Effects of Inspiratory Muscle Training and Early Mobilization on Weaning of Mechanical Ventilation: A Systematic Review and Network Meta-analysis.

OBJECTIVE: To compare the effectiveness and rank order of physical therapy interventions, including conventional physical therapy (CPT), inspiratory muscle training (IMT), and early mobilization (EM) on mechanical ventilation (MV) duration and weaning duration. DATA SOURCES: PubMed, The Cochrane Library, Scopus, and CINAHL complete electronic databases were searched through August 2019. STUDY SELECTION: Randomized controlled trials (RCTs) investigating the effect of IMT, EM, or CPT on MV duration and the weaning duration in patients with MV were included. Studies that were determined to meet the eligibility criteria by 2 independent authors were included. A total of 6498 relevant studies were identified in the search, and 18 RCTs (934 participants) were included in the final analysis. DATA EXTRACTION: Data were extracted independently by 2 authors and assessed the study quality by the Cochrane risk-of-bias tool. The primary outcomes were MV duration and weaning duration. DATA SYNTHESIS: Various interventions of physical therapy were identified in the eligible studies, including IMT, IMT+CPT, EM, EM+CPT, and CPT. The data analysis demonstrated that compared with CPT, IMT+CPT significantly reduced the weaning duration (mean difference; 95% confidence interval) (-2.60; -4.76 to -0.45) and EM significantly reduced the MV duration (-2.01; -3.81 to -0.22). IMT+CPT and EM had the highest effectiveness in reducing the weaning duration and MV duration, respectively. CONCLUSION: IMT or EM should be recommended for improving the weaning outcomes in mechanically ventilated patients. However, an interpretation with caution is required due to the heterogeneity.

Jerusalem Artichoke Powder Mixed in Enteral Feeding for Patients Who have Diarrhea in Surgical Intensive Care Unit: A Method of Preparation and a Pilot Study.

AIM AND OBJECTIVE: The Jerusalem artichoke (Helianthus tuberosus L.) is a tuber with high soluble fiber. The objective of this study was to demonstrate the method of preparation and pilot test this substance as an additive to enteral feeding. MATERIALS AND METHODS: We processed Jerusalem artichoke into a 600 micrometers powder, tested its properties, and pilot tested its use in patients who had diarrhea (King's stool score ≥12) in a surgical intensive care unit. Two grams of Jerusalem artichoke powder were mixed in each 100 mL of hospital enteral feeding formula and administered for 5 days. RESULTS: Artichoke powder slightly increased the viscosity of enteral feeding formula. The dietary fiber content of the mixture was 20.8-21.6 g% and the content of fructans was 66.0-71.5 g%. In the pilot study in 11 patients, diarrhea was improved (diarrhea score < 12) in 7/11 (63.6%) patients by day 5. Improvement in diarrhea started on day 2 [median different diarrhea score (interquartile range): -4 (-8 to 0); p = 0.03] and peaked by days 4 and 5 [-7(-10 to -3); p < 0.01 and -8(-12 to -4); p < 0.01, respectively]. There were no complications during the study except three patients had a high gastric residual volume (>200 mL). CONCLUSION: Processed powder of Jerusalem artichoke tuber has a high fiber content and increases viscosity of enteral feeding solutions only slightly. When administered as part of enteral nutrition to critically ill surgical patients, the diarrhea score improves in most patients. HOW TO CITE THIS ARTICLE: Chittawatanarat K, Surawang S, Simapaisan P, Judprasong K. Jerusalem Artichoke Powder Mixed in Enteral Feeding for Patients Who have Diarrhea in Surgical Intensive Care Unit: A Method of Preparation and a Pilot Study. Indian J Crit Care Med 2020;24(11):1051-1056.

Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey.

PURPOSE: To examine reliability and validity of a Thai version of the Family Satisfaction with Intensive Care Unit (FS-ICU 24) questionnaire and use this survey in intensive care units (ICUs) in Thailand. MATERIALS AND METHODS: The standard English FS-ICU questionnaire was translated into the Thai language using translation and culture adaptation guidelines. After reliability and validity testing, we consecutively surveyed the satisfaction of family members of ICU patients over 1 year. Adult family members of patients admitted to medical or surgical ICUs for 48 hours or more who had visited the patients at least once during the ICU stay were included. RESULTS: In all, 315 (95%) of 332 surveys were returned from family members. Cronbach's α of the Thai FS-ICU 24 questionnaire was 0.95. Factor analysis demonstrated good construct validity. The mean (±SD) of total satisfaction score, overall ICU care subscale, and decision-making subscale were 81.5 ± 14.3, 81.0 ± 15.6, and 82.0 ± 14.0. Items with the lowest scores were the waiting room atmosphere and the frequency of doctors communicating with family members about the patient's condition. The mean total satisfaction score tended to be higher in family members of survivors than in family members of nonsurvivors (81.9 ± 13.8 vs 77.7 ± 16.2, p value = 0.059). The overall satisfaction scores between medial ICU and surgical ICU were not significantly different. CONCLUSION: The Thai version of FS-ICU questionnaire was found to have acceptable reliability and validity in a Thai population and can be used to drive improvements in ICU care. TRIAL REGISTRATION: www.clinicaltrials.in.th, TCR20160603002. HOW TO CITE THIS ARTICLE: Tajarernmuang P, Chittawatanarat K, Dodek P, Heyland DK, Chanayat P, Inchai J, et al. Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey. Indian J Crit Care Med 2020;24(10):946-954.

Prediction of massive transfusion in trauma patients in the surgical intensive care units (THAI-SICU study).

PURPOSE: After damage control surgery, trauma patients are transferred to intensive care units to restore the physiology. During this period, massive transfusion might be required for ongoing bleeding and coagulopathy. This research aimed to identify predictors of massive blood transfusion in the surgical intensive care units (SICUs). METHODS: This is an analysis of the THAI-SICU study which was a prospective cohort that was done in the 9-university-based SICUs in Thailand. The study included only patients admitted due to trauma mechanisms. Massive transfusion was defined as received ≥10 units of packed red blood cells on the first day of admission. Patient characteristics and physiologic data were analyzed to identify the potential factors. A multivariable regression was then performed to identify the significant model. RESULTS: Three hundred and seventy patients were enrolled. Sixteen patients (5%) received massive transfusion in the SICUs. The factors that significantly predicted massive transfusion were an initial sequential organ failure assessment (SOFA) ≥9 (risk difference (RD) 0.13, 95% confidence interval (CI): 0.03-0.22, p = 0.01); intra-operative blood loss ≥ 4900 mL (RD 0.33, 95% CI: 0.04-0.62, p = 0.02) and intra-operative blood transfusion ≥ 10 units (RD 0.45, 95% CI: 0.06 to 0.84, p = 0.02). The probability to have massive transfusion was 0.976 in patients who had these 3 factors. CONCLUSION: Massive blood transfusion in the SICUs occurred in 5%. An initial SOFA ≥9, intra-operative blood loss ≥4900 mL, and intra-operative blood transfusion ≥10 units were the significant factors to predict massive transfusion in the SICUs.

An Open Label Randomized Controlled Trial to Compare Low Level Pressure Support and T-piece as Strategies for Discontinuation of Mechanical Ventilation in a General Surgical Intensive Care Unit.

OBJECTIVE: The purpose of this study was to compare the efficacy of continuous low pressure support (PSV) and T-piece as strategies for discontinuation of mechanical ventilation and extubation in a surgical ICU. PATIENTS AND METHODS: This was a prospective open label randomized control study in surgical ICU patients who were intubated, mechanically ventilated, and who met criteria for a spontaneous breathing trial. Eligible, enrolled patients were randomized to receive low-level pressure supportup to 7 cmH2O (PSV) or T-piece as the mode of their spontaneous breathing trial. RESULTS: A total of 520 patients were randomized (260 in PSV group and 260 in T-piece group). There were no differences between the groups in baseline characteristics except duration of MV before trial was longer in PSV group. There were also no differences in hemodynamic and respiratory measures between groups. The PSV had a significant higher number of SBT attempt before success and extubation. After extubation, the re-intubation within 48 hours had a lower trend in PSV group (PSV vs. T-piece: 10% vs. 14.6%; p=0.11). The pneumonia occurrence, hospital mortality, hospital and ICU length of stay were not significant different between groups. In multivariable analysis, PSV was associated with a lower risk of success at the first SBT (adjusted relative risk, RR 0.79 [95% confidence interval, CI, 0.70 - 0.88]; p<0.001], and a lower risk of re-intubation within 48 hours after extubation (adjusted RR 0.62 [95%CI 0.40 - 0.98]; p=0.04). There were no differences between groups in pneumonia after extubation and in hospital mortality rate. CONCLUSION: Although PSV needs a higher number of SBT trial before success and extubation, the re-intubation within 48 hours is lower than T piece. However, there were no differences between the groups in term of pneumonia after extubation, hospital mortality as well as ICU and hospital length of stay.

Characters of Nutrition Status and Energy-delivery Patterns of the University-based Surgical Intensive Care Units in Thailand (Multi-center THAI-SICU Study).

AIM: The authors aimed to describe nutrition status and energy-delivery characters in multi-center THAI-SICU study. MATERIAL AND METHODS: Eligible patients admitted in SICU were 1,686 after excluding 563 of 2,249 participants owing to very short stay or non-alive within 24 hours after admission and missing data. The study was a posthoc analysis and multicenter descriptive design. The analytic methods described categorical data in percentage and the continuous data in the median with interquartile range. Variables divided into baseline characteristics and nutrition data before SICU admission, and the pattern of energy delivery in SICU. Statistical significance accepted as a p-value less than 0.05. RESULTS: The average age was 64 (52-76) years with 57% male. The median of serum albumin level at admission (interquartile range, IQR) was 2.8 (2.2-3.4). There was 46 -47 percent of nutrition risk patient. Less than 10 percent of the patient had enteral (EN), parenteral (PN) or their combination before admission. History of weight loss and appetite loss was 27-31 percent. However, seventy percent of the patient could not define the duration of the symptom. EN was initiated early, but the tendency of full feeding was 7-10 days. At that period, supplemental PN was added around 30 percent of total calories. The composition of PN was quite low in these study which contains only 15-16 percent of total calories. The average energy delivery was 20 kcal/kg/day (the recommendation is 25-30 kcal/kg/day). CONCLUSION: The patient's nutrition status before SICU admission was at risk of 46-47% and weight loss and appetite loss might unreliable in ICU setting. EN is started early with gradually increase up to 7-10 days. The average total calories requirement is lower than a recommendation.

Relationship between Height-Weight Difference Index and Body-Fat Percentage Estimated by Bioelectrical Impedance Analysis in Thai Adults.

INTRODUCTION: The height-weight difference index (HWDI) is a new indicator for evaluating obesity status. While body-fat percentage (BF%) is considered to be the most accurate obesity evaluation tool, it is a more expensive method and more difficult to measure than the others. OBJECTIVE: Our objectives were to find the relationship between HWDI and BF% and to find a BF% prediction model from HWDI in relation to age and gender. METHOD: Bioelectrical impedance analysis was used to measure BF% in 2,771 healthy adult Thais. HWDI was calculated as the difference between height and weight. Pearson's correlation coefficient was used to assess the relationship between HWDI and BF%. Multiple linear and nonlinear regression analysis were used to construct the BF% prediction model. RESULTS: HWDI and BF% were found to be inverse which related to a tendency toward a linear relationship. Results of a multivariate linear regression analysis, which included HWDI and age as variables in the model, predicted BF% to be 34.508 - 0.159 (HWDI) + 0.161 (age) for men and 53.35 - 0.265 (HWDI) + 0.132 (age) for women. CONCLUSIONS: The prediction model provides an easy-to-use obesity evaluation tool that should help awareness of underweight and obesity conditions.

Outcomes and Risk Factors of Extubation Failure: A Multicenter Study of the THAI Surgical Intensive Care Units (SICUs).

Objective: To identify risk factors associated with extubation failure (EF) in patients admitted to surgical ICUs (SICUs). Material and Methods: Data were gathered during April 2011-January 2013 by collecting demographic, admission details, daily summary, nutritional profile, APACHE II scores, and discharge summary from patients admitted to SICUs among nine university hospitals. Exclusion criteria include pediatric patients, non-consent patients, multiple trauma, cardiovascular and thoracic, and neurosurgical patients. Data were collected to the endpoint of 28 days of admission. Morbidity and mortality were determined. Complications or adverse events that occurred during admission were detailed in separate record forms. Result: Of 4,652 patients, 2,890 were intubated. Among them, 2,749 were successfully extubated leaving 141 with extubation failure. Overall incidence of EF was 4.88% (with range from 1.41-7.33). Patient characteristics in EF groups were compared to successful groups. Advanced age, presence of congestive heart failure, vascular disease, COPD, emergency surgery, poor APACHE II and SOFA scores, and concurrent use of vasopressors, inotropes and sedatives were significant differences. The most common causes of EF were respiratory failure, inability to cough and laryngeal edema. Outcomes of EF included prolonged length of ICU stay [2 (IQR 1-5) vs. 11 (IQR 6-15) days] and hospital stay [16 (IQR 10-27) vs. 23 (IQR 15-33) days]. Patients with EF were at risk of 6-fold longer ICU stay than successful extubation. Adjusted odds ratio of age, congestive heart failure, emergency surgery, and SOFA score were identified with statistical significance to be risk factors of EF. Conclusion: EF can affect outcomes of ICU admission. Identifying the risk factors associated with EF will help reduce its incidence and improve ICU outcomes.

The Impacts of Surgical Intensive Care Unit Admission Source on Morbidity and Mortality Outcomes: The Results from the THAI-SICU Study.

Objective: The present study aims to examine the association between admission source and outcomes in surgical ICU (SICU) patients. Material and Method: The data in the present report were retrieved from the THAI-SICU database which was designed as a multi-center prospective observational study. The data were collected at 9 university-based surgical ICUs over 22 months from April 2011 to January 2013. Results: The sources of SICU admissions were categorized into operating room (OR) group with 3,238 admissions (69.6%), emergency room (ER) group with 499 admissions (10.7%), ward group with 825 admissions (17.7%), and other ICUs group with 90 admissions (1.9%). In view of transfer from other hospitals, the transfer group included 938 patients (20.2%) while the non-transfer group included 3,714 patients (79.8%). Patients admitted from other ICUs were nearly three-times more likely to die in SICU (adjusted odds ratio (OR) 2.89; 95% confidence interval (CI) 1.52-5.51, p = 0.001) than those who came from operating room. However, the ward group still had a high risk to dying (OR 2.49; 95 % CI 1.88-3.30, p<0.001). In view of outcomes for inter-hospital transfer patients, the transfer group was at greater risk of dying in SICU and had greater risk of 28-day mortality than the non-transfer group. Conclusion: Surgical, critically ill patients, who transferred from other ICUs to SICU, have the highest risk of ICU morbidity and mortality. In addition, ward patients and transfer patients also have high risk of unfavorable outcomes.

Re-Admission within 72 Hours in Thai Surgical Intensive Care Units (Thai-SICU) Study: Characteristics, and Outcomes.

Objective: To identify incidence, characteristics and outcomes of patients who were re-admitted to surgical intensive care units (SICUs). Material and Method: Multicenter prospective cohort study conducted in 9 university-affiliated surgical ICUs in Thailand (THAI-SICU study) from April 2011 to January 2013. Results: A total of 144 patients (3.1%) re-admitted to our surgical ICUs from 4,652 cases were recruited. Re-admission baseline characteristics were advanced age (mean = 71 years), low body mass index, and higher APACHE-II and SOFA score within 24 hours of first ICU admission. Many significant comorbidities were found in the re-admission group, including: hypertension, cardiovascular diseases, and respiratory diseases. ICU mortality and hospital mortality were higher in readmission group than those in the non re-admission group (20.1% vs. 9.3%, p<0.001 and 27.8% vs. 11.3%, p<0.001, respectively). The relative risk ratio for mortality between re-admission and non re-admission in ICU was 2.17 times and in hospital mortality was 2.46 times greater. Independent potential risk factors for re-admission were age (OR 1.028, 95% CI 1.001-1.051), emergency surgical intervention (OR 1.978, 95% CI 1.027-3.813), transfer back from general wards (OR 4.175, 95% CI 2.020-8.628), and respiratory failure needing mechanical ventilation (OR 2.167, 95% CI 1.065-4.407). Conclusion: Re-admission was found in 3.1% of cases in our surgical ICUs. This problem is associated with significantly higher ICU and hospital mortality. Risk factors of re-admission were patient age, emergency surgery, re-admission from general wards, and need for respiratory support.

Cost of Critically Ill Surgical Patients in Thailand: A Prospective Analysis of a Multicenter THAI-SICU Study.

Objective: To quantify the total cost per admission and daily cost of critically ill surgical patients and cost attributable to Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, invasive mechanical ventilation and major complications in surgical intensive care unit (SICU) including sepsis, acute respiratory distress syndrome (ARDS), acute lung injury (ALI), acute kidney injury (AKI), cardiac arrest, and myocardial infarction. Material and Method: A multicentre, prospective, observational, cost analysis study was carried out in SICU of five university hospitals in Thailand. Patients of age over 18 admitted to SICU (more than 6 hours) from 18 April 2011 to 30 November 2012 were recruited.The total SICU cost per admission (in Thai baht currency year 2011-2012) were recorded using hospital accounting database. Average daily SICU cost was calculated from total ICU cost divided by the ICU length of stay. The occurrence of sepsis, major cardiac and respiratory complications and duration of invasive mechanical ventilation were studied. Results: A total of 3,055 patients with 12,592 ICU-days admitted to SICU during the study period. The median (IQR) ICU- length of stay was 2 (1, 4) days. The median (IQR) total SICU cost per admission was 44,055 (29,950-73,694) Thai baht. The median (IQR) daily cost was 18,777 (13,650-22,790) Thai baht. There was a variation of total and daily SICU cost across ICUs. For each of APACHE II score increases, cost increases with a median (IQR) of 1,731.755 (1,507.418-1,956.093) Thai baht. Invasive mechanically ventilated patients had higher cost than non-ventilated patients with a median (IQR) 15,873.4 (15,631.13-16,115.67) Thai baht. The patient with any complications listed here (sepsis, ARDS, ALI, AKI, myocardial infarction) had higher costs of care than ones who had none. Conclusion: Cost of critically ill surgical patients in the public university hospital in Thailand was varied. The complications occurred in ICU increased the cost. To quantify the resource consumption of individual patient admitted to SICU, the costing method and cost components must be verified.

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.

Self-Reporting of Medication Errors in Critically Ill Surgical Patients in the THAI-SICU Study.

Objective: The objective of this study was to collect the data of medication errors by the self-report of doctors and nurses in critically ill surgical patients. Material and Method: All data were collected from THAI-SICU database in nine medical schools in Thailand during a period of 22 months. The occurrence and medication error related factors were recorded. Results: From 4,652 admissions, there were only 10 cases of medication error. Of these, there were only 7 cases of complete self-report medication error, and all of them had no critical side effects. Most cases were of receiving wrong doses of medicine especially overdosing. The medicine preparers, administrators and the error detectors were mostly nurses. For immediate outcomes, two cases were reported of low blood pressure and one case was reported of lowering self-conscious. For longterm outcomes, there were two cases of prolonged ICU stays. Regarding the contributing factors, the most frequent problem found was communication. The most important factor minimizing incidents was to increase proper care. As to suggested corrective strategies, it was found that improved supervision was most needed. Conclusion: Reporting of medication errors by a self-report of doctors and nurses is low in this cohort, which might result from occurrences not being reported. The wrong dose is the most common occurrence and the communication is the most related factor.

Treatment with Vasoactive Drugs and Outcomes in Surgical Critically Ill Patients: The Results from the THAI-SICU Study.

Objective: The purpose of this study is to assess the impact of the use of vasoactive drugs on morbidity and mortality in surgical critically ill patients. Material and Method: We conducted a multi-center prospective observational study in Thai university-based surgical intensive care units (SICU) over a 22-month period. Patient data were recorded by case record form in 3 main phases: admission, daily and discharge. Data collection included patient characteristics, pattern of vasoactive drugs use, and outcomes. Results: Nine university-based SICU comprising 4,652 patients were included in the study. The vasopressor exposed patient group had 1,155 patients (24.8%). Either vasopressor or inotrope exposed group demonstrated significantly higher ICU mortality, 28-day mortality and new arrhythmia than the non-exposed group (p<0.001). In multivariable analysis, norepinephrine or epinephrine significantly increased risks of all unfavorable outcomes while dopamine significantly increased only new arrhythmia (OR 1.44; 95% CI 1.02-2.02, p = 0.036) in vasopressor-exposed patients. Epinephrine had the highest risk of all unfavorable outcomes with an OR 3.17; 95% CI 2.10-4.78, (p<0.001) for ICU mortality, OR 2.62; 95% CI 1.73-3.97, (p<0.001) for 28-day mortality, and OR of 1.77; 95% CI 1.13-2.75, (p = 0.012) for new arrhythmia. Neither dobutamine nor milrinone showed any significant results in inotrope exposed patients. Conclusion: Vasoactive drug exposed patient groups had significantly higher incidence of new arrhythmia, ICU mortality, and 28-day mortality. Epinephrine exposure was associated with the highest risk of unfavorable outcomes. Further information from well-designed studies is needed to justify the most appropriate use of vasoactive drugs.

The Association between Red Blood Cell Transfusion and Hospital Mortality in Critically Ill Surgical Patients: The Multi-center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study).

Objective: Red blood cell transfusion (RBCT) is commonly prescribed to critically ill patients with anemia. Nevertheless, the benefits of RBCT in these patients, particularly critically ill surgical patients, are still controversial. The aim of this study is to explore the association between RBCT and hospital mortality in Thai critically ill surgical patients. Material and Method: This study was a part of the multi-center, prospective, observational study, which included adult patients admitted to the SICUs after surgery. Patients were categorized into transfusion and no transfusion groups according to whether they received RBCT during SICU stay or not. The multiple logistic regression analysis was performed to determine whether RBCT was an independent risk factor for hospital mortality. The patients were also matched between two groups based on the propensity score for RBCT requirement and were then compared. Results: There were 2,531 patients included in this study. The incidence of RBCT in SICU was 40.3%. Overall, there was no association between RBCT in SICU and hospital mortality (adjusted OR 1.33, 95% CI 0.83-2.11) except in the subgroup of patients with age of <65 years old (adjusted OR 1.99, 95% CI 1.03-3.84). However, when the amount of RBCT was more than 1,200 mL, it was independently associated with increased hospital mortality (adjusted OR 2.55, 95% CI 1.35-4.81). In the propensity-score matching cohort, there was no association between RBCT in SICU and hospital mortality (adjusted OR 1.56, 95% CI 0.88-2.77) except when the amount of RBCT was more than 600 mL (601-1,200 mL, adjusted OR 3.14, 95% CI 1.47-6.72 and >1,200 mL, adjusted OR 3.58, 95% CI 1.36-9.48). Conclusion: RBCT should be considered as a life-saving intervention but with potential risks of adverse events. Identifying patients who will likely gain benefit from RBCT and implementing the restrictive transfusion strategy may be the keys to improve outcomes.

Modalities in Venous Thromboembolism Prophylaxis and Symptomatic Venous Thromboembolism Occurrence in Critically Ill Surgical Patients (THAI-SICU Study).

Objective: This report aimed to demonstrate the current modality of venous thrombomebolism (VTE) prophylaxis at the University-based critical, surgical care units (SICUs) and the occurrence of VTE during SICUs admission. Material and Method: The data were analyzed from a multicenter prospective observational study that was conducted in 9 university based SICUs in Thailand (THAI-SICU study). VTE prophylaxis and occurrence were recorded daily and VTE events which included deep vein thrombosis (DVT) and pulmonary embolism (PE) were collected only after symptomatic events occurred and confirmed the diagnosis by Doppler ultrasonographic examination or other imaging modalities. Results: A total of 385 in 4,652 cases (8.3%) received VTE prophylaxis. The modalities of VTE prophylaxis were significant difference depended on the admission diagnosis, patient age, and severity of diseases. The result of total VTE occurrence was 18 patients (0.4%) and mortality was 4 in 18 patients (22.2%). Of these, DVT occurred in 14 patients (0.3%) and mortality was 3 of 14 patients (21.4%), and the PE occurred in 4 patients (0.1%) and mortality was 1 of 4 patients (25.0%). Conclusion: The VTE prophylaxis rate was low in Thai University based SICUs. Although the overall incidence of symptomatic VTE in the SICUs low, the mortality rate was high in this cohort.

Incidence and Risk Factors of Unplanned Extubation in Critically Ill Surgical Patients: The Multi-center Thai University-based Surgical Intensive Care Units Study (THAI-SICU Study).

Objective: Unplanned extubation (UE) is one of the most troubling events in critically ill patients who require endotracheal intubation and mechanical ventilation. The aims of this study are to determine the incidence and to identify the risk factors associated with UE in critically ill surgical patients. Material and Method: This was a multi-center prospective observational cohort study, which included surgical patients admitted to nine university-based surgical intensive care units (SICUs) in Thailand between April 2011 and January 2013. UE was defined as deliberate extubation by patients (self-extubation) or accidental extubation during procedures or transportation. The incidence of UE was calculated, the adjusted logistic regression model was performed to determine the independent risk factors for UE and the outcomes were compared between those with planned extubation and UE. Results: 2,890 patients required endotracheal intubation and mechanical ventilation were included in the analysis. Of these, 54 patients experienced UE and, therefore, the incidence of UE was 1.9%. Five independent risk factors for UE were identified; congestive heart failure (adjusted odds ratio, OR, 3.48; 95% CI, 1.29-9.40), emergency surgery (adjusted OR, 2.18; 95% CI, 1.01-4.74), non-postoperative status (adjusted OR, 2.37; 95% CI, 1.05-5.37), sedation usage (adjusted OR, 3.19; 95% CI, 1.72-5.93) and delirium (adjusted OR, 3.61; 95% CI, 1.71-7.60). ICU length of stay (LOS) was significantly longer in patients with UE than those with planned extubation (adjusted coefficient, 2.76; 95% CI, 1.34-4.19). There was no significant difference between the two groups in terms of hospital LOS as well as ICU and 28-day mortality. Conclusion: The incidence of UE in critically ill surgical patients was 1.9%. Five independent risk factors for UE were: underlying congestive heart failure, emergency surgery, non-postoperative status, sedation usage, and delirium. Patients with UE had significantly longer ICU LOS than those with planned extubation.

The Differences of Nutrition Status, Energy Delivery and Outcomes between Metropolis and Regional University-Based Thai Surgical Intensive Care Units.

Objective: The objective of this study was to compare the differences of nutrition status, nutrition delivery, and the outcomes between the metropolis (MUH) and regional university based hospitals (RUH) in Thailand. Material and Method: The nutrition data were retrieved from the THAI-SICU database. A total of 1,686 patients (MUH 927 patients vs. RUH 759 patients) with completion of nutrition status and nutrition delivery data were included in this analysis. The enrolled patients from study centers located in Bangkok were defined as MUH, and the patients from Chiang Mai were defined as RUH. Patient characteristics, nutrition status using the subjective global assessment (SGA) and nutrition risk screening (NRS), nutrition delivery, and outcomes of treatment were recorded. The outcome associations were analyzed by a multivariable regression model. Results: At admission, there were significant differences of age, gender, body mass index, disease severity, albumin level, and diagnosis. RUH had significantly poorer nutritional status than MUH (RUH vs. MUH: SGA class B and C, 57.7% vs. 37.1%, p<0.001; NRS at risk, 56.3% vs. 38.4%, p<0.001). The tendency of total calories and enteral nutrition delivery per day of RUH was significantly lower than MUH especially in the first three weeks of hospitalization. Carbohydrates were the main resource for parenteral nutrition. Although there was no difference of protein delivery, MUH had a significantly higher prescription of fat emulsion especially in the 1st-2nd weeks. Even though there were higher occurrences of intensive care unit (ICU) mortality, 28-day mortality, sepsis occurrence, ICU length of stay (LOS), and hospital LOS in RUH, the multivariable analysis did not demonstrate the statistical value of these outcomes. Conclusion: RUH had a poorer nutritional status. MUH had more total caloric intake and enteral nutrition delivery per day especially during the first three weeks. However, the treatment outcomes showed no differences in multivariable analysis.

Incidence, Outcomes and Risk Factors for Mortality of Symptomatic upper Gastrointestinal Hemorrhage in Surgical Critical Ill Patients (THAI SICU Study).

Objective: This multicenter university-based study reports the incidence, outcomes and defined risk factors for mortality of upper gastrointestinal hemorrhage (UGIH) patients in the surgical intensive care units (ICU) patients in Thailand. Material and Method: This is part of a multicenter prospective observational study in the ICU in Thailand (THAI-SICU study). Patients who had a clinical presentation of upper gastrointestinal hemorrhage or an endoscopic diagnosis from April 2011 to January 2013 were enrolled into this sub-study. Results: A total of 4,652 patients were analyzed. Fifty-five patients (1.18%) had symptomatic UGIH during ICU admission. The median age (interquartile range, IQR) was 72 (63-78) years old and the median APACHE II score (IQR) was 17 (13-22). In a comparison between the UGIH patients who survived and those who non-survived APACHE II score were higher in the non-survivors. The ICU mortality rate and 28-day mortality rate in these patients were 30.91% and 40%, respectively. In multivariable model, UGIH was significantly associated with 28-day mortality [adjusted odds ratio, OR, (95% confidence interval, CI): 1.99 (1.02 to 3.88); p = 0.043] and ICU length of stay [adjusted coefficient (95% CI): 9.36 (8.03 to 10.70); p<0.001]. Regarding the exploratory model, the significant risk factors for non-survived of UGIH patients were coagulopathy especially platelet count <50,000 [OR (95% CI): 3.96 (1.07-14.67); p = 0.039] and INR >1.5 [5 (1.04-23.98); p = 0.044], renal failure [6.48 (1.37-30.61); p = 0.018], APACHE II score [1.11 (1.02-1.22); p = 0.020] and vasopressor use [5.78 (1.6-37.18); p = 0.013]. Conclusion: The incidence of symptomatic UGIH in the THAI-SICU study was 1.18% and UGIH was associated with higher 28-day mortality rate and prolonged ICU length of stay. The risk factors for mortality were coagulopathy, renal failure, APACHE II score and vasopressor use.