Prognostic evaluation of quick sequential organ failure assessment score in ICU patients with sepsis across different income settings.

BACKGROUND: There is conflicting evidence on association between quick sequential organ failure assessment (qSOFA) and sepsis mortality in ICU patients. The primary aim of this study was to determine the association between qSOFA and 28-day mortality in ICU patients admitted for sepsis. Association of qSOFA with early (3-day), medium (28-day), late (90-day) mortality was assessed in low and lower middle income (LLMIC), upper middle income (UMIC) and high income (HIC) countries/regions. METHODS: This was a secondary analysis of the MOSAICS II study, an international prospective observational study on sepsis epidemiology in Asian ICUs. Associations between qSOFA at ICU admission and mortality were separately assessed in LLMIC, UMIC and HIC countries/regions. Modified Poisson regression was used to determine the adjusted relative risk (RR) of qSOFA score on mortality at 28 days with adjustments for confounders identified in the MOSAICS II study. RESULTS: Among the MOSAICS II study cohort of 4980 patients, 4826 patients from 343 ICUs and 22 countries were included in this secondary analysis. Higher qSOFA was associated with increasing 28-day mortality, but this was only observed in LLMIC (p < 0.001) and UMIC (p < 0.001) and not HIC (p = 0.220) countries/regions. Similarly, higher 90-day mortality was associated with increased qSOFA in LLMIC (p < 0.001) and UMIC (p < 0.001) only. In contrast, higher 3-day mortality with increasing qSOFA score was observed across all income countries/regions (p < 0.001). Multivariate analysis showed that qSOFA remained associated with 28-day mortality (adjusted RR 1.09 (1.00-1.18), p = 0.038) even after adjustments for covariates including APACHE II, SOFA, income country/region and administration of antibiotics within 3 h. CONCLUSIONS: qSOFA was independently associated with 28-day mortality in ICU patients admitted for sepsis. In LLMIC and UMIC countries/regions, qSOFA was associated with early to late mortality but only early mortality in HIC countries/regions.

Mechanical ventilation practices in Asian intensive care units: A multicenter cross-sectional study.

PURPOSE: This study investigated current practices of mechanical ventilation in Asian intensive care units, focusing on tidal volume, plateau pressure, and positive end-expiratory pressure (PEEP). MATERIALS AND METHODS: In this multicenter cross-sectional study, data on mechanical ventilation and clinical outcomes were collected. Predictors of mortality were analyzed by univariate and multivariable logistic regression. A scoring system was generated to predict 28-day mortality. RESULTS: A total of 1408 patients were enrolled. In 138 patients with acute respiratory distress syndrome (ARDS), 65.9% were on a tidal volume ≤ 8 ml/kg predicted body weight (PBW), and 71.3% were on sufficient PEEP. In 1270 patients without ARDS, 88.8% were on a tidal volume ≤ 10 ml/kg PBW. A plateau pressure < 30 cmH2O was measured in 92.2% of patients. Mortality rates increased from 13% to 74% as the generated predictive score increased from 5 to ≥8.5. Income classification, age, SOFA score, PaO2/FiO2 ratio, plateau pressure, number of vasopressors, and steroid use were associated with mortality. CONCLUSIONS: In Asia, low tidal volume ventilation and sufficient PEEP were underused in patients with ARDS. The majority of patients without ARDS were on intermediate tidal volumes. Country income, age, and severity of illness were associated with mortality.

Epidemiology, Management, and Outcomes of Sepsis in ICUs among Countries of Differing National Wealth across Asia.

Rationale: Directly comparative data on sepsis epidemiology and sepsis bundle implementation in countries of differing national wealth remain sparse. Objectives: To evaluate across countries/regions of differing income status in Asia 1) the prevalence, causes, and outcomes of sepsis as a reason for ICU admission and 2) sepsis bundle (antibiotic administration, blood culture, and lactate measurement) compliance and its association with hospital mortality. Methods: A prospective point prevalence study was conducted among 386 adult ICUs from 22 Asian countries/regions. Adult ICU participants admitted for sepsis on four separate days (representing the seasons of 2019) were recruited. Measurements and Main Results: The overall prevalence of sepsis in ICUs was 22.4% (20.9%, 24.5%, and 21.3% in low-income countries/regions [LICs]/lower middle-income countries/regions [LMICs], upper middle-income countries/regions, and high-income countries/regions [HICs], respectively; P < 0.001). Patients were younger and had lower severity of illness in LICs/LMICs. Hospital mortality was 32.6% and marginally significantly higher in LICs/LMICs than HICs on multivariable generalized mixed model analysis (adjusted odds ratio, 1.84; 95% confidence interval, 1.00-3.37; P = 0.049). Sepsis bundle compliance was 21.5% at 1 hour (26.0%, 22.1%, and 16.2% in LICs/LMICs, upper middle-income countries/regions, and HICs, respectively; P < 0.001) and 36.6% at 3 hours (39.3%, 32.8%, and 38.5%, respectively; P = 0.001). Delaying antibiotic administration beyond 3 hours was the only element independently associated with increased mortality (adjusted odds ratio, 2.53; 95% confidence interval, 2.07-3.08; P < 0.001). Conclusions: Sepsis is a common cause of admission to Asian ICUs. Mortality remains high and is higher in LICs/LMICs after controlling for confounders. Sepsis bundle compliance remains low. Delaying antibiotic administration beyond 3 hours from diagnosis is associated with increased mortality. Clinical trial registered with www.ctri.nic.in (CTRI/2019/01/016898).

The story of critical care in Asia: a narrative review.

BACKGROUND: Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia. MAIN BODY: Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty. CONCLUSIONS: Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries.

Mechanical Ventilation Discontinuation Practices in Asia: A Multinational Survey.

Rationale: There are limited data on mechanical discontinuation practices in Asia. Objectives: To document self-reported mechanical discontinuation practices and determine whether there is clinical equipoise regarding protocolized weaning among Asian Intensive Care specialists. Methods: A survey using a validated questionnaire, distributed using a snowball method to Asian Intensive Care specialists. Results: Of the 2,967 invited specialists from 20 territories, 2,074 (69.9%) took part. The majority of respondents (60.5%) were from China. Of the respondents, 42% worked in intensive care units (ICUs) where respiratory therapists were present; 78.9% used a spontaneous breathing trial as the initial weaning step; 44.3% frequently/always used pressure support (PS) alone, 53.4% intermittent spontaneous breathing trials with PS in between, and 19.8% synchronized intermittent mandatory ventilation with PS as a weaning mode. Of the respondents, 56.3% routinely stopped feeds before extubation, 71.5% generally followed a sedation protocol or guideline, and 61.8% worked in an ICU with a weaning protocol. Of these, 78.2% frequently always followed the protocol. A multivariate analysis involving a modified Poisson regression analysis showed that working in an ICU with a weaning protocol and frequently/always following it was positively associated with an upper-middle-income territory, a university-affiliated hospital, or in an ICU that employed respiratory therapists; and negatively with a low-income or lower-middle-income territory or a public hospital. There was no significant association with "in-house" intensivist at night, multidisciplinary ICU, closed ICU, or nurse-patient ratio. There was heterogeneity in agreement/disagreement with the statement, "evidence clearly supports protocolized weaning over nonprotocolized weaning." Conclusions: A substantial minority of Asian Intensive Care specialists do not wean patients in accordance with the best available evidence or current guidelines. There is clinical equipoise regarding the benefit of protocolized weaning.

Critical Care Bed Capacity in Asian Countries and Regions.

OBJECTIVE: To assess the number of adult critical care beds in Asian countries and regions in relation to population size. DESIGN: Cross-sectional observational study. SETTING: Twenty-three Asian countries and regions, covering 92.1% of the continent's population. PARTICIPANTS: Ten low-income and lower-middle-income economies, five upper-middle-income economies, and eight high-income economies according to the World Bank classification. INTERVENTIONS: Data closest to 2017 on critical care beds, including ICU and intermediate care unit beds, were obtained through multiple means, including government sources, national critical care societies, colleges, or registries, personal contacts, and extrapolation of data. MEASUREMENTS AND MAIN RESULTS: Cumulatively, there were 3.6 critical care beds per 100,000 population. The median number of critical care beds per 100,000 population per country and region was significantly lower in low- and lower-middle-income economies (2.3; interquartile range, 1.4-2.7) than in upper-middle-income economies (4.6; interquartile range, 3.5-15.9) and high-income economies (12.3; interquartile range, 8.1-20.8) (p = 0.001), with a large variation even across countries and regions of the same World Bank income classification. This number was independently predicted by the World Bank income classification on multivariable analysis, and significantly correlated with the number of acute hospital beds per 100,000 population (r = 0.19; p = 0.047), the universal health coverage service coverage index (r = 0.35; p = 0.003), and the Human Development Index (r = 0.40; p = 0.001) on univariable analysis. CONCLUSIONS: Critical care bed capacity varies widely across Asia and is significantly lower in low- and lower-middle-income than in upper-middle-income and high-income countries and regions.

Long-term outcomes and predictors of survival after cardiopulmonary resuscitation for in-hospital cardiac arrest in a tertiary care hospital in Thailand.

BACKGROUND: There are limited data available regarding long-term survival and its predictors in cases of in-hospital cardiac arrest (IHCA) in which patients receive cardiopulmonary resuscitation. PURPOSE: The objectives of this study were to determine the 1-year survival rates and predictors of survival after IHCA. PATIENTS AND METHODS: Data were retrospectively collected on all adult patients who were administered cardiopulmonary resuscitation from January 1, 2013 to December 31, 2014 in Srinagarind Hospital (Thailand). Clinical outcomes of interest and survival at discharge and 1 year after hospitalization were reviewed. Descriptive statistics and survival analysis were used to analyze the outcomes. RESULTS: Of the 202 patients that were included, 48 (23.76%) were still alive at hospital discharge and 17 (about 8%) were still alive at 1 year post cardiac arrests. The 1-year survival rate for the cardiac arrest survivors post hospital discharge was 72.9%. Prearrest serum HCO3<20 meq/L, asystole, urine <800 cc/d, postarrest coma, and absence of pupillary reflex were predictors of death. CONCLUSION: Only 7.9% of patients with IHCA were alive 1 year following cardiac arrest. Prearrest serum HCO3<20 meq/L, asystole, urine <800 cc/d, postarrest coma, and absence of pupillary reflex were the independent factors that predicted long-term mortality.

Need for Internal Medicine Subspecialists in Thailand.

Background: Matching supply side of the Internal Medicine (IM) subspecialists to the demand for complex medical care at referral medical centers would lead to more efficient health system management and ultimately optimal clinical outcome. The second decade of the universal health coverage policy in Thailand has raised the awareness on how to reach equitable utilization goals of good quality medical services, while barriers of accession have been removed. More accurate evidence-based human resource planning is timely needed. Objective: To estimate the number of the ten subspecialists in internal medicine (neurologist, cardiologist, endocrinologist, gastroenterologist and hepatologist, nephrologist, hematologist, oncologist, rheumatologist, pulmonologist, and infectious disease specialist) needed for complex medical care based on the workload in the year 2013. Material and Method: The present study applied a needs assessment model with evidence-based approach. Claimed data of inpatients in the year 2013 from the three government insurance schemes (the Civil Servant Medical Benefit, the Social Security and the Universal Health Coverage schemes), and out-patient data from Universal Coverage System were used to estimate demand for subspecialists. The Human Resource Working Group of the Royal College of Physicians of Thailand agreed on the conceptual framework to estimate the need for ten subspecialists based on clinical activities of outpatient consultations, inpatient ward rounds and non-operating room procedures on medical cases of respective diagnosis related group with severe and catastrophic comorbidities and complications by the Thai-DRG version 5. Representatives from the Associations of IM subspecialties approved the lists of ICD-10 diagnosis and ICD-9-CM procedure codes specific to each subspecialist care and proposed assumptions on rates of consultations from other specialists. Surveys were done to subspecialists in 6 major provincial clusters and representatives from IM subspecialty Associations asking time spent on main activities of patient care. The number of full-time-equivalent (FTE) subspecialists needed was calculated by multiplying the clinical workloads measured in minutes spent for each activity (ward round, ward work, inpatient and outpatient consultations) to get the total time needed, then divided by the available time for clinical activity of one subspecialist. Results: From 5.9 million inpatient discharges in the year 2013, primary responsibility of patients in respective severe and catastrophic DRGs related to specific subspecialist workloads were summed up for teaching hospitals and regional hospitals ranging from as lowest the 2,849 cases for rheumatology to the highest 24,610 cases for gastroenterology and hepatology. The number of inpatient non-operating room procedures by ICD-9-CM as listed by IM subspecialty Associations ranged from 8 times for endocrinologists to 22,927 times for cardiologists for the whole year. Of ten subspecialists, the estimated numbers of cardiologist, nephrologist, neurologist, gastroenterologist and hepatologist, endocrinologist, oncologist, rheumatologist, hematologist, pulmonologist and infectious disease subspecialist needed at teaching and regional hospitals were 516, 241; 345, 144; 312, 143; 195, 124; 189, 45; 137, 170; 90, 47; 96, 111; 203, 87 and; 129, 44 respectively according to the workload recorded in the year 2013. The forecast FTE found the overall gap of discrepancy at 7 percent. If the distributions of these subspecialists in public and private hospitals were taken into account, the gap of discrepancy in public hospitals increased to 47 percent. Conclusion: The demand-based forecast for the number of subspecialist needed was made possible with assumptions on conceptual framework for case selection, the rates of consultation and time-spent related to activities of patient care. The estimated numbers of subspecialists were anticipated far from optimum since the workload in the year 2013 was derived as a consequence of pre-existing suboptimal infrastructure of healthcare system. In addition, the deficit of subspecialists may increase in the near future when highly efficient, non- or mildly invasive, time-consuming procedures of acute illness increase. Sustainable matching demand and supply of human resource for health needed further validations of these assumptions.

Thai-shock survey 2013: survey of shock management in Thailand.

OBJECTIVE: Pragmatic surveys for shock management by Thai physicians are unavailable. The objective of this study is to identify the shock management patterns on both; the incidence of septic shock and hemorrhagic shock here in Thailand. MATERIAL AND METHOD: Two thousand questionnaires were sent to physicians who are called on to care for patients in shock across Thailand. The questionnaire is composed of 58 items regarding all aspects of the management of septic and hemorrhagic shock. A frequency scale has been defined by 5 levels of patient proportion estimates from routine practices. RESULTS: Between April and August, 2013, 533 of the distributed questionnaires (26.7%) were returned. In severe sepsis and septic shock management, 406 physicians (76.2%) have reported the routine use of the quantitative resuscitation protocols. Urine output, mean arterial pressures and central venous pressures have been more frequently used than central venous oxygen saturation and lactate levels for the resuscitation goals. Nearly 80% of these clinicians have shown "often and always" for the achievement of the resuscitation goals within 6 hours. Most of the physicians (65.3%) had never used procalcitonin biomarkers. Antimicrobial empirical treatments were started within 1 hour of admission for 87.7% of these patients and were continued for less than 5 days in 67.3% of the cases prior to de-escalating the treatments. Crystalloids have been the common, initial fluid used for resuscitation (98.9% in sepsis, 99.3% in trauma). The most commonly used vasopressors are norepinephrine (69.6%) for sepsis and dopamine (63.1%) for trauma. The median of the cortisol threshold level for steroid replacement therapy is 15 mg/dL, taken from the interquartile range or IQR of 5-19 mg/dL. Nearly all the physicians currently use hydrocortisone (96.4%). The median daily dose of hydrocortisone is 300 mg (IQR; 200-300). Approximately 50% of the physicians prescribed the hydrocortisone in divided doses to be administered every 8 hours and 31.8% ordered the medications as a continuous infusion. Tapering the dose in reduction varied by 33.6% ofthe physicians over a period of 2 to 3 days. Central venouspressures (CVP) and fluid challenge tests were more frequently used in the evaluation ofpreload rather than some of the newer fluid responsiveness methods. Less than 15% of the physicians continued to use pulmonary artery catheters in their routine practices. Regarding hemorrhagic and traumatic shock, only 162 physicians (39.3%) have been certified in Advance Traumatic Life Support (ATLS), but 311 physicians (75.6%) have reported in following with the ATLSguidelines. In patients requiring massive transfusions, physicians used packed red cells (PRC) and fresh frozen plasma (FFP) in a ratio of 1:1 (34.1%). Focus assessment sonography for trauma (FAST) was the most commonly used diagnostic method in cases of traumatic shock. CONCLUSION: Most physicians manage shock with the current protocols. Hemodynamic goals are preferred over tissue perfusion targets. Early antimicrobial therapy and de-escalation are routinely practiced without the use of infective biomarkers. Crystalloids are preferred over colloids for the initial resuscitation. CVPs and fluid challenges are still preferred over the new fluid responsiveness methods for preload assessment. Hydrocortisone is the most common steroid prescribed for septic shock but the threshold of initiation, frequency of use and methods of discontinuation vary.

A critical look at critical care medicine in thailand critical care services and critical care workforce: the current situation and a future perspective.

Critical care medicine, one of the newest medical specialties in Thailand, has had most of its evolution in the past 25 years. There have been many advances and critical care services in major regional hospitals and currently, most university medical centers have become state of the art. Critical care fellowship training; a subspecialty certification of the primary board of internal medicine, anesthesiology, and surgery; has been in place for approximately 14 years. Despite the fact that TSCCM is one of the most active societies in education and training, the number of qualified intensivists in Thailand is still much less than is necessary. In addition, critical care nurses and other related professionals necessary for the ICUs' clinical team falls short in delivering acceptable, high quality, critical care services. In the very near future, Thailand's population will become an increasingly aged society. The movement toward one ASEAN community has prompted government policies to encourage Thailand to become the Medical Hub of Asia as well as a world-class destination for healthcare. Thus, the demand for critical care services will increase disproportionally when compared to the training capacity and its popularity as a specialty to new medical graduates. A critical look at critical care medicine by policymakers and the medical community is a blueprint for preparing and optimizing the critical care workforce regarding future planning and the development of future policies.

Missed appointments at a tuberculosis clinic increased the risk of clinical treatment failure.

We investigated the charts of 381 new smear-positive tuberculosis patients at Khon Kaen Medical School during 1997-2001 using World Health Organization definitions to evaluate associations among treatment success or failure (defaulted, failed, died, or not evaluated) and tuberculosis clinic contact, demographics and clinical characteristics of the patients. Multinomial logistic regression was used for three-category outcome analysis: treatment success, transferred-out and clinical treatment failure. The treatment success and clinical treatment failure rates were 34.1% and 34.4%, respectively. About 46.5% and 85.8% of patients missed appointments at the tuberculosis clinic in the treatment success and treatment failure groups, respectively. The results show that patients who were absent from the tuberculosis clinic were 5.95 times more likely to have clinical treatment failure than treatment success, having adjusted for the effect of transfering-out and the effect of the treatment regimen and the sputum conversion status (adjusted odds ratio = 5.95; 95% CI: 2.99 to 11.84). The review showed that absence from the tuberculosis clinic was an independent risk factor for clinical treatment failure. We recommended that all new smear-positive tuberculosis patients should be followed closely at a tuberculosis clinic.

Diagnostic yield of adenosine deaminase in bronchoalveolar lavage.

Adenosine deaminase (ADA) activity rises in various body fluids in patients with tuberculosis. A prospective study was conducted to determine the diagnostic value of ADA activity in bronchoalveolar lavage. Between March 2001 and February 2003, 148 patients were enrolled in our study, mean age 55.6 years (SD 14.6), and a male to female ratio of 2.4:1. The mean duration of symptoms was 66.2 days. All patients were either sputum-smear negative for AFB or failed to produce sputum. The final diagnosis resulted in three patient groups: 43 with pulmonary tuberculosis, 70 malignancy, and 35 miscellaneous causes. The mean ADA activity in the bronchoalveolar lavage for the pulmonary tuberculosis, malignancy, and miscellaneous causes groups was 8.98 (95% CI, 3.79-14.17), 7.63 (95% CI, 4.12-11.14), and 11.61 U/l (95% CI, 3.59-19.62), respectively. No difference was detected in the ADA level in the pulmonary tuberculosis vs other groups (p=0.56, one-way ANOVA). A high level of ADA activity was found in non-tuberculous conditions such as bronchogenic carcinoma, pulmonary hemosiderosis, chronic pneumonia with empyema thoracis and chronic myeloid leukemia. We concluded that ADA activity in the bronchoalveolar lavage was not clearly diagnostic of smear-negative pulmonary tuberculosis. Early diagnosis required histopathology of biopsied transbronchial specimens obtained by fiberoptic bronchoscopy.