Incidence of proximal deep vein thrombosis in medical critical care patients.

BACKGROUND: Approximately 13-31% of medical critical care patients develop deep vein thrombosis (DVT). However, there are very few reports regarding the incidence of DVT among Asian patients without routine prophylaxis. The objectives of this study were to assess the prevalence and incidence proportion of proximal DVT in Thai medical critical care patients not receiving thrombosis prophylaxis. METHODS: We conducted a prospective cohort study in medical critical care patients admitted to Siriraj Hospital, Thailand between November 2008 and November 2009. Patients were screened for proximal DVT by duplex ultrasonography performed 48 h, 7, 14 and 28 days after admission. Primary outcomes were prevalence and incidence proportion of DVT. Factors associated with the development of proximal DVT were evaluated by multivariate analysis. RESULTS: Of the 158 patients enrolled in the study, 25 had proximal DVT (15.8%). Nine patients (5.7%) had DVT on the first test at 48 h, while 10 (6.3%), 2 (1.3%) and 4 (2.5%) patients had developed DVT on days 7, 14, and 28, respectively. Thus, the prevalence at the beginning of the study was 5.7% (95%CI 2.6-10.5) and the incidence proportion was 10.1% (95%CI 5.9-15.9). The multivariate analysis showed that age (odds ratio [OR] per 1-year increase was 1.04, 95% confidence interval [CI] 1.01-1.07), female gender (OR 4.05, 95%CI 1.51-12.03), femoral venous catheter (OR 11.18, 95%CI 3.19-44.83), and the absence of platelet transfusion (OR 0.07, 95%CI 0.003-0.43) were associated with the development of proximal DVT. Patients with proximal DVT had a longer hospital length of stay (22 days [IQR 11-60] vs. 14 days [7-23], p = 0.03) and spent more time on mechanical ventilation (10 days (3.3-57) vs. 6 days (3-12), p = 0.053) than patients without DVT. Patient mortality was not affected by the presence of DVT (52% vs. 38.3%, p = 0.29). CONCLUSIONS: Routine thromboprophylaxis is not used in our institution and the prevalence and incidence proportion of proximal DVT in Asian medical critical care patients were both substantial. Patients with older age, female gender, an intravenous femoral catheter, and the absence of platelet transfusion all had a higher chance of developing proximal DVT.

Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial.

Rationale: Recent retrospective evidence suggests the efficacy of early norepinephrine administration during resuscitation; however, prospective data to support this assertion are scarce. Objectives: To conduct a phase II trial evaluating the hypothesis that early low-dose norepinephrine in adults with sepsis with hypotension increases shock control by 6 hours compared with standard care. Methods: This single-center, randomized, double-blind, placebo-controlled clinical trial was conducted at Siriraj Hospital, Bangkok, Thailand. The study enrolled 310 adults diagnosed with sepsis with hypotension. The patients were randomly divided into two groups: early norepinephrine (n = 155) and standard treatment (n = 155). The primary outcome was shock control rate (defined as achievement of mean arterial blood pressure ≥65 mm Hg, with urine flow ≥0.5 ml/kg/h for 2 consecutive hours, or decreased serum lactate ≥10% from baseline) by 6 hours after diagnosis. Measurements and Main Results: The patients in both groups were well matched in background characteristics and disease severity. Median time from emergency room arrival to norepinephrine administration was significantly shorter in the early norepinephrine group (93 vs. 192 min; P < 0.001). Shock control rate by 6 hours was significantly higher in the early norepinephrine group (118/155 [76.1%] vs. 75/155 [48.4%]; P < 0.001). The 28-day mortality was not different between groups: 24/155 (15.5%) in the early norepinephrine group versus 34/155 (21.9%) in the standard treatment group (P = 0.15). The early norepinephrine group was associated with lower incidences of cardiogenic pulmonary edema (22/155 [14.4%] vs. 43/155 [27.7%]; P = 0.004) and new-onset arrhythmia (17/155 [11%] vs. 31/155 [20%]; P = 0.03). Conclusions: Early norepinephrine was significantly associated with increased shock control by 6 hours. Further studies are needed before this approach is introduced in clinical resuscitation practice. Clinical trial registered with www.clinicaltrials.gov (NCT01945983) (CENSER trial).

Efficacy of echocardiography during spontaneous breathing trial with low-level pressure support for predicting weaning failure among medical critically ill patients.

BACKGROUND: Echocardiography was reported to be a good predictor of weaning failure when using T-piece method, but information about its efficacy in a pressure support setting is scarce. This study aimed to investigate the efficacy of echocardiography during spontaneous breathing trial with low-level pressure support for predicting weaning failure among medical critically ill patients. METHODS: This prospective cohort study was conducted in adult respiratory failure patients that tolerated low pressure support weaning for 30 minutes. Echocardiogram was performed during pressure support ventilation before extubation. Weaning failure was defined as reintubation within 48 hours. RESULTS: Of the 52 included patients (mean age 65.9 ± 17.8 years), 14 experienced weaning failure. Severe pneumonia, metabolic acidosis, and septic shock were the leading causes of respiratory failure. Univariate analysis identified BMI > 24, peak A wave < 100 cm/s, E/Ea > 14, and inferior vena cava maximum diameter (IVCmax ) > 17 mm as factors associated with reintubation. Multivariate analysis revealed E/Ea > 14 and IVCmax  > 17 mm to be independent predictors of weaning failure. CONCLUSION: Inferior vena cava maximum diameter > 17 and E/Ea ratio ≥ 14 independently predict weaning failure in patients with preserved left ventricular systolic function. This finding confirms that preload status of both ventricles plays a major role in weaning failure.

Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle.

OBJECTIVES: To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines. DESIGN: Worldwide online survey. SETTING: Intensive care. INTERVENTION: A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle. MEASUREMENT AND MAIN RESULTS: There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits. CONCLUSIONS: The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Emergency Department Patients With Cardiogenic Pulmonary Edema: A Randomized Controlled Trial.

STUDY OBJECTIVE: High-flow nasal cannula is a new method for delivering high-flow supplemental oxygen for victims of respiratory failure. This randomized controlled trial compares high-flow nasal cannula with conventional oxygen therapy in emergency department (ED) patients with cardiogenic pulmonary edema. METHODS: We conducted an open-label randomized controlled trial in the ED of Siriraj Hospital, Bangkok, Thailand. Patients aged 18 years or older with cardiogenic pulmonary edema were randomly assigned to receive either conventional oxygen therapy or high-flow nasal cannula. The primary outcome was the respiratory rate 60 minutes postintervention. RESULTS: We enrolled 128 participants (65 in the conventional oxygen therapy and 63 in the high-flow nasal cannula groups). Baseline high-flow nasal cannula and conventional oxygen therapy mean respiratory rates were 28.7 breaths/min (SD 3.2) and 28.6 breaths/min (SD 3.5). Mean respiratory rates at 60 minutes postintervention were lower in the high-flow nasal cannula group (21.8 versus 25.1 breaths/min; difference 3.3; 95% confidence interval 1.9 to 4.6). No significant differences were found in the admission rate, ED and hospital lengths of stay, noninvasive ventilation, intubation, or mortality. CONCLUSION: In patients with cardiogenic pulmonary edema in the ED, high-flow nasal cannula therapy may decrease the severity of dyspnea during the first hour of treatment.

Hydrocortisone treatment in early sepsis-associated acute respiratory distress syndrome: results of a randomized controlled trial.

BACKGROUND: Authors of recent meta-analyses have reported that prolonged glucocorticoid treatment is associated with significant improvements in patients with severe pneumonia or acute respiratory distress syndrome (ARDS) of multifactorial etiology. A prospective randomized trial limited to patients with sepsis-associated ARDS is lacking. The objective of our study was to evaluate the efficacy of hydrocortisone treatment in sepsis-associated ARDS. METHODS: In this double-blind, single-center (Siriraj Hospital, Bangkok), randomized, placebo-controlled trial, we recruited adult patients with severe sepsis within 12 h of their meeting ARDS criteria. Patients were randomly assigned (1:1 ratio) to receive either hydrocortisone 50 mg every 6 h or placebo. The primary endpoint was 28-day all-cause mortality; secondary endpoints included survival without organ support on day 28. RESULTS: Over the course of 4 years, 197 patients were randomized to either hydrocortisone (n = 98) or placebo (n = 99) and were included in this intention-to-treat analysis. The treatment group had significant improvement in the ratio of partial pressure of oxygen in arterial blood to fraction of inspired oxygen and lung injury score (p = 0.01), and similar timing to removal of vital organ support (HR 0.74, 95 % CI 0.51-1.07; p = 0.107). After adjustment for significant covariates, day 28 survival was similar for the whole group (HR 0.80, 95 % CI 0.46-1.41; p = 0.44) and for the larger subgroup (n = 126) with Acute Physiology and Chronic Health Evaluation II score <25 (HR 0.57, 95 % CI 0.24-1.36; p = 0.20). With the exception of hyperglycemia (80.6 % vs. 67.7 %; p = 0.04), the rate of adverse events was similar. Hyperglycemia had no impact on outcome. CONCLUSIONS: In sepsis-associated ARDS, hydrocortisone treatment was associated with a significant improvement in pulmonary physiology, but without a significant survival benefit. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01284452 . Registered on 18 January 2011.

Agreement of Variables Selection and Program Development for Data Collection in Thai Intensive Care Unit by Delphi Method.

Objective: The objective of this study was to determine the data collection variables and program for Thai intensive care units (ICU) as well as to obtain agreement using the modified Delphi method. Material and Method: The variables for program development were modified from the THAI-SICU study case record form. The first open discussion on the prototype was performed in a program development workshop. After revision, the stakeholder agreement was performed by modified Delphi method on the final browser program. All the categorical variable details were scored by a rating scale at five levels. The agreement level was defined as the median score at of least four and the interquartile range (IQR) up to two. Results: During June to September 2015, a total of 20 questionnaires from invited intensive care unit (ICU) expert stakeholders were returned (11 from physicians or surgeons, and 9 from critical care nurses). All of the seven parts of the variable groups, including: 1) patient characteristics, 2) diagnosis, 3) adverse events, 4) detail of operation in surgical cases, 5) ICU intervention, 6) discharge, and 7) summarized report, were agreed upon as the preset criteria (Median ≥4 and IQR ≤2). Conclusion: The selected variables in seven parts of the variable group via browser system were widely agreed upon from stake holders in Thai ICUs.

High-frequency oscillatory ventilation for patients during exudative phase of severe ARDS.

BACKGROUND: High frequency oscillatory ventilation (HFOV) is theoretically ideal for lung protective strategy ventilation (LPSV) in acute respiratory distress syndrome (ARDS). However, recent studies revealed unsatisfactory outcomes. The authors conducted a study to examine this phenomenon in patients with early phase of moderate to severe ARDS. OBJECTIVE: To evaluate the effectiveness of HFOV in patients with early phase of moderate to severe ARDS. The primary outcome was 30 days all-cause mortality. MATERIAL AND METHOD: The study was a matched-case controlled clinical trial performed in the medical intensive care units, Faculty of Medicine, Siriraj Hospital. The authors compared HFOV with LPSV in adult patients with the early phase of ARDS who received mechanical ventilation less than 72 hours and had moderate to severe hypoxemia (PaO/FiO2 ratio less than or equal 150). RESULTS: Between June 2010 and February 2014, 49 patients with moderate to severe ARDS were included. Fourteen patients who received HFOV were matched with 16 patients who received LPSV. The 30-day mortality in HFOV group was 61.5%; while in control group, 50% (p = 0.53). The authors found use of higher doses of sedative drugs and muscle relaxants in HFOV group. In addition, this group had high-level of mean airway pressure (mPaw). The presence of hemodynamic instability was not different in both groups. CONCLUSION: In adult patients in the early phase of moderate to severe ARDS who received mechanical ventilation for less than 72 hours, HFOV did not decrease the 30-day mortality. Thus, this support should be only a rescue therapy for refractory hypoxemia cases and in highly selected patients.

The temporal changes of tissue oxygen saturation (StO2) and central venous oxygen saturation (ScvO2) during sepsis/septic shock resuscitation.

BACKGROUND: Restoration of adequate tissue oxygenation is the goal of shock resuscitation. Commonly, central venous oxygen saturation and lactate clearance are used to monitor this therapeutic endpoint in sepsis. Tissue oxygen saturation (StO2) obtained by near-infrared spectroscopy (NIRS) has been introduced as an alternative. OBJECTIVE: To determine the temporal changes of tissue oxygen saturation and central venous oxygen saturation (ScvO2) in severe sepsis/septic shock patients from initial resuscitation to 72 hours after treatment, and to explore the relationship between both parameters including the association with outcomes. MATERIAL AND METHOD: A prospective, observational study was performed in a single center 14-bed university hospital, Medical Intensive Care Unit. The present study enrolled severe sepsis/septic shock patients aged > 18 years. Central venous oxygen saturation and tissue oxygen saturation were measured at 0-1st hour (right after central venous catheter was placed), 1st-6th hour (the point when hemodynamic goal was achieved), 6th-9th hour 9th-12th hour 24th hour, 48th hour, and 72th hour in simultaneous fashion. RESULTS: Thirty-five patients were enrolled and 170 paired-measurements were made. During the first 24 hours, both tissue and central venous oxygen saturation gradually increased in the same direction. However only fair correlation was observed (r = 0.253, p = 0.01) and the agreement was not satisfactory. Mean StO2 during the first 24 hours was higher in survived patients ((82.6 +/- 9.3 vs. 74.3 +/- 16.0, p = 0.016). When partitioned ScvO2 into ranges, namely ScvO2 < 60%, 60-64%, 65-69%, 70-74%, 75-79%, 80-84% and > 85%, the corresponding StO2 values were found randomly throughout the ScvO2 ranges, without specific predilection. CONCLUSION: The temporal changes of StO2 and ScvO2 during sepsis/septic shock resuscitation were demonstrated. Their correlation and agreement were not satisfactory. No specific StO2 value for the reversal of tissue hypoxia was observed. More studies are needed to explore the benefit of StO2 as a bedside tool for tissue perfusion monitoring.

Non-invasive estimated continuous cardiac output (escCO) during severe sepsis and septic shock resuscitation.

BACKGROUND: Cardiac output (CO) is an important hemodynamic parameter during sepsis and septic shock resuscitation. Conventionally, this value is obtained at bedside by the thermodilution technique, which requires a pulmonary artery catheter (PAC). Estimated Continuous Cardiac Output (esCCO, Nihon Kohden, Japan) calculated from pulse-wave transit time (PWTT) was examined here as an alternative. MATERIAL AND METHOD: A prospective study was performed in a 14-bed ICU facility. Patients with severe sepsis and septic shock who had PAC placed were included. Serial thermodilution cardiac outputs (CO(IBT)) and esCCO (COesCCO) were obtained at the beginning of resuscitation (t0), at 48 hours (t48), and at 72 hours (t72). Other parameters from the tested device; namely, estimated continuous cardiac index (esCCI), estimated stroke volume (esSV), and estimated stroke volume index (esSVI), were also achieved. RESULTS: A total of 90-paired readings from ten ICU patients were collected. The overall correlation coefficient (R) between COesCCO and CO(IBT) was 0.76. When focusing on the correlation from each time point, we found R at t0 = 0.65, t48 = 0.74, and t72 = 0.84 (all p < 0.001). Bland and Altman analysis corrected for repeated measures showed a bias of 1.2 liter/min and limits of agreement from -2.8 to +5.2 liter/min. Results also showed fair to poor correlation with other parameters that derived from this device (esCCI, esSV esSVI). CONCLUSION: The estimated continuous cardiac output (esCCO) correlated well with the cardiac output obtained by thermodilution techniques, especially when patients were out of shock.

Therapeutic goal achievements during severe sepsis and septic shock resuscitation and their association with patients' outcomes.

BACKGROUND: Severe sepsis and septic shock are associated with high mortality. "Early goal-directed therapy" (EGDT) has been shown to improve survival. The authors report here the goal achievements in the protocol and their association with patients' outcomes. MATERIAL AND METHOD: A prospective cohort study of patients with severe sepsis and septic shock who were admitted from the Emergency Department from April 2011 to September 2012. All underwent the resuscitation protocol aimed to achieve hemodynamic goals within 6 hours after diagnosis. These goals included: 1) mean arterial > 65 mmHg, 2) urine output > 0.5 ml/kg/hour and 3) superior vena cava O2 saturation > 70% or serum lactate clearance > 10%. The primary outcome was 28-day mortality RESULTS: Of the 175 enrolled patients, 23 (13.1%) achieved all 3 goals at 6 hour while 75 (42.8%) achieved 2 goals and 52 (29.8%) achieved only 1 goal. The 28-day mortality of these patients was 8.7%, 16% and 35.5%, respectively while 44% of those who did not achieve any goal died. A central venous catheter was placed in 79 patients, 46 of whom had it inserted during the first 6 hours, and 42 of whom had a CVP of 8-12 mmHg. Only 13 patients had their ScvO2 measured. Mean arterial pressure target was achieved in 129 patients, who had lower initial APACHE II score, lower initial lactate level and higher initial blood pressures than those who did not. These patients received less fluid at 6 hours, at 24 hours and at 3 days, respectively; they also received less norepinephrine. This group had lower mortality (28-day mortality 19.4% vs. 34.86%, p = 0.043). Of 119 patients who had achieved the urine output goal, 21 reached this goal alone and their survival was better than those who did not achieve any target goal. Serum lactate was monitored in 51 patients and a clearance of > 10% was noted in 23 of them. These patients were divided into 3 groups.: group 1 consisted of patients with initial lactate < 2; group 2 were patients with initial lactate > 2, which decreased during resuscitation; group 3 consisted of patients with initial lactate > 2, which increased after wards. The mortalities were 7.7%, 14.3% and 43.6%, respectively, p = 0.011. CONCLUSION: The achievement of therapeutic targets at 6 hours after sepsis/septic shock resuscitation was associated with improved survival, especially when more goals were reached. Although the achievement of adequate tissue oxygenation was proved beneficial, only one-third of the patients were monitored.

Survey of respiratory support for intensive care patients in 10 tertiary hospital of Thailand.

OBJECTIVE: There are varieties of clinical practices for intensive care respiratory support. However there has been no published report characterizing its current practice in Thailand. The present study was undertaken to characterize the practice of respiratory support for intensive care patients in Thai tertiary hospitals. MATERIAL AND METHOD: A cross-sectional survey and retrospective historical cohort of intensive care units (ICUs) was performed on May 30, 2011 from ten tertiary hospitals in Thailand. The participating ICUs were asked to complete the following data of all patients who were mechanically ventilated in the ICUs: demographic data, characteristics of respiratory support, ICU type, causes of respiratory failure, and weaning technique. RESULTS: A total of 258 patients from ten tertiary hospitals were included and analyzed. The medical ICU patients remained in the ICU significantly longer than patients in other ICUs. Patients in surgical ICUs were significantly younger than patients in other ICUs. The prevalence of mechanically ventilated patients in this survey was 64.7% with a significantly higher proportion in the medical ICUs. The median of ventilator days was also significantly higher in the medical ICUs. An invasive ventilator was more commonly used in all ICUs rather than non-invasive ventilators. The three common causes of respiratory support were severe sepsis or septic shock, respiratory failure and post-operation, respectively. Volume-controlled continuous mandatory ventilation (VC-CMV) ventilation was more commonly used as the initial mode of ventilation in both surgical and medical ICUs. The maximum plateau pressure was significantly higher in the medical ICU patients but there were no differences in maximum tidal volume and PEEP level. One-third of the patients were in the weaning process, mostly in the medical ICUs. Pressure support was the predominant weaning mode in the medical ICUs, while synchronized intermittent mandatory ventilation (SIMV) was more predominant in the surgical ICUs. Protocol-based weaning was used in approximately two-thirds of patients who were in the weaning process. With repeated estimation equation logistic model and left censors cohort to 28 days, the medical ICUs had significantly lower ventilator free overtime individual patients when compared with surgical ICUs, while there was no difference within mixed ICUs. CONCLUSION: The VC-CMV was more commonly used as the initial mode of ventilation in both surgical and medical ICUs. Pressure support was the predominant weaning mode in the medical ICUs, while SIMV was more predominant in the surgical ICUs. Individual patients in medical ICU had a greater number of ventilator days and less probability of being ventilator-free.

The impact of intensive care unit admissions following early resuscitation on the outcome of patients with severe sepsis and septic shock.

BACKGROUND: Septic shock is a serious condition associated with a high mortality rate. The 'Early goal-directed therapy" has been reported as the effective treatment. Whether or not an intensive care unit (ICU) admission can improve the outcomes of septic shock patients, has not been elucidated. OBJECTIVE: To evaluate the impact of direct ICU admission after initial resuscitation in the emergency room (ER) on the outcomes of patients in septic shock. MATERIAL AND METHOD: A prospective cohort study including severe sepsis and septic shock patients who were admitted from the ER during the period from April 2011 to September 2012. The recorded information includes patients' baseline characteristics, hemodynamic parameters, and outcomes. The comparisons were performed between the ICU versus the non-ICU admission groups. The principal outcome was 28-day mortality. RESULTS: Of the 175 enrolled patients, 50 patients were directly admitted to the ICU and 125 patients were admitted to a general medical ward. The ICU patients were younger (58.6 +/- 19.7 vs. 66.0 ++/- 5.1 year-old, p = 0.02), had lower mean arterial blood pressures (57.8 +/- 15.3 vs. 66.6 ++/- 8.4 mmHg, p < 0.001) and presented with a higher proportion of metabolic acidosis (60% vs. 33.6%, p = 0.002). In comparison to the non-ICU group, the ICU patients received larger volume resuscitation for the first 24 hours (5,694.4 +/- 2,018.5 vs. 5,004.7 +/- 1,729.7 ml, p = 0.04); had received norepinephrine (88% vs. 68%, p = 0.007) and/or dobutamine (20% vs. 4.8%, p = 0.003), and were treated for renal replacement therapy (28% vs. 5.6%, p < 0.001) in higher proportions. There were trends toward a lower 28 day mortality (18% vs. 25.6%, p = 0.33) among the patients in the ICU group. CONCLUSIONS: Apart from the early goal-directed therapy, early ICU admission substantially improves the outcomes of septic shock patients.

Transthoracic echocardiogram for the diagnosis of right ventricular dysfunction in critically ill patients.

BACKGROUND: Acute right ventricular dysfunction (RVD) is one of the hemodynamic alterations in patients with septic shock, pulmonary embolism and ARDS. This condition had previously been diagnosed by pulmonary artery catheters (PAC). This report is on the use of transthoracic echocardiography (TTE) to diagnose RVD in critically ill patients. OBJECTIVE: To evaluate the use of TTE for the diagnosis of RVD. MATERIAL AND METHOD: A single center, cohort study, was performed in a 12-bed medical ICU. All patients who had had PAC insertions during the period from August 2009 to October 2010 were included in this study. TTE was performed by an investigator (WS. or ST) who was not aware of the patients' diagnoses. The hemodynamic parameters were measured within the hour prior to performing a TTE. The RVD was diagnosed according to the following criteria: Right atrial (RA) pressure > or = 12 mmHg, pulmonary artery occlusion pressure (PAOP) < 18 mmHg, mean pulmonary artery pressure (PAP) > 25 mmHg, and pulmonary vascular resistance (PVR) > 250 dyne*sec*cm(-5). RESULTS: The PACs were inserted in 59 patients. Of these, 15 had been diagnosed with RVD. A total of 83 TTE examinations, in comparison with hemodynamic parameters measured from PACs, were studied. The TTE parameters; left ventricular (LV) D-shape (sensitivity 61.1%, specificity 84.6%), loss of right ventricular (RV) apical triangle (sensitivity 44.4%, specificity 80%), RV systolic pressure > 40 mmHg (sensitivity 77.8%, specificity 60%) and right ventricular end systolic areas: left ventricular end systolic areas (RVESA:LVESA) > 0.65 (sensitivity 94.4%, specificity 39.1%) were consistent with RVD. The presence of at least 2 out of 4 echocardiograph findings correlated with RVD, with the area under the ROC curve at 0.79, with a sensitivity of 77.8% and a specificity of 67.7%. CONCLUSION: TTE is an accurate tool for the diagnosis RVD in critically ill patients with acceptable sensitivities and specificities.

Characteristics and Cluster Analysis of 18,030 Sepsis Patients Who Were Admitted to Thailand's Largest National Tertiary Referral Center during 2014-2020 to Identify Distinct Subtypes of Sepsis in Thai Population.

Background: This study aimed to investigate the demographic, clinical, and laboratory characteristics of sepsis patients who were admitted to our center during 2014-2020 and to employ cluster analysis, which is a type of machine learning, to identify distinct types of sepsis in Thai population. Methods: Demographic, clinical, laboratory, medicine, and source of infection data of patients admitted to medical wards of Siriraj Hospital (Bangkok, Thailand) during 2014-2020 were collected. Sepsis was diagnosed according to the Sepsis-3 criteria. Nineteen demographic, clinical, and laboratory variables were analyzed using hierarchical clustering to identify sepsis subtypes. Results: Of 98,359 admissions, 18,030 (18.3%) had sepsis. Respiratory tract was the most common site of infection. The mean Sequential Organ Failure Assessment (SOFA) score was 4.21 ± 2.24, and the median serum lactate level was 2.7 mmol/L [range: 0.4-27.5]. Twenty percent of admissions required vasopressor. In-hospital mortality was 19.6%. Ten sepsis subtypes were identified using hierarchical clustering. Three clusters (clusters L1-L3) were considered low risk, and seven clusters (clusters H1-H7) were considered high risk for in-hospital mortality. Cluster H1 had prominent hematologic abnormalities. Clusters H3 and H5 had younger ages and significant hepatic dysfunction. Cluster H5 had multiple organ dysfunctions, and a higher proportion of cluster H5 patients required vasopressor, mechanical ventilation, and renal replacement therapy. Cluster H6 had more respiratory tract infection and acute respiratory failure and a lower SpO2/FiO2 value. Conclusions: Cluster analysis revealed 10 distinct subtypes of sepsis in Thai population. Furthermore, the study is needed to investigate the value of these sepsis subtypes in clinical practice.

Comparison of limited driving pressure ventilation and low tidal volume strategies in adults with acute respiratory failure on mechanical ventilation: a randomized controlled trial.

BACKGROUND: Ventilator-induced lung injury (VILI) presents a grave risk to acute respiratory failure patients undergoing mechanical ventilation. Low tidal volume (LTV) ventilation has been advocated as a protective strategy against VILI. However, the effectiveness of limited driving pressure (plateau pressure minus positive end-expiratory pressure) remains unclear. OBJECTIVES: This study evaluated the efficacy of LTV against limited driving pressure in preventing VILI in adults with respiratory failure. DESIGN: A single-centre, prospective, open-labelled, randomized controlled trial. METHODS: This study was executed in medical intensive care units at Siriraj Hospital, Mahidol University, Bangkok, Thailand. We enrolled acute respiratory failure patients undergoing intubation and mechanical ventilation. They were randomized in a 1:1 allocation to limited driving pressure (LDP; ⩽15 cmH2O) or LTV (⩽8 mL/kg of predicted body weight). The primary outcome was the acute lung injury (ALI) score 7 days post-enrolment. RESULTS: From July 2019 to December 2020, 126 patients participated, with 63 each in the LDP and LTV groups. The cohorts had the mean (standard deviation) ages of 60.5 (17.6) and 60.9 (17.9) years, respectively, and they exhibited comparable baseline characteristics. The primary reasons for intubation were acute hypoxic respiratory failure (LDP 49.2%, LTV 63.5%) and shock-related respiratory failure (LDP 39.7%, LTV 30.2%). No significant difference emerged in the primary outcome: the median (interquartile range) ALI scores for LDP and LTV were 1.75 (1.00-2.67) and 1.75 (1.25-2.25), respectively (p = 0.713). Twenty-eight-day mortality rates were comparable: LDP 34.9% (22/63), LTV 31.7% (20/63), relative risk (RR) 1.08, 95% confidence interval (CI) 0.74-1.57, p = 0.705. Incidences of newly developed acute respiratory distress syndrome also aligned: LDP 14.3% (9/63), LTV 20.6% (13/63), RR 0.81, 95% CI 0.55-1.22, p = 0.348. CONCLUSIONS: In adults with acute respiratory failure, the efficacy of LDP and LTV in averting lung injury 7 days post-mechanical ventilation was indistinguishable. CLINICAL TRIAL REGISTRATION: The study was registered with the ClinicalTrials.gov database (identification number NCT04035915).

Limited breathing pressure or low amount of air given to the lung; which one is better for adults who need breathing help by ventilator machineWe conducted this research at Siriraj Hospital in Bangkok, Thailand, aiming to compare two ways of helping patients with breathing problems. We studied 126 patients who were randomly put into two groups. One group received a method where the pressure during breathing was limited (limited driving pressure: LDP), and the other group got a method where the amount of air given to the lungs was kept low (low tidal volume: LTV). We checked how bad the lung injury was at seven days later. The results showed that there was no difference between the two methods. Both ways of helping patients breathe had similar outcomes, and neither was significantly better than the other in preventing lung problems. The study suggests that both approaches work about the same for patients who need help with breathing using a machine.

Factors associated with mortality in acute respiratory failure patients without acute respiratory distress syndrome.

Background: Excess tidal volume and driving pressure were associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). Still, the appropriate mechanical ventilation strategy for patients who do not have ARDS needs to be understood. This study aimed to identify risk factors for mortality in acute respiratory failure patients without ARDS. Methods: We included all mechanically ventilated patients who did not meet the criteria for ARDS and were admitted to the medical intensive care unit (ICU) from October 2017 to September 2018. Patients who had tracheostomy before admission, were intubated for more than 24 hours before transfer to ICU, or underwent extracorporeal membrane oxygenation within 24 hours of ICU admission were excluded. Clinical and physiologic data were recorded and compared between survived and non-survived patients. Results: Of 289 patients with acute respiratory failure, 134 patients without ARDS were included; 69 (51%) died within 28 days. Demographics, principal diagnosis, and lung injury score on the first day of admission were not significantly different between survived and non-survived patients. In multivariate analysis, higher peak inspiratory pressure (PIP) during the first 3 days of admission [odds ratio (OR) 1.11, 95% confidence interval (CI): 1.01-1.22, P=0.04], higher sequential organ failure assessment score (OR 1.15, 95% CI: 1.04-1.28, P=0.008) and underlying cerebrovascular diseases (OR 7.09, 95% CI: 1.78-28.28, P=0.006) were independently associated with mortality in these patients, whereas dynamic lung compliance (Cdyn) and respiratory rate were not associated with mortality in the multivariate model. Conclusions: Mortality was high in mechanically ventilated patients without ARDS. Higher PIP is a potentially modifiable risk factor for mortality in these patients, independent of the baseline Cdyn. Underlying cerebrovascular diseases and increased disease severity are also independent factors associated with 28-day mortality.

Critical care bed capacity in Asian countries and regions before and during the COVID-19 pandemic: an observational study.

Background: The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of critical care. The aim of the current study was to compare the number of adult critical care beds in relation to population size in Asian countries and regions before (2017) and during (2022) the pandemic. Methods: This observational study collected data closest to 2022 on critical care beds (intensive care units and intermediate care units) in 12 middle-income and 7 high-income economies (using the 2022-2023 World Bank classification), through a mix of methods including government sources, national critical care societies, personal contacts, and data extrapolation. Data were compared with a prior study from 2017 of the same countries and regions. Findings: The cumulative number of critical care beds per 100,000 population increased from 3.0 in 2017 to 9.4 in 2022 (p = 0.003). The median figure for middle-income economies increased from 2.6 (interquartile range [IQR] 1.7-7.8) to 6.6 (IQR 2.2-13.3), and that for high-income economies increased from 11.4 (IQR 7.3-22.8) to 13.9 (IQR 10.7-21.7). Only 3 countries did not see a rise in bed capacity. Where data were available in 2022, 10.9% of critical care beds were in single rooms (median 5.0% in middle-income and 20.3% in high-income economies), and 5.3% had negative pressure (median 0.7% in middle-income and 18.5% in high-income economies). Interpretation: Critical care bed capacity in the studied Asian countries and regions increased close to three-fold from 2017 to 2022. Much of this increase was attributed to middle-income economies, but substantial heterogeneity exists. Funding: None.

Predicting factors, incidence and prognosis of cardiac arrhythmia in medical, non-acute coronary syndrome, critically ill patients.

BACKGROUND: Cardiac arrhythmia is an important complication of critically ill patients, especially in perioperative period and early after myocardial infarction. However, the information regarding this condition in medical critically ill without active coronary artery disease patients is limited. OBJECTIVE: To identify the predictive factors, incidence, and prognosis of tachyarrhythmia and bradyarrhythmia in non-coronary critically ill medical patients. MATERIAL AND METHOD: A single center prospective cohort study, included medical critically ill patients, age > or = 18 year-old, admitted in a 15-bed medical ICU between September 2010 and August 2011. The patients with active coronary artery disease, end stage organ failure and not expected to survive > or = 48 hours were excluded. The patients' baseline characteristic, APACHE II score, laboratory investigations in the first 24 hours and treatment modalities were recorded. Continuous electrocardiographic monitoring was performed during ICU admission. The arrhythmic event, requiring treatment, was recorded. RESULTS: A total of 247 patients were included, the mean age was 58.5 +/- 20.0 year-old and mean APACHE II score was 20.1 +/- 9.8. Most of them had septic shock (57.1%) and respiratory failure (55.1%). The incidence of arrhythmia was 39.7%. Of 45 patients (18.2%) who had tachyarrhythmia, new onset atrial fibrillation was demonstrated in 34 patients (13.8%), following by ventricular fibrillation (9 patients, 3.6%) and supraventricular tachycardia (2 patients, 0.8%). Bradyarrhythmia was noted in 53 patients (21.5%). Of these, junctional bradycardia was witnessed in 34 patients (13.8%), followed by symptomatic bradycardia (15 patients, 6.1%) and atrioventricular blockage (4 patients, 1.60%). The multivariate by logistic regression analysis revealed the receiving of norepinephrine and APACHE II > or = 25 as an independent predictor for tachyarrhythmia, while the receiving of norepinephrine, arterial pH < 7.3 and HCO3 > or = 18 were associated with bradyarrhythmia. The presence of arrhythmia, especially ventricular fibrillation, symptomatic sinus bradycardia and junctional bradycardia in medical ICU is associated with higher hospital mortality (bradyarrhythmia 88. 7%, tachyarrhythmia 66.70%) than the absent group (18.1%, p < 0.001). CONCLUSION: Arrhythmia is a serious complication of medical critically ill patients and associated with high mortality rate. Appropriate shock management together with proper metabolic support may prevent this condition.