Cutaneous Adverse Events After COVID-19 Vaccination.

Purpose: The morphology and timing of cutaneous reactions after Coronavirus disease (COVID-19) vaccines have been well described; however, data on the rates and risk factors are limited. Therefore, this study aimed to measure the incidence of cutaneous adverse reactions (CARs) after COVID-19 vaccination in Thailand, describe the rash characteristics according to the doses or types of vaccine, and assess the risk factors for developing CARs. Patients and Methods: This was a prospective observational study of adults who received COVID-19 vaccination and provided informed consent. Cutaneous diagnoses were made by expert dermatologists with supporting skin biopsies, as needed. Data were analyzed using descriptive statistics and logistic regression to examine the independent risk of developing a CAR. Results: Between July 2021 and January 2022, 7505 participants were vaccinated. Vaccine-related CARs occurred in 92 patients with an overall risk of 1.2%. CARs occurred after the first (n=41), second (n=23), third (n=27), and fourth (n=1) doses. Among the 92, 75 (81%) developed CARs within 7 days and 61 (66%) resolved within 7 days. Urticaria, injection site reaction, and a delayed (≥ 3 days post vaccine) local reaction were the three most common CARs occurring in 59 cases (64%). In total, 51 (55%) patients received only symptomatic and supportive treatment. Underlying urticaria and psoriasis were the independent factors for developing a CAR: adjusted odd rations of 15.63 (6.02-40.57, p < 0.001) and 5.36 (1.57-18.36, p = 0.007), respectively. A total of 6/34 (17%) and 4/31 (12%) patients developed urticarial and psoriasis flare post vaccine. Our study found superficial perivascular and intraepidermal eosinophil infiltration, which may be unusual pathological findings in vaccine-induced pemphigus foliaceous. Conclusion: CARs after COVID-19 vaccination had a low incidence and were mostly mild in severity and transient in nature. Underlying urticaria and psoriasis were risk factors for CAR development.

Association of Monocyte Distribution Width with the Need for Respiratory Support in Hospitalized COVID-19 Patients.

Background: The monocyte distribution width (MDW), a novel inflammatory biomarker reflecting morphological changes in response to inflammation, has been shown to be useful in identifying COVID-19 infection or predicting death. However, data on the association with predicting the need for respiratory support are still limited. The aim of this study was to determine the association of MDW with the need for respiratory support in patients with SARS-CoV-2 infection. Patients and methods: This is a single-center retrospective cohort study. Consecutive hospitalized COVID-19 adult patients who presented at the outpatient department (OPD) or emergency department (ED) between May and August 2021 were enrolled. Respiratory support was defined as any one of the following: conventional oxygen therapy, high-flow oxygen nasal cannula, noninvasive, or invasive mechanical ventilation. The performance of MDW was measured using the area under the receiver operating characteristic (AuROC) curve. Results: Of the 250 enrolled patients, 122 (48.8%) patients received respiratory support. The mean MDW was significantly higher in the respiratory support group: 27.2 ± 4.6 vs 23.6 ± 4.1 (p < 0.001). The MDW ≥ 25 had the best AuROC characteristics of 0.70 (95% CI: 0.65-0.76). Conclusions: The MDW is a potential biomarker that may aid in identifying individuals at risk of requiring oxygen support in COVID-19 and can be easily implemented in clinical practice. How to cite this article: Daorattanachai K, Hirunrut C, Pirompanich P, Weschawalit S, Srivilaithon W. Association of Monocyte Distribution Width with the Need for Respiratory Support in Hospitalized COVID-19 Patients. Indian J Crit Care Med 2023;27(5):352-357.

Clinical outcomes after a single induction dose of etomidate versus ketamine for emergency department sepsis intubation: a randomized controlled trial.

Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2-0.3 mg/kg of etomidate or 1-2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], - 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021-Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001 .

Clinical characteristics and outcomes of adults with peripheral extracorporeal membrane oxygenation in a developing country: A single center 8-year retrospective study.

INTRODUCTION: In our institute, we began using peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) in 2010, and peripheral veno-venous (VV) ECMO in 2015. This study aimed to describe clinical characteristics and outcomes in those patients. METHODS: We reviewed retrospective data of adults receiving peripheral ECMO from January 2010 to December 2017 and divided it into two groups for analysis: VA- and VV-ECMO. RESULTS: There were 28 patients in the VA group and 12 in VV. For VA, the mean (SD) age was 58.5 (17.2) years. The most common indication was cardiac arrest (12 patients, 42.9%); 15 patients (53.6%) were on intra-aortic balloon pump concomitantly. In the VV cohort, the mean age was 53.3 (16.2) years. Eleven (91.7%) patients had acute respiratory distress syndrome as an indication. The mortality rate of VA-ECMO was 85.7%, and VV was 58.3%. CONCLUSION: The mortality rate in our ECMO center was considerably higher than that in the international registry report. Improved team education, rigid patient selection criteria, and a reimbursement protocol should lead to ameliorated outcomes. TRIAL REGISTRATION: TCTR20190120001. Registered January 19, 2019.

High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial.

BACKGROUND: High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients. METHODS: We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation. RESULTS: Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59). CONCLUSIONS: Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://clinicaltrials.gov/ct2/show/NCT03246893?term=surat+tongyoo&draw=2&rank=3.

Outcomes of Early versus Late Endotracheal Intubation in Patients with Initial Non-Shockable Rhythm Cardiopulmonary Arrest in the Emergency Department.

BACKGROUND: Sudden cardiac arrest is a critical condition in the emergency department (ED). Currently, there is no considerable evidence supporting the best time to complete advanced airway management (AAM) with endotracheal intubation in cardiac arrest patients presented with initial non-shockable cardiac rhythm. OBJECTIVES: To compare survival to hospital discharge and discharge with favorable neurological outcome between the ED cardiac arrest patients who have received AAM with endotracheal intubation within 2 minutes (early AAM group) and those over 2 minutes (late AAM group) after the start of chest compression in ED. METHODS: We conducted a retrospective cohort study involving the ED cardiac arrest patients who presented with initial non-shockable rhythm in ED. Multivariable logistic regression analysis was used to evaluate the independent effect of early AAM on outcomes. The outcomes included the survival to hospital discharge and discharge with favorable neurological outcome. RESULTS: There were 416 eligible participants: 209 in the early AAM group and 207 participants in the late AAM group. The early AAM group showed higher survival to hospital discharge compared with the late AAM group, but no statistically significant difference (adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.59 -2.76, p = 0.524). Discharge with favorable neurological outcome is also higher in the early AAM group (aOR: 1.68, 95% CI, 0.52 -5.45, p = 0.387). CONCLUSION: This study did not demonstrate a significant improvement of survival to hospital discharge and discharge with favorable neurological outcome in the ED cardiac arrest patients with initial non-shockable cardiac arrest who underwent early AAM within two minutes. More research is needed on the timing of AAM and on airway management strategies to improve survival.

Retention of Basic-Life-Support Knowledge and Skills in Second-Year Medical Students.

PURPOSE: Basic life support (BLS) training is crucial in improvement of cardiopulmonary resuscitation (CPR) outcomes. Many studies have demonstrated improvement of skills after BLS training but the skills significantly decrease over time. Our study aimed to evaluate the retention of knowledge and skills after training following 2010 BLS guidelines in second year medical students at Faculty of Medicine, Thammasat University. MATERIALS AND METHODS: One hundred and forty-nine second-year medical students were enrolled in the prospective cohort study. Participants were tested for knowledge and skills of BLS prior to training (pre-test), immediately after training (post-test) and six months after training (retention test). RESULTS: The mean scores of pre-test, immediate post-test and retention-test were 8.52 (SD 1.88), 12.12 (SD 1.52) and 10.83 (SD 1.95), respectively. Improvement in knowledge score post-test and retention test were 3.60 (95% CI 3.22,3.99 P<0.001) and 2.31 (95% CI 1.92,2.70 P<0.001) respectively, compared with pre-test score. In post-test, detection skill, activation skill and compression skill were improved 1.67 (95% CI 1.28,2.19 P<0.001), 5.15 (95% CI 3.41,7.77 P<0.001) and 3.88 times (95% CI 2.24,6.71 P<0.001) compared with pre-test evaluation. Comparison between retention test and pre-test was improved detection skill 1.72 (95% CI 1.31,2.26 P<0.001), activation skill 4.4 (95% CI 2.93,6.75 P<0.001) and compression skill 2.56 (95% CI 1.44,4.57 P=0.001). Knowledge decreased 1.29 times in retention test compared with post-test (95% CI -1.67,0.92 P<0.001). In retention test, detection skill increased 1.03 times (95% CI 0.81,1.29 P = 0.810), activation skill decreased 0.86 times (95% CI 0.98,1.10 P =0.24) and compression skill decreased 0.66 times (95% CI 0.45,0.98 P=0.04) compared with post-test. CONCLUSION: Knowledge and skills of BLS significantly improved after training in second year medical students. However, the knowledge decreased at 6 months after training although the BLS skills still remained.

Predictors of in-hospital cardiac arrest within 24 h after emergency department triage: A case-control study in urban Thailand.

OBJECTIVE: This study describes the predictors of in-hospital cardiac arrest (IHCA) within 24 h of ED triage and evaluates their ability to predict patients at risk of IHCA. METHODS: A case-control study was conducted in the ED. 'Cases' are herein defined as hospitalised patients who experienced IHCA within 24 h after ED triage. The exclusion criteria were those younger than 16 years old, cases of traumatic arrest, or had do-not-resuscitate orders. The controls were adults, non-traumatic cases, who did not experience IHCA within 24 h of ED triage. A multivariable regression model was used to identify significant predictors of IHCA. The ability to discriminate was quantified by utilising an area under receiver operating characteristic (AuROC) curve. RESULTS: Two hundred and fifty IHCAs were compared with 1000 controls. Five predictors emerged that were: higher National Early Warning Score (NEWS) at triage, equal or increase of NEWS after ED management, coronary artery disease as a comorbid disease, the use of a vasoactive agent, and initial serum bicarbonate level lower than 23.5 mmoL/L, independently associated with IHCA. The AuROC of the final model from all predictors was 0.91 (95% CI 0.89-0.93) higher than NEWS alone model (AuROC at 0.78, 95% CI 0.74-0.81). CONCLUSIONS: We conclude that a combination of NEWS and four independent predictors identify patients at risk of IHCA more effectively than NEWS alone.

Study of basic-life-support training for college students.

OBJECTIVE: To study about attitude and knowledge regarding basic-life-support among college students outside medical system. MATERIAL AND METHOD: The cross-sectional study in the emergency department of Thammasat Hospital. The authors included college students at least aged 18 years old and volunteers to be study subjects. The authors collected data about attitudes and knowledge in performing basic-life-support by using set of questionnaires. RESULTS: 250 college students participated in the two hours trainingprogram. Most ofparticipants (42.4%) were second-year college students, of which 50 of 250 participants (20%) had trained in basic-life-support program. Twenty-seven of 250 participants (10.8%) had experience in basic-life-support outside the hospital. Most of participants had good attitude for doing basic-life-support. Participants had a significant improved score following training (mean score 8.66 and 12.34, respectively, p<0.001). Thirty-three of 250 participants (13.2%) passed the minimum score before trained testing, whereas 170 of 250 participants (68%) passed the minimum score after trained testing. CONCLUSION: With accurate knowledge and experience, lay rescuers may have more confidence tope7form basic-life-support to cardiac arrest patient. The training program in basic-life-support has significant impact on knowledge after training.