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).

Comparing Outcomes of Critically Ill Patients in Intensive Care Units and General Wards: A Comprehensive Analysis

Background

The admission of critically ill patients to intensive care unit (ICU) plays a crucial role in reducing mortality. However, the scarcity of available ICU beds presents a significant challenge. In resource-limited settings, the outcomes of critically ill patients, particularly those who are not accepted for ICU admission, have been a topic of ongoing debate and contention.

Objective

This study aimed to explore the outcomes and factors associated with ICU admission and mortality among critically ill patients in Thailand.

Methods

This prospective cohort study enrolled critically ill adults indicated for medical ICU admission. Patients were followed for 28 days regardless of whether they were admitted to an ICU. Data on mortality, hospital length of stay, duration of organ support, and factors associated with mortality and ICU admission were collected.

Results

Of the 180 patients enrolled, 72 were admitted to ICUs, and 108 were cared for in general wards. The ICU group had a higher 28-day mortality rate (44.4% vs 20.4%; P=0.001), but other outcomes of interest were comparable. Multivariate analysis identified alteration of consciousness, norepinephrine use, and epinephrine use as independent predictors of 28-day mortality. Higher body mass index (BMI), higher APACHE II score, and acute kidney injury were predictive factors associated with ICU acceptance.

Conclusion

Among patients indicated for ICU admission, those who were admitted had a higher 28-day mortality rate. Higher mortality was associated with alteration of consciousness and vasopressor use. Patients who were sicker and had higher BMI were more likely to be admitted to an ICU.

Patient-Level Meta-Analysis of Low-Dose Hydrocortisone in Adults with Septic Shock

Low-Dose Hydrocortisone and Septic ShockCorticosteroids have been evaluated as a therapy for septic shock for more than 50 years. However, uncertainty persists about their effects on mortality. Pirracchio and colleagues undertake a patient-level meta-analysis to answer this important question.

Prevalence and independent predictors of in-hospital stroke among patients who developed acute alteration of consciousness in the medical intensive care unit: A retrospective case-control study

Background

In-hospital stroke is a serious event, associated with poor outcomes and high mortality. However, identifying signs of stroke may be more difficult in critically ill patients.

Objectives

This study investigated the prevalence and independent predictors of in-hospital stroke among patients with acute alteration of consciousness in the medical intensive care unit (MICU) who underwent subsequent brain computed tomography (CT).

Methods

This retrospective study enrolled eligible patients during the period 2007 - 2017. The alterations researched were radiologically confirmed acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH).

Results

Of 4 360 patients, 113 underwent brain CT. Among these, 31% had AIS, while 15% had ICH. They had higher diastolic blood pressures and arterial pH than non-stroke patients. ICH patients had higher mean (standard deviation (SD) systolic blood pressures (152 (48) v. 129 (25) mmHg; p=0.01), lower mean (SD) Glasgow Coma Scale scores (4 (3) v. 7 (4); p=0.004), and more pupillary abnormalities (75% v. 9%; p<0.001) than AIS patients. AIS patients were older (65 (18) v. 57 (18) years; p=0.03), had more hypertension (60% v. 39%; p=0.04), and more commonly presented with the Babinski sign (26% v. 9%; p=0.04). Multivariate analysis found that pupillary abnormalities independently predicted ICH (adjusted odds ratio (aOR) 26.9; 95% CI 3.7 - 196.3; p=0.001). The Babinski sign (aOR 5.1; 95% CI 1.1 - 23.5; p=0.04) and alkalaemia (arterial pH >7.4; aOR 3.6; 95% CI 1.0 - 12.3; p=0.05) independently predicted AIS.

Conclusion

Forty-six percent of the cohort had ICH or AIS. Both conditions had high mortality. The presence of pupillary abnormalities predicts ICH, whereas the Babinski sign and alkalaemia predict AIS.

Contributions of the study

The present study reports that almost half (46%) of critically ill patients with alterations of consciousness had an acute stroke. Of these, two-thirds had an acute ischaemic stroke (AIS), and one-third had an intracranial haemorrhage (ICH). Multivariate analysis revealed that a pupillary abnormality was a predictor for ICH and the Babinski sign was identified as a predictor of AIS.

Predictive factors and outcomes of respiratory syncytial virus infection among patients with respiratory failure

Introduction

Respiratory syncytial virus (RSV) infection is an emerging infectious disease. However, the impacts of RSV infection among patients with respiratory failure have not been identified.

Objective

This study investigated the 28-day mortality and clinical outcomes of RSV infection in patients with respiratory failure.

Methods

This retrospective study enrolled patients admitted with respiratory failure and requiring mechanical ventilator support for more than 24 h at Siriraj Hospital, Bangkok, Thailand, between January 2014 and July 2019. Respiratory samples of the patients were examined to identify RSV infections. The primary outcome was 28-day mortality.

Results

Respiratory syncytial virus infection was identified in 67 of the 335 patients with respiratory failure enrolled in this study. There were no significant differences in the following baseline characteristics of the patients with and without RSV infection: mean age (72.7 ± 12.7 years vs. 71 ± 14.8 years), sex (male: 46.3% vs. 47.4%), comorbidities, and initial Murray lung injury scores (1.1 ± 0.8 vs. 1.1 ± 0.9). The 28-day mortality was 38.8% (26/67) for the RSV group and 37.1% (99/268) for the non-RSV group (p = 0.79). However, the RSV group had significantly higher proportions of bronchospasm (98.5% vs. 60.8%; p &lt; 0.001), ventilator-associated pneumonia (52.2% vs. 33.8%; p = 0.005), and lung atelectasis (10.4% vs. 3.0%; p = 0.009) than the non-RSV group.

Conclusion

Among the patients with respiratory failure, the 28-day mortality of patients with and without RSV infection did not differ. However, patients with RSV infection had an increased risk of complications, such as bronchospasm, ventilation-associated pneumonia, and lung atelectasis.

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.

Anti-SARS-CoV-2 antibody among SARS-CoV-2 vaccinated vs post-infected blood donors in a tertiary hospital, Bangkok, Thailand

SARS-CoV-2 virus infection has imposed a significant healthcare burden globally. To contain its spread and decrease infection-related mortality, several vaccines have been deployed worldwide in the past 3 years. We conducted a cross-sectional seroprevalence study to assess the immune response against the virus among blood donors at a tertiary care hospital, Bangkok, Thailand. From December 2021 to March 2022, total of 1,520 participants were enrolled, and their past history of SARS-CoV-2 infection and vaccination was recorded. Two serology test, namely, quantitative IgG spike protein (IgGSP) and qualitative IgG nucleocapsid antibody (IgGNC) were performed. The median age of study participants was 40 years (IQR 30-48) and 833 (54.8%) were men. Vaccine uptake was reported in 1,500 donors (98.7%) and 84 (5.5%) reported the past infection history. IgGNC was detected in 46/84 donors with the past infection history (54.8%) and in 36 out of the rest 1,436 (2.5%) with no past history. IgGSP positivity was observed in 1484 donors (97.6%). When compared to unvaccinated donors (n = 20), IgGSP level was higher in the donors who had received one vaccine dose (p< 0.001) and these antibody levels increased significantly among those with 3rd and 4th vaccine doses. Factors associated with low IgGSP (lowest quartile) by multivariate analysis included: no past infection history, homologous vaccination, < 3 vaccine doses, and > 90 days duration since last vaccination. In conclusion, vaccine uptake among our study donors was high (98.7%) and IgGSP antibody was observed in nearly all the vaccinated donors (97.6%). Previous SARS-CoV-2 infection, use of heterologous vaccination, vaccines ≥ 3 doses, and duration of the last vaccination >90 days affected IgGSP levels. Use of serological assays were found beneficial in the evaluation and differentiation of immune response to vaccination, and natural infection including the identification of previous asymptomatic infections.

Continuous Vancomycin Infusion versus Intermittent Infusion in Critically Ill Patients

Background

Vancomycin is the best-choice medication for methicillin-resistant staphylococcal and enterococcal infections, which are major problems in intensive care units (ICUs). Intermittent infusion is standard for vancomycin, although delayed therapeutic target achievement and supra- and subtherapeutic levels are concerns. A recently proposed alternative with superior therapeutic target achievement is continuous infusion.

Objective

To compare the benefits of continuous (CVI) and intermittent (IVI) vancomycin infusion.

Methods

This quasi-experimental study used propensity score-matched historical controls and adult patients in medical and surgical ICUs for whom vancomycin was indicated. The experimental group received CVI for ≥ 48 hours. Data on patients receiving IVI between January 2018 and October 2020 were reviewed. Capability to achieve serum vancomycin therapeutic targets (48 and 96 hours), episodes of supra- and subtherapeutic levels, treatment success, mortality, and incidence of acute kidney injury (AKI) were analyzed before and after one-to-two propensity score matching.

Results

The CVI group had 31 patients, while the unmatched IVI group had 125. More CVI patients achieved the therapeutic target within 48 hours (54.8% vs 25.6%; P=0.002). CVI patients had a higher median number of supratherapeutic episodes (2 vs 1; P=0.007) but a lower median for subtherapeutic episodes (0 vs 1; P=0.003). Other outcomes demonstrated no differences. After propensity score matching, target achievement within 48 hours (54.8% vs 22.6%; P=0.002) and fewer subtherapeutic episodes (0 vs 1; P=0.014) remained significant.

Conclusion

CVI's rapid therapeutic target achievement and fewer subtherapeutic episodes make it superior to IVI. No differences in treatment success, mortality, or AKI are evident.

Serum lactate levels in cirrhosis and non-cirrhosis patients with septic shock

Background

In septic shock patients with cirrhosis, impaired liver function might decrease lactate elimination and produce a higher lactate level. This study investigated differences in initial lactate, lactate clearance, and lactate utility between cirrhotic and non-cirrhotic septic shock patients.

Methods

This is a retrospective cohort study conducted at a referral, university-affiliated medical center. We enrolled adults admitted during 2012-2018 who satisfied the septic shock diagnostic criteria of the Surviving Sepsis Campaign: 2012. Patients previously diagnosed with cirrhosis by an imaging modality were classified into the cirrhosis group. The initial lactate levels and levels 6 hours after resuscitation were measured and used to calculate lactate clearance. We compared initial lactate, lactate at 6 hours, and lactate clearance between the cirrhosis and non-cirrhosis groups. The primary outcome was in-hospital mortality.

Results

Overall 777 patients were enrolled, of whom 91 had previously been diagnosed with cirrhosis. Initial lactate and lactate at 6 hours were both significantly higher in cirrhosis patients, but there was no difference between the groups in lactate clearance. A receiver operating characteristic curve analysis for predictors of in-hospital mortality revealed cut-off values for initial lactate, lactate at 6 hours, and lactate clearance of >4 mmol/L, >2 mmol/L, and <10%, respectively, among non-cirrhosis patients. Among patients with cirrhosis, the cut-off values predicting in-hospital mortality were >5 mmol/L, >5 mmol/L, and <20%, respectively. Neither lactate level nor lactate clearance was an independent risk factor for in-hospital mortality among cirrhotic and non-cirrhotic septic shock patients.

Conclusion

The initial lactate level and lactate at 6 hours were significantly higher in cirrhosis patients than in non-cirrhosis patients.

High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial

BACKGROUND

High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients.

METHODS

We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation.

RESULTS

Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59).

CONCLUSIONS

Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://clinicaltrials.gov/ct2/show/NCT03246893?term=surat+tongyoo&draw=2&rank=3.

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 (NCT 04031794).

Delirium in a Medical Intensive Care Unit: A Report from a Tertiary Care University Hospital in Bangkok

Objective: Delirium is a common problem in critical care. Its prevalence in the unit varies, depending upon the severity of the illness and the diagnostic methods. Currently, the CAM-ICU is a diagnostic tool with good diagnostic accuracy. Our study aimed to determine the prevalence, associated factors, and outcomes of delirium in our unit by using the CAM-ICU.Methods: Our prospective cohort study included all patients admitted to the hospital’s medical ICU from August to December 2013. Patients with psychosis and/or in a coma (RAAS<-3) were excluded. We assessed delirium by using the CAM-ICU within the first 24 hours of admission and then serially, every 48 hours until discharge. Factors associated with this condition and patients’ outcomes were also explored.Results: A total of 74 patients were included. Of these, 43% were male, 40% had sepsis, and 81% were mechanically ventilated. Twenty-eight patients (38%) had delirium upon admission.  The delirium patients were older and had a higher percentage of dementia. Univariate analysis revealed that dementia, anemia, acute metabolic acidosis, and the use of mechanical ventilation were associated with the occurrence of delirium, and, for age > 70 years, anemia and metabolic acidosis remained significant on multivariate analysis. Delirium was significantly associated with prolonged hospitalization (>30days), with OR = 4.84 (p=0.009), and with increased mortality, with OR = 25.0 (p=0.001).Conclusion: This study confirmed that delirium was common in the medical ICU and was associated with poor outcomes. Importantly, associated factors with delirium in our study appeared to be modifiable. Further study on early management and prevention of those risk factors is crucial.

In-Hospital Death after Septic Shock Reversal: A Retrospective Analysis of In-Hospital Death among Septic Shock Survivors at Thailand's Largest National Tertiary Referral Center

Advances in sepsis resuscitation have significantly improved shock control; however, many patients still die after septic shock reversal. We conducted a retrospective review to examine in-hospital death in whom shock was reversed and vasopressor was discontinued for 72 hours or longer. Factors independently associated with death were determined. Medical records of septic shock survivors from the medical intensive care unit of the Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January 2012-January 2019 were analyzed. A total of 350 septic shock patients were enrolled. Of these, 280 survived initial resuscitation. Eighty of 280 patients died, 45 died by 28 days (16.1%), and 35 (12.5%) died thereafter during their hospital stay. Multi-organ failure and hospital-acquired pneumonia (HAP) were the leading causes of death, followed by other infection and noninfectious complication. Although the death group had more laboratory derangement and required more organ support, there were four factors associated with mortality from multivariate analysis. Hospital-acquired pneumonia was the leading factor, followed by sequential organ failure assessment score and serum albumin at 72 hours after discontinuation of vasopressors, and total intravenous fluid during 72 hours after discontinuation of vasopressors. In-hospital mortality after hemodynamic restoration in patients with septic shock was substantial. Causes and contributing factors were identified. Measures to mitigate these risks would be beneficial for rendering more favorable patient outcomes.

Predictor of in-hospital mortality among acute coronary syndrome patients after treatment with an intra-aortic balloon pump in tertiary Hospital, Thailand

Objective: Intra-aortic balloon pump (IABP), a mechanical hemodynamic support device, had widely been used to treat cardiogenic shock patients for several decades. However, the information about the predictive factors associated with mortality was scarce. This study aims to identify the predictive factors associated with in-hospital mortality in acute coronary syndrome (ACS) patients who performed IABP for their hemodynamic support during admission.Methods: We conduct a retrospective cohort study design. All admission records of ACS patients with IABP at Suratthani Hospital between October 2015 and September 2019 were retrieved.Results: Overall 75 ACS patients with IABP insertion were enrolled. Thirty-one patients died during admission, in-hospital mortality was 41.3%. From the multivariable analysis, we identified 3 predictors associated with in-hospital mortality included cardiac arrest at presentation (adjusted OR [aOR]=11.18, 95%CI: 2.42-51.57, P=0.002), a higher number of inotropes or vasopressors (aOR 6.10, 95%CI 1.36-27.24, P=0.018) and Killip class IV (aOR 5.64, 95%CI 1.01-31.39, P=0.048).Conclusion: ACS patients who required IABP support had high mortality. Cardiac arrest, Killip class IV (cardiogenic shock) at presentation and requiring a higher number of inotropes or vasopressors were independent predictive factors of in-hospital mortality.

Albumin Versus Gelatin Solution for the Treatment of Refractory Septic Shock: A Patient Baseline-Matched-Cohort Study

Objective: Although albumin solution is the colloid of choice to resuscitate septic shock patients who do not respond to crystalloid solutions, its usage is limited by its cost. Gelatin solution, is less expensive, but its efficacy has not yet been identified. This study aimed to compare the outcomes of gelatin and albumin solutions for septic shock resuscitation.Methods: This baseline-matched-cohort study, enrolled septic shock patients who had a mean arterial blood pressure (MAP) below 65 mmHg after receiving at least 30 mL per kilogram of crystalloid resuscitation fluid, and who required either an albumin or gelatin solution as fluid therapy. The primary outcome was the 28-day mortality.Results: In all, 224 patients who were administered either an albumin or gelatin solution were examined. After adjusting for differences in their baseline characteristics, 206 patients were included (104 receiving albumin, and 102 given gelatin). A comparison of the albumin and gelatin groups revealed no significant baseline differences in their respective mean APACHE II scores (22.8±8.5vs.23.2±8.1), MAPs (55.1±8.0vs.54.6±9.1mmHg), and lactate levels (5.6±4.7vs.6.3±4.9mmol/L). The 28-day mortality rates were 27.9% and 38.2% for the albumin and gelatin groups, respectively, with adjusted p=0.02. Moreover, the accumulation of fluid intake over output at 72 hours was significantly lower for the albumin than the gelatin group (5,964.5±4,959.7 vs. 8,133.2±3,743.2 ml; p=0.01). The RRT rate was higher for the albumin group (30.8% vs. 15.7%; p=0.01).Conclusion: Albumin resuscitation associated with lower 28-day mortality than gelatin resuscitation. The patients in the albumin group had a higher RRT rate and a lower fluid accumulation as at 72 hours.

Serum potassium levels and outcomes in critically ill patients in the medical intensive care unit

Objective To compare the outcomes of patients with and without a mean serum potassium (K⁺) level within the recommended range (3.5-4.5 mEq/L). Methods This prospective cohort study involved patients admitted to the medical intensive care unit (ICU) of Siriraj Hospital from May 2012 to February 2013. The patients' baseline characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, serum K⁺ level, and hospital outcomes were recorded. Patients with a mean K⁺ level of 3.5 to 4.5 mEq/L and with all individual K⁺ values of 3.0 to 5.0 mEq/L were allocated to the normal K⁺ group. The remaining patients were allocated to the abnormal K⁺ group. Results In total, 160 patients were included. Their mean age was 59.3±18.3 years, and their mean APACHE II score was 21.8±14.0. The normal K⁺ group comprised 74 (46.3%) patients. The abnormal K⁺ group had a significantly higher mean APACHE II score, proportion of coronary artery disease, and rate of vasopressor treatment. An abnormal serum K⁺ level was associated with significantly higher ICU mortality and incidence of ventricular fibrillation. Conclusion Critically ill patients with abnormal K⁺ levels had a higher incidence of ventricular arrhythmia and ICU mortality than patients with normal K⁺ levels.

Factors predicting failure of noninvasive ventilation assist for preventing reintubation among medical critically ill patients

PURPOSE

Reintubation after failed extubation is associated with high mortality. Noninvasive ventilation (NIV) has been used to prevent reintubation, but the results have been inconclusive. We investigated the factors predicting failure of NIV-assisted extubation among medical critically ill patients.

MATERIALS AND METHODS

This retrospective cohort study enrolled patients who were admitted to medical intensive care units at Siriraj Hospital between March 2012 and August 2015 who required more than 48 hours of mechanical ventilation and who received NIV after endotracheal extubation. NIV was considered to have failed if the patient required reintubation during intensive care unit admission.

RESULTS

A total of 105 patients (57 male; mean age, 63.3±17.9 years) were enrolled. The reintubation rate was 45.7%. Univariate analysis identified pre-NIV Sepsis-related Organ Failure Assessment score >3.5, respiratory failure caused by pneumonia, heart rate after NIV for 1 hour of more 100 beats per minute, fluid accumulation greater than 100 mL/kg, and NIV duration more than 96 hours as factors associated with reintubation. However, multivariate analysis identified pneumonia as the only predictive factor for failure of NIV-assisted extubation among critically ill patients. Reintubated patients had significantly higher hospital mortality than successfully extubated patients.

CONCLUSIONS

Respiratory failure caused by pneumonia is predictive of failure of NIV-assisted extubation.

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.

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.

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.

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.

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.

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.

Evaluation of correlation between vascular pedicle width and intravascular volume status in Thai critically ill patients

OBJECTIVE

To evaluate the correlation between vascular pedicle widths (VPW) measured from portable chest roentgenogram (CXR) and intravascular volume status in Thai critically ill patients.

MATERIAL AND METHOD

A prospective cohort study included the critically ill patients in whom pulmonary artery catheter was placed in the Medical Intensive Care Units of Siriraj Hospital, Mahidol University between June 2009 and January 2010. The patient's baseline characteristics, hemodynamic data measured from pulmonary artery catheter (PAC) and CXR parameters were collected.

RESULTS

From thirty-four patients, thirteen (38.2%) had high pulmonary artery occlusive pressure (PAOP > or =18 mmHg). The patients with high PAOP were older (69.8 +/- 8.8 years vs. 59.2 +/- 15.4 years, p = 0.02), taller (163.2 +/- 5.3 cm vs. 157.0 +/- 10.4 cm, p = 0.03) and higher weight (67.4 +/- 12.9 kg vs. 57.1 +/- 7.8 kg, p = 0.007) than the low PAOP group. The correlations between PAOP and VPW (r = 0.68, p < 0.001) as well as between PAOP and cardiothoracic ratio (CTR) (r = 0.23, p = 0.03) were significant. From the receiver operating characteristic (ROC) curve, VPW > 68 mm is the best parameter to predict PAOP > or =18 mmHg (the area under the curve (AUC) = 0.853, p < 0.001, sensitivity = 92.3%, specificity = 85.7%). The CTR > 0.58 can be used to predict elevated PAOP > or =18 mmHg with acceptable sensitivity = 85.74% and specificity = 76.9% (AUC = 0.727, p = 0.03). The peribronchial cuffing (PBC) was detected at a higher percentage among high PAOP group than in the low PAOP group (76.9% vs. 33.3%, p = 0.03).

CONCLUSION

The VPW >68 mm, CTR >0.58 and the present of PBC can be used together to predict elevation of PAOP > or =18 mmHg among the Thai critically ill patients. By using these CXR parameters, the PAC insertion may be avoided especially in patients with contraindication.

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.

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.

The effect of lateral position on oxygenation in ARDS patients: a pilot study

BACKGROUND

The effect of body position on oxygenation in acute respiratory distress syndrome (ARDS) patients has long been known. Prone position improves the PaO2 in 60-70% of ARDS patients. However the effect of the lateral positions, which are used in routine critical care, has never been reported.

OBJECTIVE

To determine whether placing the patient in a lateral position has any effect on oxygenation in ARDS.

MATERIAL AND METHOD

Prospective observational study, comparing oxygenation in ARDS patients between supine, right and left lateral positions (> or = 60 degree).

RESULTS

We included 18 ARDS patients, their mean aged was 52.2 +/- 19.6 years, 14 were men and the ICU mortality rate was 61.1%. There was no significant change in the mean PaO2, arterial blood gas parameters, respiratory mechanics and hemodynamic parameters between the supine and decubitus positions in the overall group. However there was a trend toward increasing the mean PaO2 during right lateral position compared with the supine position (90.3 +/- 29.0 vs 84.6 +/- 20.4, p = 0.23). Nine patients who responded to the right lateral position had significantly higher mean PaO2 during the right lateral position than in the supine position (107.8 +/- 29.0 vs 85.6 +/- 21.8, p < 0.0001). In this group, four patients had predominant left pulmonary infiltration and five patients had equally bilateral pulmonary infiltration on chest X-ray. Unfortunately, the PaO2 in three patients decreased more than 10 mmHg during right lateral decubitus.

CONCLUSION

The PaO2 increased while in the right lateral position in patients with predominant left pulmonary infiltration or bilateral infiltration. This effect may be due to the small sample size. A further large-sized randomized controlled study is needed.

An outbreak of botulism in Thailand: clinical manifestations and management of severe respiratory failure

BACKGROUND

Northern Thailand's biggest botulism outbreak to date occurred on 14 March 2006 and affected 209 people. Of these, 42 developed respiratory failure, and 25 of those who developed respiratory failure were referred to 9 high facility hospitals for treatment of severe respiratory failure and autonomic nervous system involvement. Among these patients, we aimed to assess the relationship between the rate of ventilator dependence and the occurrence of treatment by day 4 versus day 6 after exposure to bamboo shoots (the source of the botulism outbreak), as well as the relationship between ventilator dependence and negative inspiratory pressure.

METHODS

We reviewed the circumstances and timing of symptoms following exposure. Mobile teams treated patients with botulinum antitoxin on day 4 or day 6 after exposure in Nan Hospital (Nan, Thailand). Eighteen patients (in 7 high facility hospitals) with severe respiratory failure received a low- and high-rate repetitive nerve stimulation test, and negative inspiratory pressure was measured.

RESULTS

Within 1-65 h after exposure, 18 of the patients with severe respiratory failure had become ill. The typical clinical sequence was abdominal pain, nausea and/or vomiting, diarrhea, dysphagia and/or dysarthria, ptosis, diplopia, generalized weakness, urinary retention, and respiratory failure. Most patients exhibited fluctuating pulse and blood pressure. Repetitive nerve stimulation test showed no response in the most severe stage. In the moderately severe stage, there was a low-amplitude compound muscle action potential with a low-rate incremented/high-rate decremented response. In the early recovery phase, there was a low-amplitude compound muscle action potential with low- and high-rate incremented response. In the ventilator-weaning stage, there was a normal-amplitude compound muscle action potential. Negative inspiratory pressure variation among 14 patients undergoing weaning from mechanical ventilation was observed. Kaplan-Meier survival analysis identified a shorter period of ventilator dependency among patients receiving botulinum antitoxin on day 4 (P=.02).

CONCLUSIONS

Patients receiving botulinum antitoxin on day 4 had decreased ventilator dependency. In addition, for patients with foodborne botulism, an effective referral system and team of specialists are needed.

Thrombocytopenic purpura associated with miliary tuberculosis

The authors report a case of thrombocytopenia associated with miliary tuberculosis. The patient was a 28-year-old woman who was admitted because of massive upper gastrointestinal hemorrhage and acute respiratory failure. Chest radiographs revealed diffuse bilateral reticulonodular infiltration and complete blood count was significant for severe thrombocytopenia. Bone marrow biopsy was performed to investigate the cause of thrombocytopenia and demonstrated multiple tiny caseating granulomas suggesting miliary tuberculosis (TB). She received anti-TB therapy and a short course of steroid with good response. Platelet count returned to normal limit within 10 days. Although isolated thrombocytopenia is uncommon in TB, it is still important to consider TB in the differential diagnosis of thrombocytopenia, particularly in patients with abnormal chest radiographs. Bone marrow examination is very helpful in this situation.

Invasive streptococcal group A infection and toxic shock syndrome in Songklanagarind hospital

BACKGROUND AND OBJECTIVES

Streptococcal group A infection is reported as a medical problem in several parts of the world. The most serious complication of this infection is streptococcal toxic shock syndrome (STSS) which is associated with a very high mortality rate. The present study aimed to determine the clinical manifestations, including underlying conditions, mortality and prognostic factors, of invasive streptococcal group A infection and STSS from southern Thailand (Songklanagarind Hospital).

METHOD

The medical records of infected patients from January 1, 1995 to June 30, 1999 were reviewed retrospectively. Criteria for diagnosis of STSS were as follows (JAMA 1993). Prognostic factors were analyzed by logistic regression model.

RESULT

176 cases of STSS and streptococcal group A infection, 89.9 per cent were community acquired infections. About 70 per cent of the infected patients had previous underlying conditions, the most common was cancer. The commonest site of infection was the skin and soft tissue (80.1%). The total mortality rate from streptococcal group A infection was 9.1 per cent. STSS was identified in 12 patients (6.8%), with a 50 per cent mortality rate. Prognostic factors for mortality in this infection were diabetic mellitus (odds ratio 9.67, p<0.025), history of steroid use (odds ratio 11.17, p<0.017), STSS (odds ratio 22.16, p<0.005) and received cancer chemotherapy (odds ratio 115.19, p<0.003). Predictive factors for STSS couldn't be identified, while age >65 years and steroid use were suggested protective factors for this condition [odds ratio 0.02, p<0.0001 and odd ratio 0.07, p<0.027 respectively].

Review of 336 patients with hepatocellular carcinoma at Songklanagarind Hospital

AIM: To determine the clinical presentations, survival and prognostic factors of hepatocellular carcinoma (HCC) in Southern Thailand.

METHODS: Retrospective analysis was performed on the 336 hepatocellular carcinoma patients treated at Songklanagarind hospital between 1 January 1991 and 31 January 1999.

RESULTS: Of these 336 patients, 276 were males and 60 were females. The mean age was 54.4 years. The common symptoms and signs were abdominal pain and hepatomegaly. The most common presentation of tumor was a dominant mass with daughter nodules. Portal vein involvement was found in 50% of total. Extra hepatic metastasis was found in 13%, and the lung was the most common site. There were 65.4% with evidence of cirrhosis and half of them were in Child's class B. HBsAg was positive in 72.6%. Regarding Okuda's tumor staging, 15%, 61% and 24% were stage I, II and III, respectively. Overall median survival was 2.1 months (11.5, 2.6 and 0.7 months for stage I, II and III respectively). Treatments of HCC improved patient survival (5.5 months vs 1.6 months for untreated patients). Most common causes of death were hepatic failure. Using multivariate analysis, the prognostic factors identified were tumor staging, alpha-fetoprotein level above 10000 μg·L^-1, extrahepatic metastasis, portal vein thrombosis and treatment.

CONCLUSION: HCC in Thailand is a fatal disease with poor outcome due to late presentation and high prevalence of liver cirrhosis. Early detection and proper management may improve outcome.