Incidence and risk factors of intraoperative hyperglycemia in non-diabetic patients: a prospective observational study.

BACKGROUND: Intraoperative hyperglycemia has been associated with multiple postoperative complications such as surgical site infection, myocardial infarction, stroke, and death. These complications are not confined to only diabetic patients. However, the incidence of intraoperative hyperglycemia in non-diabetic patients has not been fully elucidated. Additionally, these patients' risk factors were not well established in previous studies. METHODS: Four hundred forty non-diabetic patients who underwent intermediate- to high-risk surgery were included in the study. We prospectively measured the capillary blood glucose level in all patients during surgery. The incidence of intraoperative hyperglycemia was defined as at least one episode of blood glucose level of more than 180 mg/dL. Risk factors for hyperglycemia were assessed using multivariable logistic regression analysis. RESULTS: Sixty-five (14.7%) patients developed hyperglycemia during surgery. The independent risk factors for intraoperative hyperglycemia were an American Society of Anesthesiologists status ≥ 3 (odds ratio [OR] 6.09, 95% confidence interval [CI]: 2.67-13.89, p < 0.001), preoperative impaired fasting blood sugar (OR 2.28, 95%CI:1.13-4.61, p = 0.021), duration of anesthesia ≥ 3 h (OR 4.06, 95%CI: 1.23-13.45, p = 0.021), intraoperative hypotension (OR 5.37, 95%CI: 2.35-12.29, p < 0.001), intraoperative blood transfusion (OR 4.35, 95%CI: 2.15-8.79, p < 0.001), and steroid use (OR 2.39, 95%CI: 1.20-4.76, p = 0.013). Surgical site infection was higher in patients with intraoperative hyperglycemia compared with patients without intraoperative hyperglycemia (4 [6.1%] vs. 6 [1.6%], respectively, p = 0.035). CONCLUSION: The incidence of intraoperative hyperglycemia was significant in non-diabetic patients during intermediate- to high-risk surgery. Risk factors should be identified to prevent intraoperative hyperglycemia. TRIAL REGISTRATION: The study was prospectively registered at https://www.thaiclinicaltrials.org (TCTR20191114001).

Relationship between Abdominal Circumference and Incidence of Hypotension during Cesarean Section under Spinal Anesthesia.

BACKGROUND: Enlarged uterus can compress the inferior vena cava and cause hypotension when lying supine. Previous studies have shown a positive association between the abdominal circumference and size of the uterus. Therefore, the aim of this study was to evaluate the relationship between abdominal circumference and incidence of hypotension during cesarean section under spinal anesthesia. METHODS: The study cohort comprised women undergoing cesarean section under spinal anesthesia. Patients were divided into two groups according to the median abdominal circumference (<101 cm and ≥101 cm). Hypotension was defined as a systolic blood pressure of <90 mmHg or mean arterial pressure of <65 mmHg. The primary outcome of this study was the relationship between the incidence of hypotension and the abdominal circumference after spinal anesthesia in term pregnant women. RESULTS: The study cohort comprised 100 women. The incidence of hypotension did not differ between the groups (71.42% in the smaller vs. 78.43% in the larger abdominal circumference group, p=0.419). However, the decrease in mean arterial pressure and its percentage decrease from baseline were greater in the larger than in the smaller abdominal circumference group (change in mean arterial pressure: 28.33 mmHg (18.66-33.67) in the smaller vs. 36.67 mmHg (23.34-43.34) in the larger abdominal circumference group, p=0.004; percentage decrease: 31.41% (22.74-39.22) in the smaller vs. 38.47% (28.00-44.81) in the larger abdominal circumference group, p=0.022). CONCLUSIONS: Large abdominal circumference in pregnancy is associated with greater decreases in mean arterial pressure from baseline. However, the incidence of hypotension defined by standard criteria did not differ between larger and smaller abdominal circumference groups.

Survival benefit of a low ratio of visceral to subcutaneous adipose tissue depends on LDL clearance versus production in sepsis.

BACKGROUND: Patients with sepsis with a high ratio of visceral adipose tissue (VAT) to subcutaneous adipose tissue (SAT) have increased mortality. Our goal was to investigate the mechanism of this effect, noting that low LDL levels are also associated with increased sepsis mortality. Accordingly we tested for association between VAT/SAT, low-density lipoprotein (LDL) levels, and mortality. Then we examined the effect of statin treatment, which decreases LDL production, and the effect of PCSK9 genotype, which increases LDL clearance. METHODS: We performed retrospective analysis of a cohort of patients with sepsis from a tertiary care adult intensive care unit in Vancouver, Canada, who underwent abdominal computed tomography (CT) (n = 75) for clinical reasons. We compared LDL levels in patients with sepsis according to high versus low VAT/SAT and 90-day survival. We next examined the effects of statin therapy and PCSK9 loss-of-function genotype on survival. RESULTS: Patients with a low VAT/SAT had increased 90-day survival and were relatively protected against low LDL levels in sepsis compared to high VAT/SAT. Statin treatment abrogated the beneficial effects of low VAT/SAT; eliminating the difference in LDL levels and survival between patients with low and high VAT/SAT. PSCK9 loss-of-function genotype similarly eliminated the increased LDL levels in low VAT/SAT patients but, in contrast, increased the survival advantage of low VAT/SAT compared to high VAT/SAT. CONCLUSIONS: Low LDL levels per se are not simply associated with decreased sepsis survival because lowering LDL levels by inhibiting LDL production (statin treatment) is associated with adverse outcomes, while increased LDL clearance (PCSK9 loss-of-function genotype) is associated with improved outcomes in patients with low VAT/SAT.

Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients.

BACKGROUND: Acute kidney injury and hyperchloremia are commonly present in critically ill septic patients. Our study goal was to evaluate the association of hyperchloremia and acute kidney injury in severe sepsis and septic shock patients. METHODS: In this retrospective cohort study in a provincial tertiary care hospital, adult patients with severe sepsis or septic shock and serum chloride measurements were included. Serum chloride was measured on a daily basis for 48 hours. Primary outcome was development of acute kidney injury (AKI) and association of AKI and serum chloride parameters was analyzed. RESULTS: A total of 240 patients were included in the study, 98 patients (40.8 %) had hyperchloremia. The incidence of acute kidney injury (AKI) was significantly higher in the hyperchloremia group (85.7 % vs 47.9 %; p < 0.001). Maximal chloride concentration in the first 48 hours ([Cl-]max) was significantly associated with AKI. In multivariate analysis, [Cl-]max was independently associated with AKI [adjusted odds ratio (OR) for AKI = 1.28 (1.02-1.62); p = 0.037]. The increase in serum chloride (Δ[Cl-] = [Cl-]max - initial chloride concentration) demonstrated a dose-dependent relationship with severity of AKI. The mean Δ[Cl-] in patients without AKI was 2.1 mmol/L while in the patients with AKI stage 1, 2 and 3 the mean Δ[Cl-] was 5.1, 5.9 and 6.7 mmol/L, respectively. A moderate increase in serum chloride (Δ[Cl-] ≥ 5 mmol/L) was associated with AKI [OR = 5.70 (3.00-10.82); p < 0.001], even in patients without hyperchloremia [OR = 8.25 (3.44-19.78); p < 0.001]. CONCLUSIONS: Hyperchloremia is common in severe sepsis and septic shock and independently associated with AKI. A moderate increase in serum chloride (Δ[Cl-] ≥5 mmol/L) is associated with AKI even in patients without hyperchloremia.

Increased Ratio of Visceral to Subcutaneous Adipose Tissue in Septic Patients Is Associated With Adverse Outcome.

OBJECTIVES: Visceral and subcutaneous adipose tissue may contribute differentially to the septic inflammatory response. Accordingly, we tested the hypothesis that the ratio of visceral to subcutaneous adipose tissue is associated with altered sepsis outcome. DESIGN: A retrospective analysis from a cohort of sepsis patients admitted between 2004 and 2009. SETTING: A mixed medical-surgical ICU at St. Paul's Hospital in Vancouver, Canada. PATIENTS: Patients older than 16 years old who had sepsis and underwent abdominal CT scan (n = 257) for clinical reasons. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured the visceral adipose tissue and subcutaneous adipose tissue areas and calculated the visceral adipose tissue-to-subcutaneous adipose tissue ratio. Visceral adipose tissue/subcutaneous adipose tissue was not correlated with body mass index (r = -0.015, p = NS) and therefore provides additional unique information independent of body mass index. Sepsis patients with higher visceral adipose tissue/subcutaneous adipose tissue had greater 90-day mortality than patients with lower visceral adipose tissue/subcutaneous adipose tissue (log-rank test, linear-by linear association p < 0.005). After adjustment for significant covariates using Cox regression, increased visceral adipose tissue/subcutaneous adipose tissue quartile was significantly associated with increased 90-day mortality with hazard ratios of 2.01 (95% CI, 1.01-3.99) for the third visceral adipose tissue/subcutaneous adipose tissue quartile compared with the first quartile and 2.32 (95% CI, 1.15-4.69) for the highest visceral adipose tissue/subcutaneous adipose tissue quartile when compared with the first quartile. Increased mortality for patients with higher visceral adipose tissue/subcutaneous adipose tissue was found for both patients with body mass index less than 25 kg/m (p = 0.004) and for body mass index greater than or equal to 25 kg/m (p = 0.023). Furthermore, we found significantly greater need for mechanical ventilation, renal replacement therapy, and ICU stay in patients in the highest visceral adipose tissue/subcutaneous adipose tissue quartile. The ratio of proinflammatory (interleukin-8) to anti-inflammatory (interleukin-10) plasma cytokine levels was greater in patients with higher visceral adipose tissue/subcutaneous adipose tissue than in those with lower visceral adipose tissue/subcutaneous adipose tissue (p = 0.043). CONCLUSIONS: Visceral obesity, defined by a high visceral adipose tissue-to-subcutaneous adipose tissue ratio, contributes to adverse outcome in sepsis patients perhaps because of a greater pro- versus anti-inflammatory response.

The Association between Red Blood Cell Transfusion and Hospital Mortality in Critically Ill Surgical Patients: The Multi-center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study).

Objective: Red blood cell transfusion (RBCT) is commonly prescribed to critically ill patients with anemia. Nevertheless, the benefits of RBCT in these patients, particularly critically ill surgical patients, are still controversial. The aim of this study is to explore the association between RBCT and hospital mortality in Thai critically ill surgical patients. Material and Method: This study was a part of the multi-center, prospective, observational study, which included adult patients admitted to the SICUs after surgery. Patients were categorized into transfusion and no transfusion groups according to whether they received RBCT during SICU stay or not. The multiple logistic regression analysis was performed to determine whether RBCT was an independent risk factor for hospital mortality. The patients were also matched between two groups based on the propensity score for RBCT requirement and were then compared. Results: There were 2,531 patients included in this study. The incidence of RBCT in SICU was 40.3%. Overall, there was no association between RBCT in SICU and hospital mortality (adjusted OR 1.33, 95% CI 0.83-2.11) except in the subgroup of patients with age of <65 years old (adjusted OR 1.99, 95% CI 1.03-3.84). However, when the amount of RBCT was more than 1,200 mL, it was independently associated with increased hospital mortality (adjusted OR 2.55, 95% CI 1.35-4.81). In the propensity-score matching cohort, there was no association between RBCT in SICU and hospital mortality (adjusted OR 1.56, 95% CI 0.88-2.77) except when the amount of RBCT was more than 600 mL (601-1,200 mL, adjusted OR 3.14, 95% CI 1.47-6.72 and >1,200 mL, adjusted OR 3.58, 95% CI 1.36-9.48). Conclusion: RBCT should be considered as a life-saving intervention but with potential risks of adverse events. Identifying patients who will likely gain benefit from RBCT and implementing the restrictive transfusion strategy may be the keys to improve outcomes.

Incidence of and Risk Factors for Acute Respiratory Distress Syndrome in Patients Admitted to Surgical Intensive Care Units: The Multicenter Thai University- Based Surgical Intensive Care Unit (THAI-SICU) Study.

Objective: The incidence and outcomes of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) are unclear. We evaluated the cumulative incidence of, risk factors for, and outcomes of ALI/ARDS in surgical ICUs (SICUs). Material and Method: The multicenter Thai University-based Surgical Intensive Care Unit (THAI-SICU) study was a prospective, observational cohort study including nine university-based SICUs throughout Thailand from April 2011 to January 2013. All >18-year-old surgical patients who were admitted to general SICUs were recruited. The primary outcome was the incidence of ALI/ARDS. Results: In total, 4,652 patients were analyzed. ALI/ARDS new developed in 114 patients (2.5%). Patients with ALI/ARDS had higher APACHE II (20.0 vs. 11.4, respectively; p<0.001) and SOFA scores (7.3 vs. 3.1, respectively; p<0.001) and a higher incidence of past or current smoking (48% vs. 36%, respectively; p<0.001) than the non-ARDS patients. The 28-day mortality rate was significantly higher in patients with than without ALI/ARDS (50% vs. 12%; p<0.001). Higher APACHE II and SOFA scores and higher rates of current or past smoking were independent predictors of ALI/ARDS. Conclusion: The incidence of ALI/ARDS in the THAI-SICU study was low, but the mortality rate was high. Higher severity scores and smoking were associated with ALI/ARDS.

Prevalence, Outcomes and Risk factors of Acute Kidney Injury in Surgical Intensive Care Unit: A Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study).

Objective: Acute kidney injury (AKI) is one of the most common problems in critically ill patients. AKI associates with poor outcome in ICU. The recognition of the prevalence and risk factors of AKI is important. This could lead to the prevention of AKI and improve patient's outcome. This study aims to identify the prevalence, outcomes and independent risk factors of AKI in Thai surgical intensive care units. Material and Method: We conducted the prospective cohort study from nine university-based SICUs. The patients were diagnosed AKI by Acute Kidney Injury Network (AKIN) classification. The types of RRT and outcomes including mortality were collected. The risk factors of AKI were identified. Results: A total cohort of 4,652 patients was included for the present study. AKI was diagnosed in 786 (16.89%) patients. The ICU mortality was higher in patients with AKI (29.90% vs. 5.48%, p-value <0.001). Among patients with AKI staging, we found that those with AKIN III had higher ICU mortality compared to patients with AKIN II and AKIN I respectively (47.66% vs. 26.67% vs. 14.69%, p-value <0.001). Patients with AKI had higher 28 day-mortality compared with those without AKI (37.53% vs. 8.98%, p-value <0.001). The independent risk factors of AKI were higher APACHE II scores (OR 1.04, 95% CI 1.01-1.06, p-value = 0.001), lower serum albumin (OR 0.82, 95% CI 0.70-0.97, p-value = 0.020), organ failures which were in the gastrointestinal system (OR 1.53, 95% CI 1.13-2.08, p-value = 0.007), cardiovascular system (OR 1.95, 95% CI 1.34-2.83, p-value <0.001), neurological system (OR 1.37, 95% CI 1.02-1.85, p-value = 0.038) and urinary system (OR 7.00, 95% CI 5.21-9.40, p-value <0.001). Conclusion: Acute kidney injury associates with poor outcomes including increased ICU and 28-day mortality. Independent risk factors of AKI in the present study were higher APACHE II scores, lower serum albumin and organ failures on admission.

Acute Kidney Injury in Elderly Patients in Thai-Surgical Intensive Care Units (THAI-SICU) Study.

Objective: To demonstrate prevalence, characteristics and outcomes of the elderly patients who were diagnosed with acute kidney injury (AKI) in surgical intensive care units (ICUs). Material and Method: AKI data were extracted from multicenter prospective cohort study conducted in 9 university-affiliated surgical ICUs in Thailand (THAI-SICU study) from April 2011 to January 2013. The elderly group was defined as those over 65 years old. Statistical analysis was done comparing baseline characteristics and outcomes between the elderly with AKI and those without. Results: A total of 2,310 elderly patients (49.7%) were identified in our surgical ICUs from a total 4,652 cases. Of this elderly group, AKI was diagnosed in 445 cases (19.3%). The differences in the baseline characteristics of the elderly with AKI group were: older, higher number of males, greater number of smokers, and greater disease severity evaluated with APACHE-II and SOFA score than the elderly without AKI. The ICU mortality and 28-day hospital mortality were higher in the elderly with AKI than those without (28.1% vs. 5.2%, p<0.001 with RR = 5.401, 95% CI 4.231-6.895 and 35.7% vs. 9.4%, p<0.001 with RR = 3.786, 95% CI 3.138-4.569, respectively). Using multivariable logistic regression analysis and after adjustment of covariates, independent potential risk factors of developing AKI in the SICU included: older age, higher APACHE-II and SOFA score, smoking history, emergency surgery, concurrent sepsis, cardiac complications, delirium, and requiring respiratory support during ICU stay. Conclusion: Geriatric patients made up almost half of our surgical ICU population and nearly one-fifth of them suffered AKI. Once they had AKI, ICU mortality and 28-day hospital mortality were higher than those without AKI.

A comparison of the combination of atropine and glycopyrrolate with atropine alone for the reversal of muscle relaxant.

BACKGROUND: Muscle relaxant is commonly used in general anesthesia to facilitate surgery. When finishing the operation, anesthesiologists reverse the muscle relaxant with anticholinesterase, neostigmine, combined with anticholinergic for prevention of unwanted side effects from neostigmine. The only existed anticholinergic in Thailand is atropine, which has a more rapid onset than neostigmine resulting in initial tachycardia. Lately, we have glycopyrrolate that cause less increase in initial heart rate. Therefore, we would like to study the effect of heart rate of the combination between atropine and glycopyrrolate to counteract the effect of neostigmine. OBJECTIVE: Evaluate the different increase in heart rate after the reversal of muscle relaxant with neostigmine combined with atropine or glycopyrrolate plus atropine. MATERIAL AND METHOD: The study was a randomized controlled trial study. Fifty-one, ASA I or II patients undergoing elective gynecological surgery under general anesthesia technique were enrolled in the present study. They were randomly assigned by computer-generated random sequence into two groups, control group and intervention group. Control group received neostigmine 2.5 mg and atropine 1.2 mg, intervention group received neostigmine 2.5 mg, glycopyrrolate 0.2 mg and atropine 0.6 mg for reversal of neuromuscular block after finishing the operation. Both groups received the same anesthetic agents including muscle relaxant. Heart rate was recorded before drugs administration and at 1, 3, 5, and 7 minutes after injection. We also recorded heart rate in the PA CU at 0, 15, 30, 45, and 60 minutes. Secondary outcome was incidence of arrhythmia during the observation in PACU. RESULTS: There was no difference in age and baseline heart rate between the two groups. There was no different increase in heart rate after administration of reversal agent between control group and intervention group at any time (p-value = 0.496). No incidence of significant arrhythmia in both groups. CONCLUSION: There is no significant different increase in heart rate in 0.2 mg glycopyrrolate plus 0.6 mg atropine group compared to 1.2 mg atropine alone for antagonizing muscarinic effects of 2.5 mg neostigmine. Therefore, atropine 0.6 mg and glycopyrrolate 0.2 mg is an alternative to antagonize muscarinic effects of neostigmine.

The role of the hospitalists in the workforce to address the shortages of intensivists in hospitals here in Thailand.

The problem of a shortage of intensivists in Thailand is increasing annually. As stated in The Thai Society of Critical Care Medicine Database, 2013, the number of qualified intensivists currently is 163, working in 76 provinces in Thailand. This disproportion in the ratio of intensivists has affected patient outcomes. In an attempt to solve this problem, there has been an increased number of hospitalists working in place of the intensivists. Medical specialties are not available in many hospitals of Thailand. Thus, the hospitalists, who care for Intensive Care Unit (ICU) patients, are not trained to care for the acutely ill, hospitalized patients. Their competencies vary depending on their experience and training. In other countries, there has been evidence that properly trained hospitalists can work effectively in the ICU. This awareness of the importance of intensivists in Thailand is one of the stifling factors; the improvement of the hospitalists, determining the hospitalists' workforce and increasing the number of the intensivists to match future demands are needed.