Customized Citrate Anticoagulation versus No Anticoagulant in Continuous Venovenous Hemofiltration in Critically Ill Patients with Acute Kidney Injury: A Prospective Randomized Controlled Trial.

INTRODUCTION: The use of anticoagulants during continuous renal replacement therapy (CRRT) is essential. Regional citrate anticoagulation (RCA) is recommended rather than systemic heparinization to prolong the filter's lifespan in patients at high risk of bleeding. However, commercial citrate is expensive and may not be available in resource-limited areas. The objective of this study is comparing filter life between our locally made customized RCA and no anticoagulation. The primary outcomes were the first circuit life in hours and the number of filters used within the first 72 h of therapy. METHODS: We conducted a single-center prospective randomized controlled trial in critically ill patients requiring CRRT. The participants were randomized to receive continuous venovenous hemofiltration (CVVH) with either customized RCA or no anticoagulant. RESULTS: Of 76 patients, 38 were randomized to receive customized RCA and 38 to receive CVVH without anticoagulant. There was no significant difference in baseline characteristics between the two groups. Compared to anticoagulant-free group, the median circuit life of customized RCA group was significantly longer [44.9 (20.0, 72.0) vs. 14.3 (7.0, 22.0) hours; p < 0.001]. The number of filters used within 72 h was significant lower [2.0 (1.0, 2.0) vs. 2.5 (1.0, 3.0); p < 0.015]. RCA was prematurely discontinued in 5 patients due to citrate accumulation (2 cases) and severe metabolic acidosis requiring higher dose of CVVH (3 cases). No differences in bleeding complications were observed (p = 0.99). CONCLUSION: Customized citrate-based replacement solution improved filter survival in CVVH compared to anticoagulant-free strategy. This regimen is safe, feasible, and suitable for low- to middle-income countries.

Epidemiology, clinical characteristics, and treatment outcomes of patients with COVID-19 at Thailand's university-based referral hospital.

BACKGROUND: The epidemiology and outcomes of COVID-19 patients in Thailand are scarce. METHODS: This retrospective cohort study included adult hospitalized patients who were diagnosed with COVID-19 at Siriraj Hospital during February 2020 to April 2020. RESULTS: The prevalence of COVID-19 was 7.5% (107 COVID-19 patients) among 1409 patients who underwent RT-PCR for SARS-CoV-2 detection at our hospital during the outbreak period. Patients with COVID-19 presented with symptoms in 94.4%. Among the 104 patients who were treated with antiviral medications, 78 (75%) received 2-drug regimen (lopinavir/ritonavir or darunavir/ritonavir plus chloroquine or hydroxychloroquine), and 26 (25%) received a 3-drug regimen with favipiravir added to the 2-drug regimen. Disease progression was observed in 18 patients (16.8%). All patients with COVID-19 were discharged alive. CONCLUSIONS: The prevalence of COVID-19 was 7.5% among patients who underwent RT-PCR testing, and 10% among those having risk factors for COVID-19 acquisition. Combination antiviral therapies for COVID-19 patients were well-tolerated and produced a favorable outcome.

Effectiveness of direct observation and supervision at out-patient setting on improving clinical skills of medical students.

BACKGROUND: Direct observation and supervision (DOS) is the teaching method where a mentor provides direct observation during patient encounter and provides feedback to the learner in real-time manner Previous studies showed that DOS improves patient care and trainees' clinical skill but is difficult to implement. OBJECTIVE: To evaluate students' performance and attitude after implementing DOS to the 5th year medical students. MATERIAL AND METHOD: DOS was introduced for the whole class of the 5th year medical students throughout the year at out-patient setting department of Medicine, Siriraj Hospital in 2012. DOS sessions were provided during the first few patients 'encounters. Students 'performances at out-patients clinics were ratedfor other 8 subsequence sessions. The average score were compared to the 5th year medical students in 2011 (Conventional technique, CT). RESULTS: Two hundred andforty six students were supervised in DOS group. The mean score ofstudents who received DOS was significantly higher than CT group with the score of 8.2 compared to 7.9, respectively (p < 0.001). With respect to students'satisfaction, 75% of students rated DOS as a learning method with high to very high benefit. CONCLUSION: DOS method is feasible to implement and could improve student's performance with good satisfaction from medical students.

The prone position in COVID-19 impacts the thickness of peripapillary retinal nerve fiber layers and macular ganglion cell layers.

The prone position reduces mortality in severe cases of COVID-19 with acute respiratory distress syndrome. However, visual loss and changes to the peripapillary retinal nerve fiber layer (p-RNFL) and the macular ganglion cell layer and inner plexiform layer (m-GCIPL) have occurred in patients undergoing surgery in the prone position. Moreover, COVID-19-related eye problems have been reported. This study compared the p-RNFL and m-GCIPL thicknesses of COVID-19 patients who were placed in the prone position with patients who were not. This prospective longitudinal and case-control study investigated 15 COVID-19 patients placed in the prone position (the "Prone Group"), 23 COVID-19 patients not in the prone position (the "Non-Prone Group"), and 23 healthy, non-COVID individuals without ocular disease or systemic conditions (the "Control Group"). The p-RNFL and m-GCIPL thicknesses of the COVID-19 patients were measured at 1, 3, and 6 months and compared within and between groups. The result showed that the Prone and Non-Prone Groups had no significant differences in their p-RNFL thicknesses at the 3 follow-ups. However, the m-GCIPL analysis revealed significant differences in the inferior sector of the Non-Prone Group between months 1 and 3 (mean difference, 0.74 µm; P = 0.009). The p-RNFL analysis showed a significantly greater thickness at 6 months for the superior sector of the Non-Prone Group (131.61 ± 12.08 µm) than for the Prone Group (118.87 ± 18.21 µm; P = 0.039). The m-GCIPL analysis revealed that the inferior sector was significantly thinner in the Non-Prone Group than in the Control Group (at 1 month 80.57 ± 4.60 versus 83.87 ± 5.43 µm; P = 0.031 and at 6 months 80.48 ± 3.96 versus 83.87 ± 5.43 µm; P = 0.044). In conclusion, the prone position in COVID-19 patients can lead to early loss of p-RNFL thickness due to rising intraocular pressure, which is independent of the timing of prone positioning. Consequently, there is no increase in COVID-19 patients' morbidity burden.

Use of different approaches of acid-base derangement to predict mortality in critically ill patients.

BACKGROUND: There have been controversial data regarding the application of acid-base analysis based on Stewart methodology to predict clinical outcome in different populations. OBJECTIVE: To compare predictive ability of the physicochemical approach and the traditional bicarbonate approach of acid-base analysis in critically ill patients in relation to 28-days mortality and to evaluate the use of the physico chemical approach determined by the strong ion gap (SIG) in 1) medical compared to surgical critically ill patients; and 2) sepsis compared to non-sepsis patients. MATERIAL AND METHOD: This retrospective cohort study included 410 critically ill patients in the adult medical and surgical intensive care units (ICU) at a tertiary care hospital over a 2-year period. For each patient, values derived from the bicarbonate approaches including anion gap (AG), corrected anion gap (cAG) and lactate and those obtained from the physicochemical approach like SIG were simultaneously computed at ICU admission. The comparison of predictive ability between different approaches was assessed by forward stepwise logistic regression and the area under the receiver operating characteristic (aROC) curves. RESULTS: Of the 410 patents enrolled, 205 (50%) were admitted in the medical ICU and 226 patients (55%) were male. Overall 28-day mortality was 44.6% (183/410). The comparison between medical and surgical patients showed no difference in age (59 vs. 64 yr), APACHE II score (21 vs. 20), presence of sepsis (71% vs. 70%) and 28-day mortality (45% vs. 44%). Acid-base disturbance in non-survivors (n = 183) and survivors (n = 227) determined by pH (7.39 +/- 0.04 vs. 7.41 +/- 0.01), serum bicarbonate (16.0 +/- 6.1 vs. 17.9 +/- 7.4) and PaCO2 (32.4 +/- 13.4 vs. 29.4 +/- 8.2) were comparable. However non-survivors had higher levels of SIG (9.7 +/- 6.2 vs. 6.4 +/- 5.2) and cAG (27.5 +/- 8.8 vs. 20.3 +/- 8.6) than survivors did. According to a ROC curves, the predictive ability to discriminate between survivors and non-survivors of lactate, cAG AG and SIG are 0.77, 0.72, 0.68 and 0.67, respectively. Correlations between the SIG and values derived from bicarbonate approach are fair. There was no difference in SIG values between surgical and medical patients with the same severity scores. Sepsis patients (n = 291) had significantly higher SIG than non-sepsis patients (n = 129) did (8.81 +/- 6.38 vs. 5.74 +/- 4.14; p = 0.01). CONCLUSION: Compared to the traditional approach, an alternative Stewart approach does not provide any greater advantage to predict mortality in the studied population. Because of complex calculation, the usefulness of such approach on the routine clinical practice may be limited.

Clinical accuracy of RIFLE and Acute Kidney Injury Network (AKIN) criteria for predicting hospital mortality in critically ill patients with multi-organ dysfunction syndrome.

BACKGROUND: The Acute Dialysis Quality Initiative (ADQI) group developed RIFLE criteria and the Acute Kidney Injury Network published AKIN classification that modified form RIFLE criteria. OBJECTIVE: The authors aimed to compare the ability of RIFLE and AKIN criteria to measure the incidence of acute kidney injury (AKI) and to predict clinical outcomes in critically illpatients. MATERIAL AND METHOD: A retrospective cohort study, in Siriraj Hospital, Bangkok. The critically ill patients admitted to medical intensive care unit (ICU) during January 2006-December 2008 were classified according to the maximum RIFLE and AKIN classification reached during their hospital stay Demographic data, hospital mortality, hospital length of stay, need of renal replacement therapy was collected. RESULTS: Three hundred patients were included in this study, AKI occurred in 200 (66.7%) patients: Risk 12.7%, Injury 20.7%, Failure 33.3% defined by RIFLE criteria. According to AKIN criteria, AKI occurred 230 (76.7%) patients: stage 1 16%, stage 2 13.3% and stage 3 47.3%. AKIN classification was diagnosed AKI, approximately 10% more than RIFLE (p < 0.001). The hospital mortality was 51.7% and the mortality in patients with AKI was significantly higher than patients without AKI (p < 0.001). The predictive ability using the AUC-ROC showed poor discrimination for the prediction of mortality of both RIFLE and AKIN: 0.63 and 0.69, respectively. However, AKIN showed superior prediction of mortality than RIFLE (p = 0.003). The APACHE II had the best discriminative accuracy for mortality (AUC = 0.80), followed by the SAPS3 scores (AUC = 0.77) and SAPS2 (AUC = 0.76). CONCLUSION: AKIN criteria improved sensitivity for detection of AKI and its discrimination for prediction of in-hospital mortality was better than that of RIFLE criteria. However, APACHE II had the best discriminative value for prediction of mortality in the critically ill patients.

Dynamics of central venous oxygen saturation and serum lactate during septic shock resuscitation.

BACKGROUND: Septic shock is a serious condition leading to high mortality and morbidity. Many varieties of attempts aiming toward improving outcomes have been implemented. However the appropriate therapeutic endpoint of shock resuscitation is still under investigation. The authors report here the dynamics of commonly used parameters, namely central venous oxygen saturation (ScvO2) and lactate concentration during resuscitation. MATERIAL AND METHOD: Adult patients admitted with severe sepsis and septic shock from October 1, 2009 to January 31, 2009 were enrolled. During hemodynamic resuscitation, the central venous blood was drawn for ScvO2 and lactate measurement right after the CVC was placed (T1) and at the point where the blood pressure goal was achieved (T2). The third and the fourth measurements were obtained at 1 and 2 hours thereafter (T3 and T4). These samples were ice chilled and were sent to central laboratory for blood gas analysis and lactate determination. RESULTS: Twenty patients underwent the study. There was no significant change in ScvO2 from T1 to T4. All but five ScvO2 at T1 were above 70%. Lactate level gradually declined during the course of treatment and the clearance from T1 to T3 was calculated as 15.4%. No correlation between ScvO2 and lactate level was noted at any sampling time. When partitioning venous oxygen saturation in to 4 groups, that is ScvO2 < 65, 65 - < 75, 75-<85 and > 85, respectively, those with ScvO2 > 85% had the highest lactate concentration. CONCLUSION: Central venous oxygen saturation and its changes during treatment were heterogeneous which made this parameter less reliable than others to monitor management. The lactate clearance, although slow, is uniform and may be used alone or in combination with other parameters to monitor resuscitation.

Efficacy and hemodynamic outcome of prolonged intermittent renal replacement therapy (PIRRT) in critically ill patients: a preliminary report.

BACKGROUND: Acute kidney injury (AKI) is frequently part of a multiple-organ dysfunction syndrome presenting in critically ill patients. Prolonged intermittent renal replacement therapy (PIRRT) provides the advantages of both continuous renal replacement therapy (CRRT) in term of hemodynamic stability and the cost-effectiveness of intermittent hemodialysis (IHD). This study aims to study PIRRT in the aspects of efficacy and hemodynamic outcomes. MATERIAL AND METHOD: The authors present a single-center experience accumulated over 20 months from February 2009 to September 2010 with two PIRRT techniques, called SLEDD and SLEDD-f. Eight-hour treatments were performed daily for three consecutive days. Hemodynamic parameters were recorded at different time points and blood samples were taken for urea and solute clearance before and after treatment. RESULTS: Sixty critically ill patients with AKI were randomly assigned to undergo PIRRT 33 patients received SLEDD and 27 patients received SLEDD-f. Our results demonstrate significant decrease in BUN, creatinine, serum potassium and phosphate in both PIRRT techniques. Moreover with the use of similar filters and blood flow rates, SLEDD-f was comparable with SLEDD in terms of small solute clearance and detoxification. For hemodynamic outcomes, the authors found that MAP increased after completion of the first session of PIRRT and along the three consecutive days of daily PIRRT, together with the gradual improvement of vasopressor scores. CONCLUSION: The prolonged intermittent renal replacement therapy (PIRRT) appears to be an outstanding technique for treatment of critically ill patients with AKI and it also seems to have cost effectiveness. Moreover it is suitable to a limited resource region such as Thailand.

Extracorporeal membrane oxygenation (ECMO) support for acute hypoxemic respiratory failure patients: outcomes and predictive factors.

Background: Extracorporeal membrane oxygenation (ECMO) is an important rescue therapy for patients with refractory respiratory or circulatory failure. High cost and associated complications warrant careful case selection. The aim of this study was to investigate the outcomes and factors associated with mortality in acute hypoxemic respiratory failure patients who received ECMO support, and to externally validate preexisting ECMO survival prediction scoring systems. Methods: This retrospective study enrolled acute hypoxemic respiratory failure patients who received veno-venous (VV) or veno-arterial (VA) ECMO support at Siriraj Hospital (Bangkok, Thailand) from 2010 to 2020. All relevant baseline patient characteristics including ECMO survival prediction scores were recorded. The primary outcome was in-hospital mortality. Multivariate logistic regression analysis was employed to identify independent predictors of in-hospital mortality. Results: Of a total of 65 patients, 34 (52%) were male, the median (IQR) age was 61 years (49-70 years), the median body mass index (BMI) was 22.6 kg/m2 (20.6-28 kg/m2), and the median Sequential Organ Failure Assessment (SOFA) score was 13 [11-16]. Forty-three patients (66%) received VV-ECMO, and 22 (34%) received VA-ECMO support. In-hospital mortality was 69%. Multivariate analysis identified a SOFA score >14, hospitalized >72 hours before ECMO initiation, PaO2/FiO2 ratio <60, and pH <7.2 as independent predictors of in-hospital mortality. These four parameters were combined to create the SHOP (S: SOFA >14, H: hospitalize >72 hours, O: PF ratio <60, and P: pH <7.2) score. Compared with three different preexisting ECMO survival prediction scoring systems, the SHOP score had the highest area under the curve (AUC) for predicting in-hospital mortality (overall: 0.873, VV-EMCO: 0.866, and VA-EMCO: 0.891). Conclusions: In-hospital mortality among ECMO-supported patients was high at 69%. SOFA score >14, hospitalized >72 hours, PaO2/FiO2 ratio <60, and pH <7.2 were found to be independent predictors of in-hospital mortality. A SHOP score of 2 or higher significantly predicts in-hospital mortality in EMCO-supported patients. Trial Registration: www.clinicaltrials.gov (reg. No. NCT04031794).

Characteristics, outcomes, and risk factors for in-hospital mortality of COVID-19 patients: A retrospective study in Thailand.

Introduction: Data on the characteristics and outcomes of patients hospitalized for Coronavirus Disease 2019 (COVID-19) in Thailand are limited. Objective: To determine characteristics and outcomes and identify risk factors for hospital mortality for hospitalized patients with COVID-19. Methods: We retrospectively reviewed the medical records of patients who had COVID-19 infection and were admitted to the cohort ward or ICUs at Siriraj Hospital between January 2020 and December 2021. Results: Of the 2,430 patients included in this study, 229 (9.4%) died; the mean age was 54 years, 40% were men, 81% had at least one comorbidity, and 13% required intensive care unit (ICU). Favipiravir (86%) was the main antiviral treatment. Corticosteroids and rescue anti-inflammatory therapy were used in 74 and 6%, respectively. Admission to the ICU was the only factor associated with reduced mortality [odds ratio (OR) 0.01, 95% confidence interval (CI) 0.01-0.05, P < 0.001], whereas older age (OR 14.3, 95%CI 5.76-35.54, P < 0.001), high flow nasal cannula (HFNC; OR 9.2, 95% CI 3.9-21.6, P < 0.001), mechanical ventilation (OR 269.39, 95%CI 3.6-2173.63, P < 0.001), septic shock (OR 7.79, 95%CI, 2.01-30.18, P = 0.003), and hydrocortisone treatment (OR 27.01, 95%CI 5.29-138.31, P < 0.001) were factors associated with in-hospital mortality. Conclusion: The overall mortality of hospitalized patients with COVID-19 was 9%. The only factor associated with reduced mortality was admission to the ICU. Therefore, appropriate selection of patients for admission to the ICU, strategies to limit disease progression and prevent intubation, and early detection and prompt treatment of nosocomial infection can improve survival in these patients.

Use of saline flush to prevent filter clotting in continuous renal replacement therapy without anticoagulant.

OBJECTIVE: This study aims to compare filter life between saline flushed and non-saline flushed strategies in critically ill patients at high risk of bleeding who are undergoing CRRT without anticoagulation. MATERIAL AND METHOD: A cohort of 121 critically ill patients with severe acute kidney injury (AKI) requiring CRRT in the medical intensive care unit (ICU) and cardiac care unit (CCU) of a tertiary care academic center were included. 78 of them used saline flushed through CRRT circuit. RESULTS: There was no significant difference between the two groups of treated patients in baseline characteristics, including the extent of coagulopathy and platelet count. Mean circuit survival was 21.2 h for circuits using saline flush and 20.4 h for those using non-saline flush (p = 0.8).The Kaplan-Meier curves revealed no difference in circuit survival time between saline flushed and non-saline flushed groups (p = 0.8). CONCLUSION: The use of saline flush into pre-filter site of CRRT circuit does not provide any benefit on circuit clotting prevention in high-risk of bleeding patients requiring CRRT without anticoagulant.

Correlation of arterial, central venous and capillary lactate levels in septic shock patients.

BACKGROUND: Blood lactate level increases in response to tissue hypoxia and this level is currently used to monitor shock management. To obtain the arterial lactate value in clinical practice is a time consuming process. Our previous study demonstrated good correlation between the capillary lactate determined by a portable lactate analyzer and the standard arterial lactate in critically ill patients. This study was aimed to examine the uses of this capillary lactate in septic shock. MATERIAL AND METHOD: A prospective comparison of arterial, venous and capillary lactate level from septic shock patients admitted in the general wards and the Medical ICU, Department of Medicine, Siriraj hospital was performed during October 2009 to February 2010. RESULTS: Thirty patients were included in the study. The mean age was 66 (24-86) years and 16 (53%) were female. The correlation between arterial and central venous was 0.992 and the correlation between arterial and capillary lactate level was 0.945 (p = 0.01 in both comparisons). In addition, there was certain agreement between the arterial and the capillary lactate especially when arterial lactate was below 10 mmol/L. CONCLUSION: The capillary lactate level determined by the portable lactate analyzer (Accutrend Plus) correlated well with arterial lactate level. This method, when used cautiously, may be used to monitor septic shock treatment as an alternative to the standard arterial lactate determination.

Right ventricular dysfunction in septic shock.

BACKGROUND: Right ventricular dysfunction (RVD) is common in critically ill patients and the presence of this condition affects patients' outcomes. Improving the knowledge background and establishing the incidence of RVD in septic shock patients would render the management more efficacious. This study was performed to evaluate the incidence and outcomes of RVD in septic shock patients. MATERIAL AND METHOD: A single center retrospective observational study was performed in the Medical ICU, Siriraj Hospital, Mahidol University between January 2007 and October 2009. Patients with septic shock in whom pulmonary artery catheter (PAC) was inserted were included in the study. RESULTS: The PAC was placed in 118 patients during the study period. The patients' mean age was 58.0 +/- 18.5 years and 71 of them (59.3%) were male. The mean body mass index was 25.0 +/- 6.6 Kg/m2 and the mean APACHE II score was 26.1 +/- 7.7. The admission diagnoses were severe sepsis or septic shock (70%), severe pneumonia (38%), acute respiratory distress syndrome (21%). Twenty one patients (17.8%) meet the diagnosis criteria of RVD. The hospital mortality in RVD patients tended to be higher than the non-RVD patients (81.0% vs. 60.8%, p 0.06). Although similar proportions of both group received ventilatory support, the RVD patients had lower tidal volume and had higher peak airway pressure. Also the RVD group had lower PaO2/FiO2 ratio. In addition, the RVD group had lower cardiac output and more frequently underwent renal replacement therapy. CONCLUSION: In patients with septic shock, the incidence of RVD is substantial. The significant factors associated with RVD include low tidal volume and high peak airway pressure. Measures to prevent the alteration in lung compliance in septic shock patients may prevent RVD and improve patients' outcomes.

High Mobility Group Box 1 and Interleukin 6 at Intensive Care Unit Admission as Biomarkers in Critically Ill COVID-19 Patients.

Exuberant inflammation manifesting as a "cytokine storm" has been suggested as a central feature in the pathogenesis of severe coronavirus disease 2019 (COVID-19). This study investigated two prognostic biomarkers, the high mobility group box 1 (HMGB1) and interleukin-6 (IL-6), in patients with severe COVID-19 at the time of admission in the intensive care unit (ICU). Of 60 ICU patients with COVID-19 enrolled and analyzed in this prospective cohort study, 48 patients (80%) were alive at ICU discharge. HMGB1 and IL-6 plasma levels at ICU admission were elevated compared with a healthy control, both in ICU nonsurvivors and ICU survivors. HMGB1 and IL-6 plasma levels were higher in patients with a higher Sequential Organ Failure Assessment (SOFA) score (> 10), and the presence of septic shock or acute kidney injury. HMGB1 and IL-6 plasma levels were also higher in patients with a poor oxygenation status (PaO2/FiO2 < 150 mm Hg) and a longer duration of ventilation (> 7 days). Plasma HMGB1 and IL-6 levels at ICU admission also correlated with other prognostic markers, including the maximum neutrophil/lymphocyte ratio, D-dimer levels, and C-reactive protein levels. Plasma HMGB1 and IL-6 levels at ICU admission predicted ICU mortality with comparable accuracy to the SOFA score and the COVID-GRAM risk score. Higher HMGB1 and IL-6 were not independently associated with ICU mortality after adjustment for age, gender, and comorbidities in multivariate analysis models. In conclusion, plasma HMGB1 and IL6 at ICU admission may serve as prognostic biomarkers in critically ill COVID-19 patients.

Impact of septic shock hemodynamic resuscitation guidelines on rapid early volume replacement and reduced mortality.

BACKGROUND: Septic shock is one of the most serious conditions associated with high mortality. We recently developed a modified septic shock management guideline focusing on rapid restoration of hemodynamics by using clinical endpoint. Our aim was to analyze patients' outcomes following the guideline implementation. MATERIAL AND METHOD: A retrospective review of hemodynamic data sheet and clinical outcomes of patients admitted to medical ICU and medical Wards and during June 2004 and February 2006. RESULTS: One hundred and four patients' records were retrieved. The patients' mean age was 62.5 +/- 18.6 year. Their mean APACHE II score were 24.9 +/- 6.7 and the overall mortality was 59%. Sixty eight patients (65.4%) underwent guideline directed therapy (guideline group). The guideline group received higher volume resuscitation from the first hour of resuscitation (1,016.3 + 675.0 ml vs. 521.4 + 359.2 ml, p < 0.001) to the forty eighth hour (10,096.9 +/- 3,256.1 ml vs. 8,067.3 +/- 2,591.9 ml, p = 0.006). More of them achieved the therapeutic goal within 6 hours (86.8% vs. 44.4%, p < 0.001) and their hospital mortality was lower (41.2% vs. 69.4%, p = 0.008). When analyzing differences between those who survived and those who died, more of the surviving patients underwent guideline directed treatment (79.5% vs. 55%, p = 0.012). They received higher volume replacement from the first hour to the end of the twelfth hour (first hour 1,098.0 +/- 723.0 vs. 660.9 +/- 478.9 ml, p < 0.001; the end of the twelfth hour 3,746.6 +/- 1,799 vs. 3,014.1 +/- 1,579.9 ml, p = 0.038) and more of them achieved the therapeutic goal within 6 hours (95.5% vs. 55%, p < 0.001). Multivariate analysis of factors associated with mortality disclosed APACHE II score, volume resuscitation more than 800 ml in the first hour and achievement of the therapeutic goal within 6 hours. CONCLUSION: Implementation of our modified septic shock guideline is associated with rapid initial volume replacement, prompt achievement of therapeutic goal and improved outcomes. Volume resuscitation greater than 800 ml in the first hour is associated with better survival.

Diagnosis of corticosteroid insufficiency in Thai patients with septic shock.

BACKGROUND: The reported incidence of critical illness-related corticosteroid insufficiency (CIRCI) varies widely, depending on the patient population studied and the diagnostic criteria used. Surviving Sepsis Campaign guidelines suggest that corticosteroid therapy should be considered for adult septic shock when hypotension responds poorly to adequate fluid resuscitation and vasopressors, regardless of any results of diagnostic tests. However, steroid treatment may be associated with an increase risk of infection. This study aims to identify the best diagnostic tool for predicting responsiveness to corticosteroid therapy in Thai septic shock patients with poorly responsive to fluid resuscitation and vasopressors. MATERIAL AND METHOD: Twenty-nine septic shock patients who were poorly responsive to fluid therapy and vasopressors were studied. A baseline serum total cortisol was measured in all patients and then 250 mcg corticotropin was injected to patients. Cortisol level was obtained 30 and 60 minutes after injection. All patients were given hydrocortisone (100 mg i.v., then 200 mg i.v. in 24 hrs for at least 5 days). Patients were considered steroid responsive if vasopressor agent could be discontinued within 48 hrs after the first dose of hydrocortisone. RESULTS: Hospital mortality was 62% in which 45% of the patients were steroid responsive. Baseline serum cortisol was 27.6 +/- 11.4 microg/dl in the steroid-responsive patients compared with 40 +/- 16.9 microg/dl in the steroid-nonresponsive patients (p = 0.03). The area under the ROC curves for predicting steroid responsiveness was 0.72 for baseline cortisol level. Serum cortisol level of 35 microg/dl or less was the most accurate diagnostic threshold to determine hemodynamic response to hydrocortisone treatment (p = 0.04). Using baseline cortisol level of < or = 35 microg/dl to diagnose adrenal insufficiency, the sensitivity was 85%, the specificity was 62% and the accuracy was 72%. A use of (delta cortisol) showed sensitivity of 50%, specificity of 30% and accuracy of 41%. CONCLUSION: Baseline cortisol level < or = 35 microg/dl is a useful diagnostic threshold for diagnosis of steroid responsiveness in Thai patients with septic shock and ACTH stimulation test should not be used.

Critical Care Management of Patients with COVID-19: Early Experience in Thailand.

Since late December 2019, the world has been challenged with an outbreak of COVID-19. In Thailand, an upper middle-income country with a limited healthcare infrastructure and restricted human resources, nearly 3,000 confirmed COVID-19 cases have been reported as of early May 2020. Public health policies aimed at preventing new COVID-19 cases were very effective in halting the pandemic in Thailand. Case fatality in Thailand has been low (1.7%), at least in part due to early stratification according to risk of disease severity and timely initiation of supportive care with affordable measures. We present our initial experience with COVID-19 in Thailand, focusing on several aspects that may have played a crucial role in curtailment of the pandemic, and elements of care for severely ill COVID-19 patients, including stratification, isolation, and affordable diagnostic approaches and supportive care measures. We also discuss local considerations concerning some proposed experimental treatments.

Venovenous extracorporeal membrane oxygenation versus conventional mechanical ventilation to treat refractory hypoxemia in patients with acute respiratory distress syndrome: a retrospective cohort study.

OBJECTIVE: To compare the treatment outcome of venovenous extracorporeal membrane oxygenation (VV-ECMO) versus mechanical ventilation in hypoxemic patients with acute respiratory distress syndrome (ARDS) at a referral center that started offering VV-EMCO support in 2010. METHODS: This retrospective cohort study enrolled adults with severe ARDS (PaO2/FiO2 ratio of <100 with FiO2 of ≥90 or Murray score of ≥3) who were admitted to the intensive care unit of Siriraj Hospital (Bangkok, Thailand) from January 2010 to December 2018. All patients were treated using a low tidal volume (TV) and optimal positive end-expiratory pressure. The primary outcome was hospital mortality. RESULTS: Sixty-four patients (ECMO, n = 30; mechanical ventilation, n = 34) were recruited. There was no significant difference in the baseline PaO2/FiO2 ratio (67.2 ± 25.7 vs. 76.6 ± 16.0), FiO2 (97 ± 9 vs. 94 ± 8), or Murray score (3.4 ± 0.5 vs. 3.3 ± 0.5) between the ECMO and mechanical ventilation groups. The hospital mortality rate was also not significantly different between the two groups (ECMO, 20/30 [66.7%] vs. mechanical ventilation, 24/34 [70.6%]). Patients who underwent ECMO were ventilated with a significantly lower TV than patients who underwent mechanical ventilation (3.8 ± 1.8 vs. 6.6 ± 1.4 mL, respectively). CONCLUSION: Although VV-ECMO promoted lower-TV ventilation, it did not improve the in-hospital mortality rate. Trial registration: www.clinicaltrials.gov (NCT04031794).

The clinical outcome of acute kidney injury in critically ill Thai patients stratified with RIFLE classification.

OBJECTIVE: The Acute Dialysis Quality Initiative (ADQI) Group published a consensus definition (the RIFLE criteria) for acute renal failure. We sought to assess the ability of the RIFLE criteria to predict mortality in critically ill Thai patients with acute kidney injury (AKI). MATERIAL AND METHOD: We performed a retrospective cohort study, in Siriraj Hospital (a large single tertiary care academic center in Thailand) on 121 patients admitted during November 2005-November 2006. We classified patients according to the maximum RIFLE class (class R, class I or class F) reached during their hospital stay. Demographic data, hospital mortality, hospital length of stay, and need of renal replacement therapy was collected. RESULTS: Patients with maximum RIFLE class R, class I and class F had hospital mortality rates of 35.7%, 35.7% and 65.9%, respectively, compared with 20% for patients without acute kidney injury. Overall hospital mortality of the patients in AKI group (Risk, Injury, Failure group) was increased when compared with no AKI group (Odds ratio = 4.2; 95% Confidence Interval, 1.6-10.6; p =0.003). Mortality was not significantly different among those with the "Risk" and "Injury" class of RIFLE AKI compared with those without AKI, but mortality increased significantly with the "Failure" class (Odds ratio = 7.7; 95% Confidence Interval, 2.7-21.8; p < 0.001). There was the highest rate of renal replacement therapy in the failure group (52.3%) compared with no AKI group (5.7%), and injury group (7.1%) (p < 0.001). CONCLUSION: Acute kidney injury 'risk, injury, failure', as defined by the newly developed RIFLE classification, is associated with increased hospital mortality and renal replacement therapy in critically ill Thai patients.

Roles of extracorporeal blood purification in sepsis.

Severe sepsis represents the leading cause of mortality and morbidity in critically ill patients. Although the authors' understanding of the complex pathophysiological alterations that occur in severe sepsis and septic shock has increased greatly, mortality associated with the disorder remains unacceptably high. Recent treatment guidelines have reinforced the importance of early goal directed therapy. Recently, moderate doses of corticosteroid replacement and activated protein C (drotrecogin alfa[activated]) are the therapies demonstrating efficacy. Extra-corporeal blood purification techniques offer a variety of techniques that can efficiently eliminate septic mediators. The rationale for its use in sepsis is sound Animal and human studies show promise with improvements in hemodynamics and mortality, but are limited by number and design. These techniques require large-scale well-conducted studies to demonstrate the validity in sepsis.