis, four patients had infective endocarditis, two had the sepsis syndrome and two suffered from pneumonia and spontaneous bacterial peritonitis. The authors suspected that many cases are not reported particularly where pig-rearing or pork consumption are common. In the absence of an effective vaccine, prevention by public health surveillance is important. Prompt treatment of any cuts and wounds among pork-handlers is a sensible precaution. Furthermore, a high index of suspicion and early detection in order to identify and apply effective antimicrobial agents is necessary to successfully treat S. suis infection.

Clinical spectrum of hepatic tuberculosis: comparison between immunocompetent and immunocompromised hosts.

BACKGROUND: Hepatic tuberculosis has been reported in normal and immunocompromised hosts. However, no published comparisons between these two groups of subjects with hepatic tuberculosis have been found. The aim of this study was to compare the clinical manifestations, biochemical tests, radiologic features and pathological findings of hepatic tuberculosis in immunocompromised and immunocompetent patients. METHOD: The authors reviewed retrospectively 20 patients with hepatic tuberculosis admitted between January 1993 and October 2000 to Chulalongkorn University Hospital, Thailand. There were 12 immunocompromised patients (10 HIV-infected males, 1 systemic lupus erythematosus (SLE) male, 1 SLE female) and 8 immunocompetent patients (6 males, 2 females). The clinical manifestations, biochemical tests, radiologic features and pathological findings were compared between these 2 groups. The diagnosis of Mycobacterium tuberculosis (M. tb) was the combination of a demonstrated organism in hemo- or specimen culture, histopathology (positive acid fast bacilli) and rapid identification of M. tb from nested polymerase chain reaction (nPCR) assay based on amplification of the IS 6110 insertion sequences. RESULTS: The clinical features were similar in both groups with fever, weight loss and hepatomegaly as the main manifestations. The biochemical findings were also similar but the alkaline phosphatase (ALP) was significantly higher in the immunocompromised group (p < 0.001). Hepatomegaly and diffuse increased echogenicity were common in both groups. Ascitis and calcifications were found more commonly in the immunocompetent subjects, although the differences were not statistically significant. Non-caseating granuloma without detection of acid fast bacilli was a common finding in both groups. The nested PCR assay increased the sensitivity from 49 per cent to 86 per cent compared to the regular PCR assay but specificity was 100 per cent in both techniques. The mortality was significantly higher in immunocompetent patients (p < 0.05) due to the extreme age and severe coexisting diseases. CONCLUSION: Fever, weight loss, hepatomegaly, disproportionate elevation of ALP and reverse A/G ratio were common in hepatic tuberculosis. A disproportionate elevation of ALP was significantly higher in the immunocompromised hosts. Nested PCR assay showed good sensitivity and specificity in the diagnosis of this disease.

Thrombocytopenic purpura associated with miliary tuberculosis.

The authors report a case of thrombocytopenia associated with miliary tuberculosis. The patient was a 28-year-old woman who was admitted because of massive upper gastrointestinal hemorrhage and acute respiratory failure. Chest radiographs revealed diffuse bilateral reticulonodular infiltration and complete blood count was significant for severe thrombocytopenia. Bone marrow biopsy was performed to investigate the cause of thrombocytopenia and demonstrated multiple tiny caseating granulomas suggesting miliary tuberculosis (TB). She received anti-TB therapy and a short course of steroid with good response. Platelet count returned to normal limit within 10 days. Although isolated thrombocytopenia is uncommon in TB, it is still important to consider TB in the differential diagnosis of thrombocytopenia, particularly in patients with abnormal chest radiographs. Bone marrow examination is very helpful in this situation.