Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand.

OBJECTIVE: This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults. DATA SOURCES: We conducted a search on PubMed for nebulized budesonide treatment. SELECTED STUDIES: Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies. RESULTS: Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings. CONCLUSION: Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

Appropriateness of recommended chest compression depths for cardiopulmonary resuscitation based on chest computed tomography parameters among Thai population: A multicenter retrospective study.

Aim: We evaluated the appropriateness of various chest compression (CC) depths among Thai population by comparing the calculated heart compression fraction (HCF) using mathematical methods based on chest computed tomography (CT) measurements. Methods: This multicenter retrospective cross-sectional study was conducted from September 2014 to December 2020. Chest parameters included external anteroposterior diameter (EAPD), internal anteroposterior diameter (IAPD), heart anteroposterior diameter (HAPD), and non-cardiac soft tissue measured at the level of maximum left ventricular diameter (LVmax). We compared the HCFs as calculated from CT parameters using different CC depths at 5 cm, 6 cm, 1/4 of EAPD, and 1/3 of EAPD, with further subgroup analysis stratified by sex and BMI. Results: A total of 2927 eligible adult patients with contrast-enhanced chest CT were included. The study group had mean age of 60.1 ± 14.7 years, mean BMI of 22 ± 4.4 kg/m2, and were 57% males. The mean HCFs were 41.5%, 53.5%, 42.4%, and 62.6%, for CC depths of 50 mm, 60 mm, 1/4 of EAPD, and 1/3 of EAPD respectively. HCF was significantly lower in male patients for all CC depths. Advanced age and higher BMI showed significant correlation with lower HCF for CC depths of 50 mm and 60 mm. Conclusion: The CC depth measure of 50-60 mm demonstrated efficacy in maintaining HCF and coronary perfusion in the general population except for geriatric and obese individuals. Adjusting CC depth to 1/4-1/3 of the EAPD yielded better outcomes. Future research should prioritize determining individualized CC depths based on EAPD proportion.

Optimal chest compression position for cardiopulmonary resuscitation determined by computed tomography image: retrospective cross-sectional analysis.

The objective of this study was to determine the height of optimal hand position for chest compression during adult cardiopulmonary resuscitation (CPR) from the tip of the sternal xiphoid process (TOX) along with the relative heights of the left ventricular outflow tract (LVOT) and abdominal organs among the Thai population. The retrospective cross-sectional study was conducted through a review of medical records and contrast-enhanced chest computed tomography. The total of 204 Thai patients without obvious chest deformity at Ramathibodi Hospital from January to June 2018 was included as part of a multi-regional study. The heights of the level of maximal LV width (LVmax), LOVT, top of liver and stomach with respect to TOX were measured on midline sagittal image. Mean age and body mass index (BMI) were 59.5 years and 23.9 kg/m2, respectively. One hundred and one subjects (49.5%) had pulmonary diseases. Mean height of the LVmax from TOX was 37.7 mm, corresponding to 20% of the sternal length (SL) in the inspiration arm raised position (IAR). The adjusted height of LVmax from TOX in the expiration arm-down position (EAD) was 89.7 mm (48% of SL). The inter-nipple line was at 84.5 mm (45.1% of SL) from TOX on IAR. Among 178 and 109 subjects whose uppermost part of the liver and stomach were above TOX, 80.4% and 94.5% were located within the lower half of the sternum, respectively. The adjusted optimal hand position for chest compression during CPR was at approximately 89.7 mm from TOX in EAD (48% of SL). The hand position at the upper part of the lower half of the sternum is closest to the adjusted LVmax and has a better chance to avoid compression of intraabdominal organs.Trial registration This trial was retrospectively registered on 2 February 2023 in the Thai Clinical Trial Registry, identification number TCTR 20230202006.

Predictive Factors of Oxygen Therapy Failure in Patients with COVID-19 in the Emergency Department.

Background: Most patients with coronavirus disease 2019 (COVID-19) pneumonia require oxygen therapy, including standard oxygen therapy and a high-flow nasal cannula (HFNC), in the Emergency Department (ED), and some patients develop respiratory failure. In the COVID-19 pandemic, the intensive care unit (ICU) was overburdening. Therefore, prioritizing patients who require intensive care is important. This study aimed to find predictors and develop a model to predict patients at risk of requiring an invasive mechanical ventilator (IMV) in the ED. Methods: We performed a retrospective, single-center, observational study. Patients aged ≥18 years who were diagnosed with COVID-19 and required oxygen therapy in the ED were enrolled. Cox regression and Harrell's C-statistic were used to identifying predictors of requiring IMV. The predictive model was developed by calculated coefficients and the ventilator-free survival probability. The predictive model was internally validated using the bootstrapping method. Results: We enrolled 333 patients, and 97 (29.1%) had required IMV. Most 66 (68.0%) failure cases were initial oxygen therapy with HFNC. Respiratory rate-oxygenation (ROX) index, interleukin-6 (IL-6) concentrations ≥20 pg/mL, the SOFA (Sequential Organ Failure Assessment) score without a respiratory score, and the patient's age were independent risk factors of requiring IMV. These factors were used to develop the predictive model. ROX index and the predictive model at 2 hours showed a good performance to predict oxygen therapy failure; the c-statistic was 0.814 (95% confidence level [CI] 0.767-0.861) and 0.901 (95% CI 0.873-0.928), respectively. ROX index ≤5.1 and the predictive model score ≥8 indicated a high probability of requiring IMV. Conclusion: The COVID-19 pandemic was limited resources, ROX index, IL-6 ≥20 pg/mL, the SOFA score without a respiratory score, and the patient's age can be used to predict oxygen therapy failure. Moreover, the predictive model is good at discriminating patients at risk of requiring IMV and close monitoring.

Thirty-day mortality among patients with acute delirium in the emergency department.

Purpose: The number of visits to the emergency department (ED) is growing among older patients. Older people are at risk of acute delirium, which is associated with mortality. Our primary objective was to determine the 30-day mortality outcome between older patients with and without acute delirium. Methods: From August 2018 to October 2019, we conducted a prospective cohort study in the ED of a tertiary care and university hospital. Patients over the age of 65 years who presented to the ED were included in the study. Within the first 12 h after the ED visit, delirium was assessed by using the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). We collected data on 30-day mortality, ED LOS, hospital length of stay (LOS), and the 30-day ED revisit rate. Results: We enrolled 173 patients in this study; 49 (28%) patients had acute delirium according to the CAM-ICU. The overall 30-day mortality was 4% (7/173). Delirium had no effect on 30-day mortality (adjusted odds ratio [OR], 2.15; 95% confidence interval [CI], 0.37-12.55; P = 0.40). Delirium was not associated with hospital LOS (adjusted mean difference -18.83 h; 95% CI, -71.94-34.28; P = 0.49) and the 30-day ED revisit rate (adjusted OR, 1.55; 95% CI, 0.59-4.11; P = 0.37). However, an increasing trend in ED LOS was observed (adjusted mean difference 16.39 h; 95% CI, -0.160-32.96; P = 0.05). Conclusions: We found insufficient evidence to establish an association between delirium and 30-day mortality, hospital LOS, or 30-day emergency department revisits. Trial registration: The trial was retrospectively registered in the Thai Clinical Trial Registry, identification number TCTR2021082700 on August 27, 2021.

Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial.

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3-18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

Effect of mini-course training in communication and teamwork on non-technical skills score in emergency residents: a prospective experimental study.

BACKGROUND: Non-technical skill (NTS) teaching is a recent development in medical education that should be applied in medical education, especially in medical specialties that involve critically ill patients, resuscitation, and management, to promote patient safety and improve quality of care. Our study aimed to compare the effects of mini-course training in NTS versus usual practice among emergency residents. METHODS: In this prospective (non-randomized) experimental study, emergency residents in the 2021-2022 academic year at Ramathibodi Hospital, a tertiary care university hospital, were included as participants. They were categorized into groups depending on whether they underwent a two-hour mini-course training on NTS (intervention group) or usual practice (control group). Each participant was assigned a mean NTS score obtained by averaging their scores on communication and teamwork skills given by two independent staff. The outcome was the NTS score before and after intervention at 2 weeks and 16 weeks. RESULTS: A total of 41 emergency residents were enrolled, with 31 participants in the intervention group and 10 in the control group. The primary outcome, mean total NTS score after 2 weeks and 16 weeks, was shown to be significantly better in intervention groups than control groups (25.85 ± 2.06 vs. 22.30 ± 2.23; P < 0.01, 28.29 ± 2.20 vs. 23.85 ± 2.33; P < 0.01) although the mean total NTS score did not differ between the groups in pre-intervention period. In addition, each week the NTS score of each group increased 0.15 points (95% CI: 0.01-0.28, P = 0.03), although the intervention group showed greater increases than the control (0.24 points) after adjustment for time (95% CI: 0.08-0.39, P < 0.01). CONCLUSION: Emergency residents who took an NTS mini-course showed improved mean NTS scores in communication and teamwork skills versus controls 2 weeks and 16 weeks after the training. Attention should be paid to implementing NTS in the curricula for training emergency residents. TRIAL REGISTRATION: This trial was retrospectively registered in the Thai Clinical Trial Registry on 29/11/2022. The TCTR identification number is TCTR20221129006.

Using computed tomography to evaluate proper chest compression depth for cardiopulmonary resuscitation in Thai population: A retrospective cross-sectional study.

INTRODUCTION: The effectiveness of cardiopulmonary resuscitation is determined by appropriate chest compression depth and rate. The American Heart Association recommended CC depth at 5-6 cm to indicate proper cardiac output during cardiac arrest. However, many studies showed the differences in the body builds between Caucasians and Asians. Therefore, this study aimed to determine heart compression fraction (HCF) in the Thai population by using contrast-enhanced computed tomography (CT) scan of the chest and a mathematical model. MATERIALS AND METHODS: Consecutive contrast-enhanced CT scans of the chest performed at Ramathibodi Hospital were retrospectively reviewed from January to March 2018 by two independent radiologists. Patients' characteristics, including gender, age, weight, height, and pre-existing diseases, were recorded, and the chest parameters were measured from a CT scan. The heart compression fraction (HCF) was subsequently calculated. RESULTS: Of 306 subjects, there were 139 (45.4%) males, 148 (47.4%) lung diseases and 10 (3.3%) heart diseases. Mean age and BMI were 60.4 years old and 23.8 kg/m2, respectively. Chest diameter, heart diameter, and non-cardiac soft tissue were significantly smaller in females compared to males. Mean (SD) HCF proportional with 50 mm and 60 mm depth were 38.3% (13.3%) and 50% (14.3%), respectively. There were significant differences of HCF proportional by 50 mm and 60 mm depth between men and women (33.2% vs 42.6% and 44% vs 54.9%, respectively (P<0.001)). In addition, a decrease in HCF was significantly observed among higher BMI groups. CONCLUSION: The CT scan and mathematical model showed that 38% and 50% HCF proportions were generated by 50 mm and 60 mm CC depth. HCF proportions were significantly different between genders and among BMI groups. The recommended depth of 5-6 cm is likely to provide sufficient CC depth in the population of Thailand.

Association between Mode of Transport and Patient Outcomes in the Emergency Department following Out-of-Hospital Cardiac Arrest: A Single-Center Retrospective Study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a health problem worldwide, carrying a high mortality rate. Comparison of emergency department (ED) return of spontaneous circulation (ROSC) after OHCA in relation to emergency medical services (EMS) and non-EMS modes of transportation to the hospital was conducted to assess the impact points of the EMS system in Thailand. METHODS: This retrospective observational study enrolled all OHCA patients who visited the ED of Ramathibodi Hospital, a tertiary university hospital in Bangkok, between January 1, 2008, and May 31, 2020. Patients were differentiated into EMS and non-EMS groups according to mode of transportation to the ED. Patients' characteristics and comorbidities, witnessed arrests, bystander chest compression, initial rhythm, and resuscitation treatment were documented. ED-sustained ROSC, ED survival, 30-day survival, and 30-day survival with good cerebral performance category (CPC) scores were monitored and recorded. Multivariate logistic analyses were performed to assess factors influencing clinical outcomes. RESULTS: A total of 339 patients were enrolled, 117 (34.51%) of whom were in the EMS transport group. There were no differences between the EMS and non-EMS groups in ED-sustained ROSC (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.58-1.70; P = 0.98), or ED survival (aOR, 0.99; 95% CI, 0.57-1.71; P = 0.97). There were also no differences in 30-day survival or 30-day survival with good CPC score between the two groups. CONCLUSIONS: In our cohort data of OHCA, ED-sustained ROSC and ED survival outcomes were not superior in the EMS transportation group. Evidence to show that EMS transportation affected 30-day survival and 30-day good CPC score was also lacking. Thus, public promotion of Thailand's EMS system is advocated with a simultaneous improvement of EMS response to enhance OHCA outcomes.

The Accuracy of Sepsis Screening Score for Mortality Prediction at Emergency Department Triage.

INTRODUCTION: Sepsis has a mortality rate of 10-40% worldwide. Many screening tools for sepsis prediction and for emergency department (ED) triage are controversial. This study compared the accuracy of the scores for predicting 28-day mortality in adult patients with sepsis in the triage area of the ED. METHODS: Adult patients who presented to the ED of a tertiary-care university hospital from January-December 2019 with an initial diagnosis of sepsis or other infection-related conditions were enrolled. We calculated predictive scores using information collected in the ED triage area. Prognostic accuracy was measured by the area under the receiver operating characteristic curve (AUROC) for predicting 28-day mortality as a primary outcome. The secondary outcomes included mechanical ventilation usage and vasopressor usage for 28 days. RESULTS: We analyzed a total of 550 patients. The 28-day mortality rate was 12.4% (n = 68). The 28-day mortality rate was best detected by the National Early Warning Score (NEWS) (AUROC = 0.770; 95% confidence interval [CI]: 0.705-0.835), followed by the quick Sequential Organ Failure Assessment (qSOFA) score (AUROC = 0.7473; 95% CI: 0.688-0.806), Search Out Severity (SOS) score (AUROC = 0.749; 95% CI: 0.685-0.815), Emergency Severity Index (ESI) triage (AUROC = 0.599; 95% CI: 0.542-0.656, and the Systemic Inflammatory Response System (SIRS) criteria (AUROC = 0.588; 95% CI: 0.522-0.654]). The NEWS also provided a higher AUROC and outperformed for 28-day mechanical ventilator usage and 28-day vasopressor usage. CONCLUSION: The NEWS outperforms qSOFA, SOS, SIRS, and ESI triage in predicting 28-day mortality, mechanical ventilator, and vasopressor usage of a patient with sepsis who is seen at ED triage.

Characteristics and outcomes of out-of-hospital cardiac arrest patients before and during the COVID-19 pandemic in Thailand.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains one of the leading causes of death worldwide, and bystander CPR with public-access defibrillation improves OHCA survival outcomes. The COVID-19 pandemic has posed many challenges for emergency medical services (EMS), including the suggestion of compression-only resuscitation and recommendations for complete personal protective equipment, which have created operational difficulties and prolonged response time. However, the risk factors affecting OHCA outcomes during the pandemic are poorly defined. This study aimed to assess the characteristics and outcomes of OHCA patients before and during the COVID-19 pandemic in Thailand. METHODS: This single-center, retrospective cohort study used data from electronic medical records and EMS paper records. All OHCA patients who visited Ramathibodi Hospital's emergency department before COVID-19 (March 2018 to December 2019) and during COVID-19 (March 2020-December 2021) were identified, and the number of emergency department returns of spontaneous circulation (ED-ROSC) and characteristics in OHCA patients before and during the COVID-19 pandemic in Thailand were collected. RESULTS: A total of 136 patients were included (78 men [59.1%]; mean [SD] age, 67.9 [18] years); 60 of these were during the COVID-19 period (beginning March 2020), and 76 were before the COVID-19 period. The overall baseline characteristics that differed significantly between the two groups were bystander witness and mode of chest compression (p-values < 0.001 and < 0.001, respectively). The ED ROSC during the COVID-19 period was significantly lower than before the COVID-19 period (26.67% vs. 46.05%, adjusted OR 0.21, p-value < 0.001). There were significant differences in survival to admission between the COVID-19 period and before (25.00% and 40.79%, adjusted OR 0.26, p-value 0.005). However, 30-day survivals were not significantly different (3.3% during the COVID-19 period and 10.53% before the COVID-19 period). CONCLUSIONS: During the COVID-19 pandemic in Thailand, ED ROSC and survival to admission in out-of-hospital cardiac arrest patients were significantly reduced. Additionally, the witness responses and mode of chest compression were very different between the two groups. TRIAL REGISTRATION: This trial was retrospectively registered on 7 December 2021 in the Thai Clinical Trial Registry, identification number TCTR20211207006.

The Ramathibodi early warning score as a sepsis screening tool does not reduce the timing of antibiotic administration.

BACKGROUND: Administration of antibiotics to septic patients within 1 h was recommended in 2018 by the Surviving Sepsis Campaign (SSC) as a strategy to improve survival outcomes. The use of sepsis screening tools in emergency departments (EDs) is important for early diagnosis and initiation of sepsis care. This study aimed to assess the impact of the Ramathibodi early warning score (REWs) on the administration of antibiotics within 1 h of presentation. METHODS: This was an observational retrospective cohort study with propensity score matching between the sepsis-3 criteria (pre-period) and the REWs (post-period) as screening tools in adult patients with sepsis in EDs. The primary outcome was the proportion of receiving antibiotics within 1 h of presentation in the pre- and post-periods. RESULTS: A total of 476 patients were analyzed without propensity matching. The proportion of antibiotic administration within 1 h was higher in patients screened using the REWs compared with standard of care in the total study population (79.5% vs. 61.4%, p < 0.001). After propensity score matching, 153 patients were included in both groups. The proportion of antibiotic administration within 1 h was similar in patients screened using the REWs and those receiving standard of care (79.7% vs. 80.4%, p = 0.886). However, time to intensive care unit (ICU) admission was faster in patients screened using the REWs. Delays in receiving antibiotics of longer than 3 h were associated with increased mortality (adjusted hazard ratio 7.04, 95% confidence interval 1.45 to 34.11, p = 0.015). CONCLUSIONS: Implementing the REWs as a tool in sepsis screening protocols in EDs did not improve rates of antibiotic administration within 1 h as recommended by the SSC. However, time to ICU admission was improved after implementation of the REWs.

Effect of appropriate dose, spectrum, and timing of antibiotics on 28-day mortality in patients with sepsis in the emergency department.

BACKGROUND: Appropriate antibiotics prescribing is key to treatment and to preventing mortality in patients with sepsis. The aim of this study was to determine the effect of the appropriate timing, spectrum, and dose of antibiotics on 28-day mortality in patients with sepsis. METHODS: We performed a retrospective cohort observational study. We enrolled patients with sepsis in the emergency department of a tertiary care hospital between 1 March and 31 July 2019. Patients were coded into an appropriate antibiotics group (time, spectrum, dose) and an inappropriate antibiotics group. We collected information of patient characteristics, comorbidities, vital signs, laboratory test results, and initial treatment. We followed patient outcomes, 28-day mortality, hospital deaths, 28-day ventilator-free days, and 28-day hospital-free days. RESULTS: A total of 593 patients were enrolled, with 323 (54.46%) in the appropriate antibiotics group. We used multivariate logistic analyses to assess factors for mortality. Primary outcomes of appropriate antibiotics (administration within 60 min of triage, appropriate spectrum and dose) did not affect 28-day mortality (adjusted odds ratio [OR], 0.57; 95% confidence interval [CI] 0.22-1.144; P=0.23). Subgroup analysis showed that appropriate spectrum alone influenced 28-day mortality (adjusted OR, 0.38; 95% CI, 0.15-0.99; P=0.047). Appropriate antibiotics was not associated with in-hospital mortality (adjusted OR, 0.62; 95% CI, 0.29-1.30; P=0.21). CONCLUSION: Appropriate antibiotics included timing less than 60 min, spectrum and the dose was not significantly affected in 28-day mortality in emergency sepsis patients. TRIAL REGISTRATION: The trial was retrospectively registered in the Thai Clinical Trial Registry, identification number TCTR20211216003 .

The 28-Day Mortality Outcome of the Complete Hour-1 Sepsis Bundle in the Emergency Department.

INTRODUCTION: The Surviving Sepsis Campaign published the Hour-1 Sepsis Bundle in 2018. The first-hour management of patients with sepsis in the emergency department (ED) is important, as suggested in the Hour-1 Sepsis Bundle. The objectives of the present study were to evaluate 28-day mortality and delayed septic shock with use of a complete and incomplete Hour-1 Sepsis Bundle in the ED. METHODS: This prospective cohort study included adult patients with sepsis from March to July 2019. We followed the sepsis protocol used in the ED of a tertiary care hospital. RESULTS: We enrolled 593 patients, with 55.9% in the complete Hour-1 Sepsis Bundle group. The 28-day mortality was 3.9% overall and no significant difference between the complete and incomplete Hour-1 Sepsis Bundle groups (3.6% vs. 4.2%, P = 0.707). Complete Hour-1 Sepsis Bundle treatment was not associated with 28-day mortality (adjusted OR = 2.04, 95% confidence interval [CI] = 0.72-5.74, P = 0.176) or delayed septic shock (adjusted OR = 0.74, 95% CI = 0.30-1.78, P = 0.499). Completion of each bundle did not affect outcomes of 28-day mortality and delayed septic shock. CONCLUSIONS: The complete Hour-1 Sepsis Bundle treatment in the ED was not significantly associated with 28-day mortality and delayed septic shock. TRIAL REGISTRATION: The trial was registered in the Thai Clinical Trial Registry, TCTR 20200526013.

Direct Versus Video Laryngoscopy in Emergency Intubation: A Randomized Control Trial Study.

OBJECTIVE: To compare the intubation success rate of the first attempt between Video Laryngoscopy (VDL) and Direct Laryngoscopy (DL) in the emergency department (ED). METHODS: This is a study of a randomized control trial includes the patients with acute respiratory failure and the emergency physician who intended to perform intubation in the ED from July 2015 to June 2016. We were selected the patients randomly by the sequentially numbered opaque sealed envelopes technique and were assigned to undergo the first attempt of either VDL (n=78) or DL (n=80). We collected the data information regarding the demographic characteristics, predictors of difficult intubation, rapid sequence intubation, attempt, Cormack-Lehane view, and immediate complications. RESULTS: The success of VDL in the first attempt was 73.1%, which were tended to be better than DL (58.8%) (p=0.060). Glottis view (Cormack-Lehane view 1-2) of VDL was significantly better (88.5%) than of DL (72.5%) (p=0.010). The immediate complications were not different. CONCLUSIONS: VDL showed a trend of better success than DL. VDL can increase the first-attempt intubation success and provide a better glottis view in emergency intubation. TRIAL REGISTRATION: The trial was registered in the Thai Clinical Trial Registry, identifier TCTR 20200503003. Registered 16 June 2020, 'Retrospectively registered', http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=6186.

Prognostic Accuracy of VqSOFA for Predicting 28-day Mortality in Patients with Suspected Sepsis in the Emergency Department.

BACKGROUND: Sepsis screening in the emergency department (ED) is challenging. The quick Sequential Organ Failure Assessment (qSOFA) score had poor accuracy for predicting mortality in both the intensive care unit and ED. High lactate levels were associated with an increased mortality. However, a previous study using lactate levels in combination with the qSOFA score did not observe a meaningful improvement in predictive accuracy. This study assessed the prognostic accuracy of venous lactate levels plus the qSOFA (VqSOFA) score for predicting 28-day mortality. METHODS: Patients who visited the Ramathibodi ED with suspected sepsis were enrolled. The VqSOFA, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores were calculated using the initial vital signs and laboratory values. Prognostic accuracy was measured using the area under the receiver operating characteristic (AUROC) curve of the VqSOFA score and Sepsis-3 criteria for predicting 28-day mortality. RESULTS: In total, 1,139 patients were enrolled, 118 of whom died within 28 days of admission. The AUROCs of the VqSOFA, qSOFA, and SOFA scores were 0.851 (95% CI 0.813-0.889), 0.813 (95% CI 0.772-0.854), and 0.728 (95% CI 0.671-0.784), respectively. Using VqSOFA score ≥ 3 as the cutoff, the sensitivity, specificity, and positive likelihood ratio were 74.6%, 82.5%, and 4.25%, respectively. VqSOFA ≥ 3 was linked to a low probability of 28-day survival and higher odds of vasopressor and ventilator use within 24 h. CONCLUSIONS: VqSOFA was more predictive of 28-day mortality and vasopressor and mechanical ventilator use than the qSOFA and SOFA scores.

Risk factors for non-invasive ventilation failure in influenza infection with acute respiratory failure in emergency department.

OBJECTIVE: Non-invasive ventilation (NIV) has been widely used in hypoxemic acute respiratory failure (ARF) due to influenza pneumonia in the emergency department (ED). However, NIV used in influenza-associated acute respiratory failure had a variable rate of failure. Previous studies have reported that prolonged use of NIV was associated with increased mortality. Our study aimed to identify risk factors for NIV failure in influenza infection with acute respiratory failure in ED. METHOD: We performed a retrospective cohort observational study. Enrolled patients were older than 18 years who used NIV due to influenza infection with ARF between 1 January 2017 to 31 December 2018 in Ramathibodi Emergency Department. Patients characteristics, comorbidity, clinical, laboratory outcome, chest imaging, initial NIV setting, and parameters were collected in ED setting. Sequential organ failure assessment (SOFA) score and PaO2/FiO2 (PF) ratio were calculated from the first arterial blood gas in ED. We followed the outcome success or failure of the NIV used. RESULTS: A total of 162 patients were enrolled and 72 (44%) suffered NIV failure in influenza infection with ARF. We used univariate and multivariate logistic analyses to assess risk factors for NIV failure. The ability of risk factor to predict NIV failure was analyzed using the area under the receiver operating characteristic (AUROC). Risk factors of NIV failure included SOFA score (P = 0.001), PF ratio (P = 0.001) and quadrant infiltrations in chest x-rays (CXR) (P = 0.001). SOFA score, PF ratio, and number quadrant infiltrations in chest radiography have good ability to predict NIV failure, AUROC 0.894 (95%CI 0.839-0.948), 0.828 (95%CI 0.764-0.892), and 0.792 (95%CI 0.721-0.863), respectively and no significant difference in the ability to predict NIV failure among three parameters. The use of PF ratio plus number quadrant infiltrations in chest radiography demonstrated a higher predictive ability for NIV failure in influenza infection with ARF. CONCLUSIONS: SOFA score, PF ratio, and quadrant infiltrations in chest radiography were good predictors of NIV failure in influenza infection with ARF.

Effects of thiamine on vasopressor requirements in patients with septic shock: a prospective randomized controlled trial.

BACKGROUND: Thiamine, an essential vitamin for aerobic metabolism and glutathione cycling, may decrease the effects of critical illnesses. The objective of this study was to determine whether intravenous thiamine administration can reduce vasopressor requirements in patients with septic shock. METHODS: This study was a prospective randomized double-blind placebo-controlled trial. We included adult patients with septic shock who required a vasopressor within 1-24 h after admission between March 2018 and January 2019 at a tertiary hospital in Thailand. Patients were divided into two groups: those who received 200 mg thiamine or those receiving a placebo every 12 h for 7 days or until hospital discharge. The primary outcome was the number of vasopressor-free days over 7 days. The pre-defined sample size was 31 patients per group, and the study was terminated early due to difficult recruitment. RESULTS: Sixty-two patients were screened and 50 patients were finally enrolled in the study, 25 in each group. There was no difference in the primary outcome of vasopressor-free days within the 7-day period between the thiamine and placebo groups (mean: 4.9 days (1.9) vs. 4.0 days (2.7), p = 0.197, mean difference - 0.9, 95% CI (- 2.9 to 0.5)). However, the reductions in lactate (p = 0.024) and in the vasopressor dependency index (p = 0.02) at 24 h were greater among subjects who received thiamine repletion vs. the placebo. No statistically significant difference was observed in SOFA scores within 7 days, vasopressor dependency index within 4 days and 7 days, or 28-day mortality. CONCLUSIONS: Thiamine was not associated to a significant reduction in vasopressor-free days over 7-days in comparison to placebo in patients with septic shock. Administration of thiamine could be associated with a reduction in vasopressor dependency index and lactate level within 24 h. The study is limited by early stopping and low sample size. TRIAL REGISTRATION: TCTR, TCTR20180310001. Registered 8 March 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3330 .

Clinical outcomes of empirical high-dose meropenem in critically ill patients with sepsis and septic shock: a randomized controlled trial.

BACKGROUND: Appropriate antimicrobial dosing is challenging because of changes in pharmacokinetics (PK) parameters and an increase in multidrug-resistant (MDR) organisms in critically ill patients. This study aimed to evaluate the effects of an empirical therapy of high-dose versus standard-dose meropenem in sepsis and septic shock patients. METHODS: We performed a prospective randomized open-label study to compare the changes of modified sequential organ failure assessment (mSOFA) score and other clinical outcomes of the high-dose meropenem (2-g infusion over 3 h every 8 h) versus the standard-dose meropenem (1-g infusion over 3 h every 8 h) in sepsis and septic shock patients. Patients' characteristics, clinical and microbiological outcomes, 14 and 28-day mortality, vasopressor- and ventilator-free days, intensive care unit (ICU) and hospital-free days, percent of the time of antibiotic concentrations above the minimum inhibitory concentration (%T>MIC), and safety were assessed. RESULTS: Seventy-eight patients were enrolled. Median delta mSOFA was comparable between two groups (- 1 in the high-dose group vs. - 1 in the standard-dose group; P value = 0.75). There was no difference between the two groups regarding clinical and microbiological cure, 14- and 28-day mortality, vasopressor- and ventilator-free days, and ICU- and hospital-free days. In patients admitted from the emergency department (ED) with a mSOFA score ≥ 7, the high-dose group demonstrated significantly better microbiological cure compared with the standard-dose group (75% (9/12 patients) vs. 20% (2/10 patients); P value = 0.03). Likewise, the high-dose group presented higher microbiological cure rate in patients admitted from ED who had either APACHE II score > 20 (83.3% (10/12) vs. 28.6% (2/7); P value = 0.045) or on mechanical ventilator (87.5% (7/8) vs. 23.1% (3/13); P value = 0.008) than the standard-dose group. Adverse events were comparable between the two groups. CONCLUSIONS: Empirical therapy with the high-dose meropenem presented comparable clinical outcomes to the standard-dose meropenem in sepsis and septic shock patients. Besides, subgroup analysis manifested superior microbiological cure rate in sepsis or septic shock patients admitted from ED. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03344627, registered on November 17, 2017.