Duplicated inferior vena cava, the uncommon cause of decreasing extracorporeal membrane oxygenation blood flow: A case report and review.

Duplicated inferior vena cava (DIVC) is a rare anomaly of the venous system, which is mostly found accidentally during intra-abdominal surgery and radiographic study. This anomaly is asymptomatic but may be related to venous thromboembolism in some patients. We present a case of a patient who had inadequate drainage for extracorporeal membrane oxygenation, which was found to be related to duplicated inferior vena cava.

Population Pharmacokinetics/Pharmacodynamics and Clinical Outcomes of Meropenem in Critically Ill Patients.

Several pathophysiological changes can alter meropenem pharmacokinetics in critically ill patients, thereby increasing the risk of subtherapeutic concentrations and affecting therapeutic outcomes. This study aimed to characterize the population pharmacokinetic (PPK) parameters of meropenem, evaluate the relationship between the pharmacokinetic/pharmacodynamic index of meropenem and treatment outcomes, and evaluate the different dosage regimens that can achieve 40%, 75%, and 100% of the dosing interval for which the free plasma concentrations remain above the MIC of the pathogens (fT>MIC) targets. Critically ill adult patients treated with meropenem were recruited for this study. Five blood samples were collected from each patient. PPK models were developed using a nonlinear mixed-effects modeling approach, and the final model was subsequently used for Monte Carlo simulations to determine the optimal dosage regimens. A total of 247 concentrations from 52 patients were available for analysis. The two-compartment model with linear elimination adequately described the data. The mean PPK parameters were clearance (CL) of 4.8 L/h, central volume of distribution (VC) of 11.4 L, peripheral volume of distribution (VP) of 14.6 L, and intercompartment clearance of 10.5 L/h. Creatinine clearance was a significant covariate affecting CL, while serum albumin level and shock status were factors influencing VC and VP, respectively. Although 75% of the drug-resistant infection patients had fT>MIC values of >40%, approximately 83% of them did not survive the infection. Therefore, 40% fT>MIC might not be sufficient for critically ill patients, and a higher target, such as 75 to 100% fT>MIC, should be considered for optimizing therapy. A 75% fT>MIC could be reached using approved doses administered via a 3-h infusion.

Comparison of Glycemic Control between Continuous Regular Insulin Infusion and Single-dose Subcutaneous Insulin Glargine Injection in Medical Critically Ill Patients.

BACKGROUND AND AIMS: This study aimed to compare glycemic control between continuous intravenous regular insulin infusion and single-dose subcutaneous insulin glargine injection in medical critically ill patients. SUBJECTS AND METHODS: A prospective noninferiority study was conducted in medical critically ill patients who developed hyperglycemia and required regular insulin infusion by the Intensive Care Unit glycemic control protocol. The eligible patients were switched from the daily regular insulin requirement to single-dose subcutaneous insulin glargine injection by a 100% conversion dose. Arterial blood glucose was checked every 2 h for 24 h. Success cases were blood glucose levels of 80-200 mg/dL during the study period. The mean time-averaged area under the curves (AUCs) of blood glucose levels between the two types of insulin were compared by t-test. RESULTS: Of 20 cases, 14 cases (70%) were successful. The mean time-averaged AUCs of blood glucose levels between the two types of insulin were not significantly different (155.91 ± 27.54 mg/dL vs. 151.70 ± 17.07 mg/dL, P = 0.56) and less than the predefined noninferior margin. No severe hypoglycemic cases were detected during the study period. CONCLUSIONS: Single-dose subcutaneous insulin glargine injection was feasibly applied for glycemic control in medical critically ill patients. The glycemic control in the critically ill patients by a single dose of subcutaneous insulin glargine was comparable to standard intravenous regular insulin infusion. A conversion dose of 100% of the daily requirement of regular insulin is suggested.

Quality of Dying in the Medical Intensive Care Unit: Comparison between Thai Buddhists and Thai Muslims.

BACKGROUND AND AIMS: Religious belief is an important aspect that influences the life of a patient, especially in Asia. We aim to compare the quality of death in an Intensive Care Unit (ICU) between Buddhists and Muslims from the perspectives of the relatives of the patients and the nurses and physicians. SUBJECTS AND METHODS: This was a cohort study of critically ill patients who died after admission to a medical ICU in Songklanagarind Hospital in Thailand between 2015 and 2016. We interviewed by telephone the relatives of patients. The nurses and physicians who cared for the patients responded to a self-questionnaire. RESULTS: A total of 112 patients were enrolled in the study. The quality of death and dying-1 scores in Thai Buddhists and Muslim patients rated by the relatives (8 vs. 8, P = 0.55), nurses (8 vs. 8, P = 0.28), and physicians (7 vs. 7, P = 0.74) were not different. The ratings by the nurses correlated with the relatives (rs = 0.41, P < 0.001) but did not correlate with the physicians (rs = 0.15, P = 0.12). Compared with Buddhist patients, Muslim patients were more likely to have documentation in place at the time of the death of do not resuscitate (100% vs. 80.2%, P = 0.02) and withholding and withdrawing life support (100% vs. 80.2%, P = 0.02). CONCLUSION: There was no difference in the quality of dying and death between Thai Buddhists and Muslims. However, some elements of palliative care were not similar.

Mortality correlation factors in patients with lymphoma and acute myeloid leukemia admitted into the intensive care unit at a referral center in the south of Thailand.

BACKGROUND: Recent treatments in hematological malignancies have substantially improved. Unfortunately, once a patient with a hematological malignancy has complications, the prognosis is poor and the in hospital and ICU mortality rates are high. Debates concerning the reluctance to admit patients into ICUs with poor prognoses often emerge. The aim of the present study is to identify the patients who are more likely to benefit from ICU admissions. OBJECTIVES: To assess the outcomes and to identify early mortality risk factors in patients with lymphoma and acute myeloid leukemia admitted to the Intensive Care Unit (ICU) at Songklanagarind Hospital in the south of Thailand. MATERIAL AND METHOD: This is a retrospective study of patients diagnosed with lymphoma and acute myeloid leukemia admitted to the ICU during the period of January 2004 through May 2008. Demographic factors, acute physiology, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and variables noted in the first 24-hours were collected. The risk factors for deaths in the ICU were studied by univariate and multivariate analysis. The risk factors taken from the best multivariate analysis model were calculated to predict the probability of lCU mortality. RESULTS: A total of 145 patients were studied. The ICU mortality rate was 55.2%. The major cause of death was septic shock. Using univariate analysis, the significant mortality risk factors were neutropenia, mechanical ventilation, the use of vasopressors, abnormal serum creatinine (Cr) and APACHE II scores (p < 0.05). Using multivariate analysis, ICU mortality was best predicted on admission by mechanical ventilation, the use of vasopressors and the APACHE II scores. The presence of neutropenia, mechanical ventilation, vasopressors and an APACHE II score of greater than 27 predicts 80% sensitivity and a 75% specificity for an 82% ICU mortality. CONCLUSION: Patients with lymphoma and acute myeloid leukemia admitted into the ICU referral center in the south of Thailand who had mechanical ventilation, use of vasopressors and APACHE II scores greater than 27 were associated with a higher ICU mortality rate. The authors suggest that early identification of the subgroup of patients whose probability of survival is so low that advanced ICU support should not be continued would be a more reasonable goal. This will allow more efficient care to potential survivors not in this group.

Characters of physician and nurse staffing in Thai intensive care units (ICU-Resource I study).

OBJECTIVE: There have been no data available on physicians and nurses who are vital human resources in Thailand. The objective of this study is to describe these characteristics as well as their working patterns in Thai ICUs. MATERIAL AND METHOD: Data were retrieved from the ICU RESOURCE I study. Physician and nurse characteristics, working patterns and workloads in participating ICUs were recorded. After hour consultations, nurse staff years of experience, nurse specialist training and patient to bedside nurse ratios (PNR) were collected. RESULTS: One hundred and fifty-five hospitals are included in this study. Intensivists are available in 53 hospitals with a median of 0-1 intensivist per unit. Most intensivists are working in academic ICUs. The two specialties most involved in surgical ICUs were in critical care (34.1%) and surgical recovery (47.7%). Almost all pediatric ICUs were covered by pediatricians and only a quarter of them had been staffed with critical care pediatricians (28.6%). Less than 30 percent of Thai ICUs are covered by intensivists. About 42.3% of Thai ICUs have no night shift physician and the units contact the attending physicians directly. Experienced (more than 5 years) nurses staffing ICUs are at 62.5 percent. A total of 85.2% of the ICUs have certificated critical care nurses. Only 23.2% of all ICUs have an advance practice nurse (APN). The median PNR was 2.1 with an exception in academic ICUs. CONCLUSION: Intensivists continue to be only scarcely available in Thai ICUs. Nurse workloads in non-academic ICUs were higher than those in academic ICUs. Specialty training for certified critical care nurses is in place for only one-third of the total number of ICU nurses. APNs are available in 25% of participating ICUs (Thai Clinical Trial Registry: TCTR201200005).

Comparative efficacy of peptide-based versus standard polymeric enteral nutrition in ICU patients at high nutritional risk: a multicenter randomized controlled trial.

Within intensive care units (ICU), the administration of peptide-based formulas (PBF) may confer nutritional advantages for critically ill patients identified with heightened nutritional risk. This investigation aimed to ascertain the efficacy of PBF in comparison to standard polymeric formulas (SPF) among this patient cohort. A double-blind, randomized controlled trial was conducted across three ICUs, encompassing 63 adult patients characterized by elevated modified Nutrition Risk in Critically Ill (mNUTRIC) scores. Enrollment occurred promptly subsequent to ICU admission, with participants allocated to receive either PBF or SPF. Primary outcome was the duration to achieve caloric targets. Secondary outcomes involved the evaluation of mean daily gastric residual volume, mechanical ventilation period, infection rates within the ICU, length of hospitalization, mortality rates, nutritional status and inflammatory markers, specifically serum albumin and interleukin-6 levels. Patients in the PBF group reached their caloric targets more expeditiously compared to the SPF group (2.06 ± 0.43 days versus 2.39 ± 0.79 days; p = 0.03). No significant differences were discernible between the groups regarding gastric residual volume, duration of mechanical ventilation, ICU length of stay, mortality, or infection rates. Both cohorts exhibited minimal adverse effects and were devoid of any instances of abdominal distension. While not reaching statistical significance, the observed trends in albumin and interleukin-6 levels suggest a potential advantage of PBF utilization. The implementation of PBF enabled swifter attainment of caloric goals in ICU patients at high nutritional risk without adversely impacting other clinical parameters. Given its favorable tolerance profile and potential immunomodulatory properties, PBF may be considered a valuable nutritional intervention in this setting.Thai Clinical Trials Registry TCTR20220221006. Registered 21 February 2022, https://www.thaiclinicaltrials.org/show/TCTR20220221006 .

Validation of the prognostic scoring system for in-hospital mortality prediction in cardiogenic shock patients requiring veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: A few prognostic scoring systems have been developed for predicting mortality in patients with cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO), albeit with variations in performance. This study aimed to assess and compare various mortality prediction models in a cohort of patients receiving VA-ECMO following cardiogenic shock or arrest. METHODS: We retrospectively analyzed 77 patients with cardiogenic shock who were placed on VA-ECMO support between March 2014 and August 2021. The APACHE II, SAPS II, SAVE, Modified SAVE, ENCOURAGE, and ECMO-ACCEPTS scores were calculated for each patient to predict the in-hospital mortality. RESULTS: Fifty-six (72.7%) patients died. All prediction model scores, except the ECMO-ACCEPTS, differed significantly between non-survivors and survivors as follows: ENCOURAGE, 23 versus 16 (p < 0.001); SAVE, -6 versus -3 (p = 0.008); Modified SAVE, -5 versus 0 (p = 0.005); APACHE II, 32 versus 22 (p = 0.009); and SAPS II, 67 versus 49 (p = 0.002). The ENCOURAGE score demonstrated the best discriminatory ability with an area under the receiver-operating characteristic curve of 0.81 (95% confidence interval: 0.7-0.81). All prognostic scoring systems possessed limited calibration ability. However, the SAPS II, SAVE, and ENCOURAGE scores had lower Akaike and Bayesian information criteria values, which were consistent with the results of the Hosmer-Lemeshow C statistic test, indicating better performance than the other scores. CONCLUSIONS: The ENCOURAGE score can help predict in-hospital mortality in all subsets of VA-ECMO patients, even though it was originally designed to predict intensive care unit mortality in the post-acute myocardial infarction setting.

Prediction of fluid responsiveness in septic shock patients: comparing stroke volume variation by FloTrac/Vigileo and automated pulse pressure variation.

OBJECTIVES: The aim of this study was to assess and compare the ability of the automatically and continuously measured stroke volume variation (SVV) obtained by FloTrac/Vigileo, and pulse pressure variation (PPV) measured by an IntelliVue MP monitor, to predict fluid responsiveness in mechanically ventilated septic shock patients. METHOD: We conducted a prospective study on 42 septic shock patients. SVV, PPV and other haemodynamic data were recorded before and after fluid administration of 500 ml of 6% hydroxyethyl starch. Responders were defined as patients with an increase in stroke volume index of at least 15% after fluid loading. RESULTS: Twenty-four (57.1%) patients were classified as fluid responders. The baseline SVV correlated with the baseline PPV (r=0.96, P<0.001). SVV and PPV were significantly higher in responders than in nonresponders (15.5±4.5 vs. 8.2±3.3% and 16.4±5.2 vs. 8.3±3.5, respectively, P<0.001 for both). There was no difference between the area under the receiver operating characteristic curves of SVV [0.92, 95% confidence interval 0.832-1.00] and PPV (0.916, 95% confidence interval 0.829-1.00). The optimal threshold values in predicting fluid responsiveness were 10% for SVV (sensitivity 91.7% and specificity 83.3%) and 12% for PPV (sensitivity 83.3% and specificity 83.3%). Our results were independent of the site of arterial catheterisation. CONCLUSION: The SVV, obtained by FloTrac/Vigileo, and the automated PPV, obtained by the IntelliVue MP monitor, showed comparable performance in terms of predicting fluid responsiveness in passively ventilated septic shock patients, with a regular cardiac rhythm and a tidal volume not less than 8 ml kg(-1).

Glomerular filtration rate correlation and agreement between common predictive equations and standard 24-hour urinary creatinine clearance in medical critically ill patients.

Background: Determining kidney function in critically ill patients is paramount for the dose adjustment of several medications. When assessing kidney function, the glomerular filtration rate (GFR) is generally estimated either by calculating urine creatinine clearance (UCrCl) or using a predictive equation. Unfortunately, all predictive equations have been derived for medical outpatients. Therefore, the validity of predictive equations is of concern when compared with that of the UCrCl method, particularly in medical critically ill patients. Therefore, we conducted this study to assess the agreement of the estimated GFR (eGFR) using common predictive equations and UCrCl in medical critical care setting. Methods: This was the secondary analysis of a nutrition therapy study. Urine was collected from participating patients over 24 h for urine creatinine, urine nitrogen, urine volume, and serum creatinine measurements on days 1, 3, 5, and 14 of the study. Subsequently, we calculated UCrCl and eGFR using four predictive equations, the Cockcroft-Gault (CG) formula, the four and six-variable Modification of Diet in Renal Disease Study (MDRD-4 and MDRD-6) equations, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The correlation and agreement between eGFR and UCrCl were determined using the Spearman rank correlation coefficient and Bland-Altman plot with multiple measurements per subject, respectively. The performance of each predictive equation for estimating GFR was reported as bias, precision, and absolute percentage error (APE). Results: A total of 49 patients with 170 urine samples were included in the final analysis. Of 49 patients, the median age was 74 (21-92) years-old and 49% was male. All patients were hemodynamically stable with mean arterial blood pressure of 82 (65-108) mmHg. Baseline serum creatinine was 0.93 (0.3-4.84) mg/dL and baseline UCrCl was 46.69 (3.40-165.53) mL/min. The eGFR from all the predictive equations showed modest correlation with UCrCl (r: 0.692 to 0.759). However, the performance of all the predictive equations in estimating GFR compared to that of UCrCl was poor, demonstrating bias ranged from -8.36 to -31.95 mL/min, precision ranged from 92.02 to 166.43 mL/min, and an unacceptable APE (23.01% to 47.18%). Nevertheless, the CG formula showed the best performance in estimating GFR, with a small bias (-2.30 (-9.46 to 4.86) mL/min) and an acceptable APE (14.72% (10.87% to 23.80%)), especially in patients with normal UCrCl. Conclusion: From our finding, CG formula was the best eGFR formula in the medical critically ill patients, which demonstrated the least bias and acceptable APE, especially in normal UCrCl patients. However, the predictive equation commonly used to estimate GFR in critically ill patients must be cautiously applied due to its large bias, wide precision, and unacceptable error, particularly in renal function impairment.

The incidence of phlebitis development of high concentration of continuous amiodarone infusion with in-line filter compared to the low concentration without in-line filter: a retrospective propensity score-matched analysis.

BACKGROUND: Phlebitis-associated peripheral infusion of intravenous amiodarone is common in clinical practice, with an incidence between 5% and 65%. Several factors, including drug concentration, catheter size, and in-line filter used, are significantly associated with phlebitis occurrence. We performed a retrospective propensity score-matched analysis to find out whether in-line filter will reduce the incidence of amiodarone-induced phlebitis (AIP) in high concentration of amiodarone infusion compared to low concentration without in-line filter. METHODS: Clinical records of all patients who required intravenous amiodarone infusion for cardiac arrhythmias, between January 2017 to December 2019 were retrieved. The incidence of AIP was recorded and subsequently compared among high concentration (2 mg/ml) with an in-line filter and low concentration (1.5 mg/ml) infusion without an in-line filter after a 1 to 2 propensity score matched. RESULTS: The data indicated that among the 214 cases of amiodarone infusion collected, 28 cases used an in-line filter with high concentration while 186 cases received a low concentration of amiodarone infusion without an in-line filter. After 1:2 propensity score matching, the incidence of phlebitis in the high concentration with in-line filter group was significantly higher than the low concentration without in-line filter group (28.6% vs. 3.6%, P<0.01). CONCLUSIONS: Despite the usage of in-line filter, the high concentration of amiodarone infusion resulted in a higher incidence of peripheral phlebitis. Central venous catheterization for a high concentration of amiodarone infusion is recommended.

Ability of a modified Sequential Organ Failure Assessment score to predict mortality among sepsis patients in a resource-limited setting.

BACKGROUND: Some variables of the Sequential Organ Failure Assessment (SOFA) score are not routinely measured in sepsis patients, especially in countries with limited resources. Therefore, this study was conducted to evaluate the accuracy of the modified SOFA (mSOFA) and compared its ability to predict mortality in sepsis patients to that of the original SOFA score. METHODS: Sepsis patients admitted to the medical intensive care unit of Songklanagarind Hospital between 2011 and 2018 were retrospectively analyzed. The primary outcome was all-cause in-hospital mortality. RESULTS: A total of 1,522 sepsis patients were enrolled. The mean SOFA and mSOFA scores were 9.7±4.3 and 8.8±3.9, respectively. The discrimination of the mSOFA score was significantly higher than that of the SOFA score for all-cause in-hospital mortality (area under the receiver operating characteristic curve, 0.891 [95% confidence interval, 0.875-0.907] vs. 0.879 [0.862-0.896]; P<0.001), all-cause intensive care unit (ICU) mortality (0.880 [0.863-0.898] vs. 0.871 [0.853-0.889], P=0.01) and all-cause 28-day mortality (0.887 [0.871-0.904] vs. 0.874 [0.856-0.892], P<0.001). The ability of mSOFA score to predict all-cause in-hospital and 28-day mortality was higher than that of the SOFA score within the subgroups of sepsis according to age, sepsis severity and serum lactate levels. The mSOFA score was demonstrated to have a performance similar to the original SOFA score regarding the prediction of mortality in sepsis patients with cirrhosis or hepatic dysfunction. CONCLUSIONS: The mSOFA score was a good alternative to the original SOFA core in predicting mortality among sepsis patients admitted to the ICU.

Image-guided percutaneous biopsy and pathological diagnosis in atypical tuberculous spondylitis: a case series and clinical outcomes.

Background: Tuberculous spondylitis can be difficult to distinguish from alternative spinal pathologies such as malignancy, particularly if the imaging features are not typical. Biopsy and histopathological analysis are facilitative to the early and accurate diagnosis of atypical tuberculous spondylitis and the clinical management. The purpose of this study is to describe some of the atypical imaging features of tuberculous spondylitis diagnosed by image-guided percutaneous biopsy, as well as associated treatment outcomes. Methods: We performed a retrospective analysis of all patients diagnosed with tuberculous spondylitis after image-guided percutaneous biopsy at The Third Affiliated Hospital of Southern Medical University between 2013 and 2020. Of the patients identified, those with atypical imaging features were selected for case review. All patients were given anti-tuberculous medication treatment with or without surgery. The imaging features, histological and microbiological results, and clinical presentations and outcomes were evaluated. Neurological function was evaluated according to the Frankel grading system. The clinical outcomes were evaluated by Visual Analogic Scale (VAS) scores for pain, imaging [X-ray, computed tomography (CT), and magnetic resonance imaging (MRI)] results, and laboratory examinations. Comparison of VAS scores was made by Student t-test. Results: Of the 102 patients identified with tuberculous spondylitis between 2013 and 2020, eight patients (two females and six males) with a mean age of 41.6 years (range, 18-61 years) demonstrated atypical imaging findings, including central vertebral body lesion, multiple skip vertebral lesions, extradural mass lesion and anterior subperiosteal lesion. All eight patients received anti-tuberculous medication treatment, and six underwent surgery. One patient developed a pleural effusion after debridement of the thoracic lesion. The mean follow-up period was 16.2 months (6-37 months). The VAS scores before treatment and at the final follow-up showed significant differences (7.25±1.49 and 0.0±0.0, respectively, P<0.01). Improved neurological function were observed in all patients. Solid fusion and osteogenic osteosclerosis were observed at the final follow-up, and no recurrence was observed in any cases. Conclusions: All eight patients had a good prognosis. Image-guided biopsy and histopathological analysis are helpful for the early diagnosis of tuberculous spondylitis, especially when imaging features are not typical for this condition.

Efficacy and Safety of Enteral Erythromycin Estolate in Combination With Intravenous Metoclopramide vs Intravenous Metoclopramide Monotherapy in Mechanically Ventilated Patients With Enteral Feeding Intolerance: A Randomized, Double-Blind, Controlled Pilot Study.

BACKGROUND: In this pilot study, we aimed to determine the efficacy and safety of enteral erythromycin estolate in combination with intravenous metoclopramide compared to intravenous metoclopramide monotherapy in mechanically ventilated patients with enteral feeding intolerance. METHODS: This randomized, double-blind, controlled pilot study included 35 mechanically ventilated patients with feeding intolerance who were randomly assigned to receive 10-mg metoclopramide intravenously every 6-8 hours in combination with 250-mg enteral erythromycin estolate (study group) or placebo every 6 hours for 7 days. The primary outcome was an administered-to-target energy ratio of ≥80% at 48 hours, indicating a successful feeding. Secondary, prespecified outcomes were daily average gastric residual volume (GRV), total energy intake, administered-to-target energy ratio, hospital length of stay, in-hospital mortality, and 28-day mortality. RESULTS: The rate of successful feeding was not significantly different between the study and placebo groups (47.1% and 61.1%, respectively; P = .51). The average daily GRV was significantly lower in the study group than in the placebo group (ß = 91.58 [95% Wald CI, -164.35 to -18.8]), determined by generalized estimating equation. Other secondary outcomes were comparable, and the incidence of adverse events was not significantly different between the 2 groups. One common complication was cardiac arrhythmia, which was mostly self-terminated. CONCLUSION: Although the combination therapy of enteral erythromycin estolate and intravenous metoclopramide reduced GRV, the successful feeding rate and other patient-specific outcomes did not improve in mechanically ventilated patients with feeding intolerance.

Maximal Glycemic Difference, the Possible Strongest Glycemic Variability Parameter to Predict Mortality in ICU Patients.

BACKGROUND: This retrospective study aimed to determine the correlation of blood glucose and glycemic variability with mortality and to identify the strongest glycemic variability parameter for predicting mortality in critically ill patients. METHODS: A total of 528 patients admitted to the medical intensive care unit were included in this study. Blood glucose levels during the first 24 hours of admission were recorded and calculated to determine the glycemic variability. Significant glycemic variability parameters, including the standard deviation, coefficient of variation, maximal blood glucose difference, and J-index, were subsequently compared between intensive care unit survivors and nonsurvivors. A binary logistic regression was performed to identify independent factors associated with mortality. To determine the strongest glycemic variability parameter to predict mortality, the area under the receiver operating characteristic of each glycemic variability parameter was determined, and a pairwise comparison was performed. RESULTS: Among the 528 patients, 17.8% (96/528) were nonsurvivors. Both survivor and nonsurvivor groups were clinically comparable. However, nonsurvivors had significantly higher median APACHE-II scores (23 [21, 27] vs. 18 [14, 22]; p < 0.01) and a higher mechanical ventilator support rate (97.4% vs. 74.9%; p < 0.01). The mean blood glucose level and significant glycemic variability parameters were higher in nonsurvivors than in survivors. The maximal blood glucose difference yielded a similar power to the coefficient of variation (p = 0.21) but was significantly stronger than the standard deviation (p = 0.005) and J-index (p = 0.006). CONCLUSIONS: Glycemic variability was independently associated with intensive care unit mortality. Higher glycemic variability was identified in the nonsurvivor group regardless of preexisting diabetes mellitus. The maximal blood glucose difference and coefficient of variation of the blood glucose were the two strongest parameters for predicting intensive care unit mortality in this study.

Clinical characteristics, outcomes, and predictors of leptospirosis in patients admitted to the medical intensive care unit: A retrospective analysis.

BACKGROUND: Early diagnosis and detection of clinical deterioration of leptospirosis are challenges to all clinicians. This study aimed to report the characteristics and outcomes of patients admitted to the medical intensive care unit (MICU) for severe leptospirosis and to identify the clinical predictors of MICU admission. METHODS: This was a 10-year retrospective study that included all patients diagnosed as leptospirosis, based on either serology or a Thai-Lepto score (TLS) of >4. All clinical characteristics and laboratory data were collected and compared between MICU cases and general ward cases. Binary logistic regression was applied to identify the independent factors for MICU admission. RESULTS: Of the 68 patients who were diagnosed as leptospirosis based on inclusion criteria, 43 serologically-confirmed cases were subsequently analyzed. Fifty percent of the cases were admitted to the MICU and, compared with those admitted to the general ward, had higher Sequential Organ Failure Assessment (SOFA) score [10 (7-13) vs. 5 (2.2-5.6), p < 0.001]; higher TLS [7.5 (6.5-9.25) vs. 5.5 (3.5-6.5), p < 0.001]; lower mean arterial blood pressure (74.7 ± 15 mmHg vs. 84.2 ± 16.3 mmHg, p = 0.04); lower platelet count in ×103 cell/mm3 [65 (52.8-105.8) vs. 159 (87.3-181.5), p = 0.008); higher total bilirubin level [4.4 (1.5-8.7) mg/dL vs. 1.2 (0.7-2.8) mg/dL, p = 0.01]; and required more inotropes and vasopressors (87% vs. 4.3%, p < 0.001), mechanical ventilator support (91.3% vs. 4.3%, p < 0.001), and renal replacement therapy (39.1% vs. 0%, p < 0.001). TLS, SOFA score, requirement for mechanical ventilation, and use of inotropes and vasopressors were the predictors of MICU admission. TLS > 6 and SOFA score >6 gave similar power to predict MICU admission. CONCLUSION: Among patients with leptospirosis, TLS, SOFA score, inotrope or vasopressor requirement, and mechanical ventilator support were the independent predictors of MICU admission. TLS > 6 and SOFA score >6 indicated the need for MICU admission.

Characteristics and Outcomes of Severe ARDS Patients Receiving ECMO in Southern Thailand.

Extracorporeal membrane oxygenation (ECMO) is a treatment option considered for acute respiratory distress syndrome (ARDS) patients who are refractory to conventional treatments. However, treatment with ECMO has not shown significant reduction of mortality which may be due to inappropriate selection criteria. Thus, we aim to evaluate the treatment outcomes of patients treated with ECMO in our center and determine an optimal cutoff level of the Respiratory ECMO Survival Prediction (RESP) score for case selection. This was a retrospective case-control study conducted at Songklanagarind Hospital, Thailand, from January 2014 to August 2018. ECMO patients were randomly matched to a control group of patients with severe ARDS within the same time period. There were 19 cases diagnosed with ARDS and treated with ECMO and 57 controls with ARDS. The patients in both groups had an average APACHE II score of 30.2 (SD = 4.7) and mainly had bacterial pneumonia. The in-hospital mortality was not significantly different between the cases and controls (68.4% vs 63.2%, respectively); however, the ECMO cases had a significantly longer length of intensive care unit stay and cost of hospitalization. Active malignancy, male gender, PaO2/FiO2 ratio, and hypotension needing vasopressors were the risk factors for mortality. The RESP score did not discriminate between the survivors and nonsurvivors. Thus, more patient is needed to construct a better selection criterion.

Comparison of the accuracy of three early warning scores with SOFA score for predicting mortality in adult sepsis and septic shock patients admitted to intensive care unit.

BACKGROUND: The purpose of this study was to compare the accuracy of the Modified Early Warning Score (MEWS), National Early Warning Score (NEWS) and Search Out Severity (SOS), with the quick Sequential Organ Failure Assessment (qSOFA) and SOFA scores, to predict outcomes in sepsis patients. METHODS: A retrospective study was conducted in intensive care unit of university teaching hospital. RESULTS: A total of 1,589 sepsis patients were enrolled. The SOFA score had the best accuracy to predict hospital mortality, with an area under the receiver operating characteristic curve (AUC) of 0.880 followed by SOS (0.878), MEWS (0.858), qSOFA (0.847) and NEWS (0.833). The SOS score provided a similar performance with SOFA score in predicting mortality. CONCLUSION: The SOS presents nearly as good as the SOFA score, to predict mortality among sepsis patients admitted to the ICU. The early warning score is another, alternative tool to use for risk stratification and sepsis screening for ICU sepsis patients.

Comparison of the performance of SOFA, qSOFA and SIRS for predicting mortality and organ failure among sepsis patients admitted to the intensive care unit in a middle-income country.

INTRODUCTION: The Sepsis-3 definition provides a change of two or more scores from zero or a known baseline of the Sequential Organ Failure Assessment (SOFA) as criteria of sepsis. The aim of this study was to compare the SOFA score and the quick SOFA (qSOFA) to Systemic Inflammatory Response Syndrome (SIRS) criteria in predictive ability of mortality and organ failure. METHODS: A-10year retrospective cohort study was conducted in a teaching hospital in Thailand. RESULTS: A total of 2350 of mixed sepsis patients by Sepsis-2 definition were included. The all-cause hospital mortality rate was 44.5%. Of the total sample, 95.6% (n=2247) of patients met criteria for sepsis under the Sepsis-3 definition. The SOFA score presented the best discrimination with an area under the receiver operating characteristic curve (AUC) of 0.839. The AUC of SOFA score for hospital mortality was significantly higher than qSOFA (AUC 0.814, P=0.003) and SIRS (AUC 0.587, P<0.0001). Also, the SOFA score had superior performance than other scores for predicting intensive care unit (ICU) mortality and organ failure. CONCLUSIONS: The SOFA is a superior prognostic tool for predicting mortality and organ failure than qSOFA and SIRS criteria among sepsis patients admitted to the ICU.

National Early Warning Score (NEWS) at ICU discharge can predict early clinical deterioration after ICU transfer.

OBJECTIVE: This study aims to determine the ability of the National Early Warning Score at ICU discharge (NEWSdc) to predict the development of clinical deterioration within 24h. METHODS: A prospective observational study was conducted. The NEWS was immediately recorded before discharge (NEWSdc). The development of early clinical deterioration was defined as acute respiratory failure or circulatory shock within 24h of ICU discharge. The discrimination of NEWSdc and the best cut off value of NEWSdc to predict the early clinical deterioration was determined. RESULTS: Data were collected from 440 patients. The incidence of early clinical deterioration after ICU discharge was 14.8%. NEWSdc was an independent predictor for early clinical deterioration after ICU discharge (OR 2.54; 95% CI 1.98-3.26; P<0.001). The AUROC of NEWSdc was 0.92±0.01 (95% CI 0.89-0.94, P<0.001). A NEWSdc>7 showed a sensitivity of 93.6% and a specificity of 82.2% to detect an early clinical deterioration after ICU discharge. CONCLUSION: Among critically ill patients who were discharged from ICU, a NEWSdc>7 showed the best sensitivity and specificity to detect early clinical deterioration 24h after ICU discharge.