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.

Characteristics and outcomes of treatment in status asthmaticus patients at emergency department.

INTRODUCTION: The characteristics and treatment outcomes of status asthmaticus patients in emergency department (ED) have not been described previously especially in Thailand. OBJECTIVE: To describe the characteristics, treatment outcomes and factors associated with status asthmaticus in Thai patients presenting to a single center ED. METHODS: A prospective observational study was performed at Thammasat University hospital, Thailand. The data collected included demographics, asthma history and control, previous ED attendances and hospital admissions, presenting clinical, laboratory and radiographic features, treatments given, and outcomes. Multivariable regression was used to determine independent factors associated with status asthmaticus. RESULTS: Over one year (2015-16), 209 patients were recruited, aged 6 - 54 years (median 33 y), of whom 145 (69.3%) had status asthmaticus. The factors associated with status asthmaticus were: (i) age > 60 y, (ii) presence of a comorbidity, (iii) having uncontrolled asthma, (iv) hospitalizations or visits to the ED in the last year, and (v) using > 1 metered dose inhaler canister per month. Status asthmaticus patients were significantly less likely to speak in sentences (p=0.001) and more likely to have poor air entry and chest wall retraction (p<0.0001), an abnormal chest X ray (p=0.011), receive magnesium sulphate and be admitted into hospital (p<0.0001). No patients died. CONCLUSIONS: Status asthmaticus was common in this cohort of patients in our setting. Our findings are consistent with previous studies and underscore the need for better patient management.

Prospective Observational Study of Emergency Airway Management in Emergency Department.

Background and Objective: In the emergency department (ED), airway management by emergency physicians is becoming more common. The presented study described emergency intubation indications, methods, operator characteristics, success rates, and adverse event rates. Material and Method: Prospective observational study using data collection form was done in the ED of Thammasat University Hospital from September 2012 to August 2015. Data were collected by each physician intubator at the time of each intubation. Results: The author recorded 1,393 encounters underwent intubation in ED. Intubation was ultimately successful in 99.43%. Cardiac arrest (18.95%) and head injury (7.32%) were the most common indication for intubation in medical encounters and trauma encounters, respectively. The overall success rates on the first attempt were 74.66% (95% confidence interval (CI); 72.37-76.94%). Rapid sequence intubation (RSI) was used in 22.47% of all encounters, had success rates on the first attempt of intubation higher than sedation without paralysis (79.55% vs. 66.09%, risk difference 15.93%, 95% CI for difference [8.64-23.23%]; p<0.01). Senior physicians in emergency medicine had the highest rates of successful intubation on the first attempt (81.94%, 95% CI; 78.84-85.03%). The overall adverse event rates were 8.47%. Conclusion: The presented study observed high overall intubation success rates in ED. RSI has the highest success rates in the first attempt of intubation. Resident and staff in emergency medicine take major role in airway management. Training in emergency medicine residency programs can improve airway management skill.

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.

Incidence of neurological manifestations and complications in patients with COVID-19 infection: a propensity score matching analysis.

BACKGROUND: The novel coronavirus, SARS-CoV-2, can lead to potential neurological complications in COVID-19 patients. This study aims to assess the prevalence and associated risk factors of these complications among Thai individuals. METHODS: We conducted a retrospective study on hospitalized adults with COVID-19 at Thammasat University Hospital from April 2020 to September 2021, totaling 990 patients. We used propensity score matching and logistic regression to determine associated risk factors. RESULTS: Of the patients, 21.7% (215 individuals) manifested neurological complications, categorized as follows: Skeletal muscle injury: 16.3% Acute cerebrovascular disease: 0.8% Delirium: 2.4% Impaired consciousness: 2.6% Seizures: 0.5% Post-matching revealed risk factors significantly associated with neurological complications: overweight status, hypertension, diabetes mellitus, dyslipidemia, and severe infection. However, in a multivariable analysis, only severe infection remained significant (adjusted OR 3.71; p = 0.010). The presence of neurological complications was linked with an elevated mortality risk (OR 1.77, p = 0.005). CONCLUSIONS: In the Thai COVID-19 patient cohort, roughly 22% experienced neurological complications, with severe infection standing out as a major risk factor. This underscores the importance of closely monitoring neurological symptoms in COVID-19 patients.

Association of Scene Time with Mortality in Major Traumatic Injuries Arrived by Emergency Medical Service.

Introduction: Trauma is a major cause of death worldwide, and prehospital care is critical to improve patient outcomes. However, there is controversy surrounding the effectiveness of limiting scene time to 10 min or less in the care of major trauma patients. This study aimed to investigate the association between scene time and mortality in major trauma patients. Methods: A retrospective cohort study was conducted on major trauma patients treated by the Thammasat University Hospital Emergency Medical Services (EMS) team from 2020 to 2022. We included traumatic adult patients who had an injury severity score (ISS) of 16 or higher. The primary outcome was 24-h mortality. Multivariable risk regression analysis was used to evaluate the independent effect of scene time on 24-h mortality. Results: A total of 104 patients were included, of whom 11.5% died within 24 h. After adjusting for age, systolic blood pressure, Glasgow Coma Scale, and ISS, patients who had a scene time over 10 min showed a significant association with mortality (33.3% vs. 8.7%, P = 0.031). Intravenous fluid administration at the scene showed a trend toward a significant association with mortality. Conclusions: This study provides evidence to support the importance of minimizing scene time for major trauma patients. The findings suggest that a balance between timely interventions and adequate resources should be considered to optimize patient outcomes. Further studies to investigate the impact of prehospital interventions on trauma patient outcomes are needed.

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.

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 .

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.

Predicting Difficult Intubation in Emergency Department by Intubation Assessment Score.

BACKGROUND: The difficult intubation is associated with failure of emergency tracheal intubation. This study aimed to develop and validate a model for predicting difficult intubation in emergency department (ED). METHODS: A cross-sectional study was conducted in the ED. We collected data from all consecutive adult patients who underwent emergency tracheal intubation. Patients were excluded if they were intubated by low experience intubator. The difficult intubation was defined by grade III or IV of Cormack and Lehane classification. We used multivariable regression model to identify significant predictors of difficult intubation and weighted points proportional to the beta coefficient values. The ability to discriminate was quantified by using the area under receiver operating characteristics curve (AuROC). The bootstrapping method was used to validate the performance. RESULTS: A total of 1,212 intubations were analyzed. One hundred and fifty-seven intubations were enrolled in difficult intubation group. Five independence predictors were identified, and each was assigned a number of points proportional to its beta coefficient: male gender (one), large tongue (two), limit mouth opening (two), poor neck mobility (two), and presence of obstructed airway (three). Intubation assessment score model was created and applied to all subjects. The AuROC was 0.81 (95% confidence interval (CI): 0.77 - 0.85) for the development dataset, and 0.80 (95% CI: 0.76 - 0.85) for the validation dataset. We defined three risk groups: low risk (zero to one points), intermediate risk (two to three points), and high risk (above three points), and the difficult intubation rate was 4.7%, 22.5%, and 53.6%, respectively. CONCLUSIONS: Intubation assessment score model was constructed from patients' simple characteristics and performed well in predicting difficult intubation and can discriminate between with and without difficult intubation.

Targeted temperature management in neurological intensive care unit.

Targeted temperature management (TTM) shows the most promising neuroprotective therapy against hypoxic/ischemic encephalopathy (HIE). In addition, TTM is also useful for treatment of elevated intracranial pressure (ICP). HIE and elevated ICP are common catastrophic conditions in patients admitted in Neurologic intensive care unit (ICU). The most common cause of HIE is cardiac arrest. Randomized control trials demonstrate clinical benefits of TTM in patients with post-cardiac arrest. Although clinical benefit of ICP control by TTM in some specific critical condition, for an example in traumatic brain injury, is still controversial, efficacy of ICP control by TTM is confirmed by both in vivo and in vitro studies. Several methods of TTM have been reported in the literature. TTM can apply to various clinical conditions associated with hypoxic/ischemic brain injury and elevated ICP in Neurologic ICU.

The Outcomes of Targeted Temperature Management After Cardiac Arrest at Emergency Department: A Real-World Experience in a Developing Country.

Targeted temperature management (TTM) is indicated for comatose survivors of cardiac arrest to improve outcomes. However, the benefit of TTM was verified by rigid controlled clinical trials. This study aimed at evaluating its effects in real-world practices. A prospective observational study was done at the emergency department of tertiary care, Thammasat Hospital, from March 2012 until October 2015. We included all who did not obey verbal commands after being resuscitated from cardiac arrest regardless of initial cardiac rhythm. We excluded patients with traumatic arrest, uncontrolled bleeding, younger than 15 years old, and of poor neurological status (Glasgow coma scale below 14) before cardiac arrest. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcome (Cerebral Performance Categories 1 or 2 within 30 days). We used the logistic regression model to estimate the propensity score (PS) that will be used as a weight in the analysis. To analyze outcomes, the PS was introduced as a factor in the final logistic regression model in conjunction with other factors. A total of 192 cases, 61 and 131 patients, were enrolled in TTM and non-TTM groups, respectively. Characteristics believed to be related to initiation of TTM: gender, age, cardiac etiology, out-of-hospital cardiac arrest, witness arrest, collapse time, initial rhythm, received defibrillation, and advanced airway insertion, were included in multivariable analysis and estimated PS. After adjusted regression analysis with PS, the TTM group had a better result in survival to hospital discharge (34.43% vs. 12.21%; adjusted incidence risk ratio (IRR), 2.95; 95% confidence interval (CI), 1.49-5.84; p = 0.002). For neurological outcome, the TTM group had a higher number of favorable neurological outcomes (24.59% vs. 6.87%; IRR, 3.96; 95% CI, 1.67-9.36; p = 0.002). In real-world practices without a strictly controlled environment, TTM can improve survival and favorable neurological outcome in postcardiac arrest patients regardless of initial rhythm.