Prevalence, predictive factors, and outcomes of refeeding syndrome among medically critically ill patients: A retrospective cohort study.

BACKGROUND: Refeeding syndrome (RFS) is a life-threatening metabolic derangement occurring when nutrition is reintroduced after prolonged starvation. Limited data exist regarding RFS prevalence, risk factors, and outcome, particularly in critically ill patients. METHODS: A retrospective cohort study was conducted in a medical intensive care unit from June 2018 to August 2020. RFS diagnostic criteria from the National Institute for Health and Care Excellence (NICE) and the American Society for Parenteral and Enteral Nutrition (ASPEN) were used. The primary outcome was 30-day mortality. RESULTS: Among 216 patients, RFS was diagnosed in 22.7% and 27.3% of patients per the NICE and ASPEN criteria, respectively. There was no significant difference in 30-day mortality between patients with and without RFS (22/59 [37.3%] vs 53/157 [33.8%]; P = 0.627). Independent predictors of RFS were malignancy (odds ratio [OR] = 2.09; 95% CI = 1.06-4.15; P = 0.035), septic shock (OR = 2.26; 95% CI = 1.17-4.39; P = 0.016), and high NICE RFS risk classification (OR = 2.52; 95% CI = 1.20-5.31; P = 0.015). Factors associated with reduced RFS risk were Sequential Organ Failure Assessment (SOFA) scores >12 (OR = 0.45; 95% CI = 0.23-0.88; P = 0.020) and high-dose vasopressor treatment (OR = 0.34; 95% CI = 0.14-0.79; P = 0.012). CONCLUSION: RFS affected one-fourth of the critically ill patients but did not significantly impact 30-day mortality. Malignancy, septic shock, and high NICE RFS risk classification were positively associated with RFS, whereas high SOFA scores and extensive vasopressor use were linked to decreased risk.

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

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

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

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.

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.

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 < 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.

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

BACKGROUND: Trials and study-level meta-analyses have failed to resolve the role of corticosteroids in the management of patients with septic shock. Patient-level meta-analyses may provide more precise estimates of treatment effects, particularly subgroup effects. METHODS: We pooled individual patient data from septic shock trials investigating the adjunctive use of intravenous hydrocortisone. The primary outcome was 90-day all-cause mortality, and it was also analyzed across predefined subgroups. Secondary outcomes included mortality at intensive care unit and hospital discharge, at 28 and 180 days, and vasopressor-, ventilator-, and organ failure­free days. Adverse events included superinfection, muscle weakness, hyperglycemia, hypernatremia, and gastroduodenal bleeding. RESULTS: Of 24 eligible trials (n=8528), 17 (n=7882) provided individual patient data, and 7 (n=5929) provided 90-day mortality. The marginal relative risk (RR) for 90-day mortality of hydrocortisone versus placebo was 0.93 (95% confidence interval [CI], 0.82 to 1.04; P=0.22; moderate certainty). It was 0.86 (95% CI, 0.79 to 0.92) for hydrocortisone with fludrocortisone and 0.96 (95% CI, 0.82 to 1.12) without fludrocortisone. There was no significant differential treatment effect across subgroups. Hydrocortisone was associated with little to no difference in any of the secondary outcomes except vasopressor-free days (mean difference, 1.24 days; 95% CI, 0.74 to 1.73; high certainty). Hydrocortisone may not be associated with an increase in the risk of superinfection (RR, 1.04; 95% CI, 0.95 to 1.15; low certainty), hyperglycemia (RR, 1.05; 95% CI, 0.98 to 1.12; low certainty), or gastroduodenal bleeding (RR, 1.11; 95% CI, 0.83 to 1.48; low certainty). Hydrocortisone may be associated with an increase in the risk of hypernatremia (RR, 2.01; 95% CI, 1.56 to 2.60; low certainty) and muscle weakness (n=2647; RR, 1.73; 95% CI, 1.49 to 1.99; low certainty). CONCLUSIONS: In this patient-level meta-analysis, hydrocortisone compared with placebo was not associated with reduced mortality for patients with septic shock. (Funded by "Programme d'Investissements d'Avenir," a research Professorship from the National Institute of Health and Care Research, Leadership Fellowships from the National Health and Medical Research Council of Australia, and Emerging Leaders Fellowship from the National Health and Medical Research Council of Australia; PROSPERO registration number, CRD42017062198.)

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

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

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

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.

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.

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.

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.

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

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

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

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

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

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

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.