Implementing pain, agitation, delirium, and sleep deprivation protocol in critically ill patients: A pilot study on pharmacological interventions.

Critically ill patients frequently experience pain, agitation, delirium, and sleep deprivation, which have been linked to increased mortality and unfavorable clinical outcomes. To address these challenges, the Pain, Agitation, Delirium, and Sleep Deprivation (PADS) protocol was developed, aiming to mitigate mortality and improve clinical outcomes. This study focuses on assessing the protocol's impact using a robust before-and-after study design in the medical and surgical intensive care units (ICUs) at Ramathibodi Hospital. Using an observational approach, this study compares clinical outcomes before and after implementing the PADS protocol in the ICUs. Two patient cohorts were identified: the "before" group, comprising 254 patients with retrospective data collected between May 2018 and September 2019, and the "after" group, consisting of 255 patients for whom prospective data was collected from May to September 2020. Analysis reveals improvements in the after group. Specifically, there was a significant increase in 14-day ICU-free days (9.95 days vs. 10.40 days, p value = 0.014), a decrease in delirium incidence (18.1% vs. 16.1%, p value < 0.001), and a significant reduction in benzodiazepine usage (38.6% vs. 24.6%, p value = 0.001) within the after group. This study emphasizes the protocol's potential to improve patient care and highlights its significance in the ICU context.

Long-term outcomes of delirium in critically ill surgical patients: A multicenter prospective cohort study.

OBJECTIVE: To identify the mortality rates and dependency rate (functional outcomes) of delirious patients at 12-months after surgical intensive care unit (SICU) admission and to determine the independent risk factors of 12-months mortality and dependency rate in a cohort of SICU patients. METHODS: A prospective, multi-center study was conducted in 3 university-based hospitals. Critically-ill surgical patients who were admitted to SICU and followed-up at 12-months after ICU admission were enrolled. RESULTS: A total of 630 eligible patients were recruited. 170 patients (27%) had postoperative delirium (POD). The overall 12-months mortality rate in this cohort was 25.2%. Delirium group showed significantly higher mortality rates than non-delirium group at 12-months after ICU admission (44.1% vs 18.3%, P < 0.001). Independent risk factors of 12-months mortality were age, diabetes mellitus, preoperative dementia, high Sequential Organ Failure Assessment (SOFA) score and POD. POD was associated with 12-months mortality (adjusted hazard ratio, 1.49; 95% confidence interval 1.04-2.15; P = 0.032). The dependency rate defined as the Basic Activities Daily Living (B-ADL) ≤70 was 52%. Independent risk factors of B-ADL were age ≥ 75 years, cardiac disease, preoperative dementia, intraoperative hypotension, on mechanical ventilator and POD. POD was associated with dependency rate at 12-months. (adjusted risk ratio, 1.26; 95%CI 1.04-1.53; P = 0.018). CONCLUSIONS: Postoperative delirium was an independent risk factor of death and was also associated with dependent state at 12 months after a surgical intensive care unit admission in critically ill surgical patients.

Prediction of Fluid Responsiveness by the Effect of the Lung Recruitment Maneuver on the Perfusion Index in Mechanically Ventilated Patients During Surgery.

Introduction: Excessive or inadequate fluid administration during perioperative period affects outcomes. Adjustment of volume expansion (VE) by performing fluid responsiveness (FR) test plays an important role in optimizing fluid infusion. Since changes in stroke volume (SV) during lung recruitment maneuver (LRM) can predict FR, and peripheral perfusion index (PI) is related to SV; therefore, we hypothesized that the changes in PI during LRM (ΔPILRM) could predict FR during perioperative period. Methods: Patients who were scheduled for elective non-laparoscopic surgery under general anesthesia with a mechanical ventilator and who required VE (250 mL of crystalloid solution infusion over 10 min) were included. Before VE, LRM was performed by a continuous positive airway pressure of 30 cm H2O for 30 sec; hemodynamic variables with their changes (PI, obtained by pulse oximetry; and ΔPILRM, calculated by using [(PI before LRM-PI after LRM)/PI before LRM]*100) were obtained before and after LRM. After SV (measured by esophageal doppler) and PI had returned to the baseline values, VE was infused, and the values of these variables were recorded again, before and after VE. Fluid responders (Fluid-Res) were defined by an increase in SV ≥10% after VE. Receiver operating characteristic curves of the baseline values and ΔPILRM were constructed and reported as areas under the curve (AUC) with 95% confidence intervals, to predict FR. Results: Of 32 mechanically ventilated adult patients included, 13 (41%) were in the Fluid-Res group. Before VE and LRM, there were no differences in the mean arterial pressure (MAP), heart rate, SV, and PI between patients in the Fluid-Res and fluid non-responders (Fluid-NonRes) groups. After LRM, SV, MAP, and, PI decreased in both groups, ΔPILRM was greater in the Fluid-Res group than in Fluid-NonRes group (55.2 ± 17.8% vs. 35.3 ± 17.3%, p < 0.001, respectively). After VE, only SV and cardiac index increased in the Fluid-Res group. ΔPILRM had the highest AUC [0.81 (0.66-0.97)] to predict FR with a cut-off value of 40% (sensitivity 92.3%, specificity 73.7%). Conclusions: ΔPILRM can be applied to predict FR in mechanical ventilated patients during the perioperative period.

Validation of a delirium predictive model in patients admitted to surgical intensive care units: a multicentre prospective observational cohort study.

OBJECTIVE: To internally and externally validate a delirium predictive model for adult patients admitted to intensive care units (ICUs) following surgery. DESIGN: A prospective, observational, multicentre study. SETTING: Three university-affiliated teaching hospitals in Thailand. PARTICIPANTS: Adults aged over 18 years were enrolled if they were admitted to a surgical ICU (SICU) and had the surgery within 7 days before SICU admission. MAIN OUTCOME MEASURES: Postoperative delirium was assessed using the Thai version of the Confusion Assessment Method for the ICU. The assessments commenced on the first day after the patient's operation and continued for 7 days, or until either discharge from the ICU or the death of the patient. Validation was performed of the previously developed delirium predictive model: age+(5×SOFA)+(15×benzodiazepine use)+(20×DM)+(20×mechanical ventilation)+(20×modified IQCODE>3.42). RESULTS: In all, 380 SICU patients were recruited. Internal validation on 150 patients with the mean age of 75±7.5 years resulted in an area under a receiver operating characteristic curve (AUROC) of 0.76 (0.683 to 0.837). External validation on 230 patients with the mean age of 57±17.3 years resulted in an AUROC of 0.85 (0.789 to 0.906). The AUROC of all validation cohorts was 0.83 (0.785 to 0.872). The optimum cut-off value to discriminate between a high and low probability of postoperative delirium in SICU patients was 115. This cut-off offered the highest value for Youden's index (0.50), the best AUROC, and the optimum values for sensitivity (78.9%) and specificity (70.9%). CONCLUSIONS: The model developed by the previous study was able to predict the occurrence of postoperative delirium in critically ill surgical patients admitted to SICUs. TRIAL REGISTRATION NUMBER: Thai Clinical Trail Registry (TCTR20180105001).

Fatal Air Embolism after Choroidal Melanoma Endoresection without Air Infusion: A Case Report.

BACKGROUND: The aim of this study was to report 2 cases of pulmonary air embolism developing several hours after choroidal melanoma endoresection without the use of air infusion during the surgery, with fatality in 1 patient. METHODS: The method of this study was case report. PARTICIPANTS: Two patients with large choroidal melanomas who collapsed several hours after endoresection without air infusion as a result of pulmonary air embolism. RESULTS: A 72-year-old man collapsed 4 h and 30 min after endoresection without air infusion. Computerized tomography angiography confirmed air embolism. The patient died after 86 min of cardiopulmonary resuscitation. A 41-year-old woman collapsed 5 h and 30 min after endoresection, performed without air infusion and with close monitoring, which included right internal jugular vein catheterization intraoperatively. Transthoracic and transesophageal echography, performed preoperatively, intraoperatively, and postoperatively, revealed air embolism only after collapse occurred. Imaging showed the embolism to be biventricular because of patent foramen ovale. The patient was treated promptly with extracorporeal membrane oxygenation and mechanical ventilation, which resulted in a full recovery. CONCLUSIONS: Air embolism can develop after endoresection for choroidal melanoma, despite avoiding air infusion. Further studies are needed to understand how this occurs. Special measures are indicated to detect this complication and to treat it promptly and effectively.

Effectiveness of securing central venous catheters with topical tissue adhesive in patients undergoing cardiac surgery: a randomized controlled pilot study.

BACKGROUND: Central venous catheters (CVCs) play an important role during cardiac surgery. Topical tissue adhesives form a thin film of coating that becomes bound to keratin in the epidermis. The advantage of this "super glue" lies in its antimicrobial activity. This study aimed to evaluate fixation of CVCs with topical tissue adhesive in patients (prone to bleed) undergoing cardiac surgery regarding its ability to reduce the incidence of pericatheter leakage. METHODS: This randomized controlled trial included 150 patients > 15 years of age who were (1) scheduled to undergo elective cardiac surgery, (2) required CVC insertion at the internal jugular vein, and (3) scheduled for transfer postoperatively to the cardiac intensive care unit. We randomly assigned patients to a topical tissue adhesive group (TA) or a standard control group (SC). The primary outcome was a change in dressing immediately postoperatively due to pericatheter blood oozing. Secondary outcomes were the number of dressings, total dressings per catheter day, and composite outcome of catheter failure within 3 days. Both intention-to-treat and per-protocol analyses were performed. Seven patients violated the protocol (three TA patients and four SC patients). RESULTS: Regarding the primary outcome, the SC group exhibited a significantly increased incidence of dressing change immediately postoperatively due to pericatheter leakage compared with the TA group in both the intention-to-treat analysis (5.33% vs 18.67%, RR 0.25 [95% CI 0.08 to 0.79], P = 0.012) and the per-protocol analysis (5.56% vs 16.90%, RR 0.289 [95% CI 0.09 to 0.95], P = 0.031). No significant differences were noted in the number of dressings, total dressings per catheter day, or composite outcome of catheter failure within 3 days between the two groups. Multiple logistic regression analysis was performed to adjust baseline characteristics that were different in the per-protocol analysis. The results showed that the risk ratio of immediate postoperative dressing change in TA patients was 0.25 compared to the SC group ([95% CI 0.07 to 0.87], P = 0.029) in the per-protocol analysis. CONCLUSION: The use of a topical tissue adhesive can reduce the incidence of immediate postoperative pericatheter blood oozing. TRIAL REGISTRATION: TCTR20180608004 , retrospectively registered on June 06, 2018.

Effects of thiamine on vasopressor requirements in patients with septic shock: a prospective randomized controlled trial.

BACKGROUND: Thiamine, an essential vitamin for aerobic metabolism and glutathione cycling, may decrease the effects of critical illnesses. The objective of this study was to determine whether intravenous thiamine administration can reduce vasopressor requirements in patients with septic shock. METHODS: This study was a prospective randomized double-blind placebo-controlled trial. We included adult patients with septic shock who required a vasopressor within 1-24 h after admission between March 2018 and January 2019 at a tertiary hospital in Thailand. Patients were divided into two groups: those who received 200 mg thiamine or those receiving a placebo every 12 h for 7 days or until hospital discharge. The primary outcome was the number of vasopressor-free days over 7 days. The pre-defined sample size was 31 patients per group, and the study was terminated early due to difficult recruitment. RESULTS: Sixty-two patients were screened and 50 patients were finally enrolled in the study, 25 in each group. There was no difference in the primary outcome of vasopressor-free days within the 7-day period between the thiamine and placebo groups (mean: 4.9 days (1.9) vs. 4.0 days (2.7), p = 0.197, mean difference - 0.9, 95% CI (- 2.9 to 0.5)). However, the reductions in lactate (p = 0.024) and in the vasopressor dependency index (p = 0.02) at 24 h were greater among subjects who received thiamine repletion vs. the placebo. No statistically significant difference was observed in SOFA scores within 7 days, vasopressor dependency index within 4 days and 7 days, or 28-day mortality. CONCLUSIONS: Thiamine was not associated to a significant reduction in vasopressor-free days over 7-days in comparison to placebo in patients with septic shock. Administration of thiamine could be associated with a reduction in vasopressor dependency index and lactate level within 24 h. The study is limited by early stopping and low sample size. TRIAL REGISTRATION: TCTR, TCTR20180310001. Registered 8 March 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3330 .

Relationship between Abdominal Circumference and Incidence of Hypotension during Cesarean Section under Spinal Anesthesia.

BACKGROUND: Enlarged uterus can compress the inferior vena cava and cause hypotension when lying supine. Previous studies have shown a positive association between the abdominal circumference and size of the uterus. Therefore, the aim of this study was to evaluate the relationship between abdominal circumference and incidence of hypotension during cesarean section under spinal anesthesia. METHODS: The study cohort comprised women undergoing cesarean section under spinal anesthesia. Patients were divided into two groups according to the median abdominal circumference (<101 cm and ≥101 cm). Hypotension was defined as a systolic blood pressure of <90 mmHg or mean arterial pressure of <65 mmHg. The primary outcome of this study was the relationship between the incidence of hypotension and the abdominal circumference after spinal anesthesia in term pregnant women. RESULTS: The study cohort comprised 100 women. The incidence of hypotension did not differ between the groups (71.42% in the smaller vs. 78.43% in the larger abdominal circumference group, p=0.419). However, the decrease in mean arterial pressure and its percentage decrease from baseline were greater in the larger than in the smaller abdominal circumference group (change in mean arterial pressure: 28.33 mmHg (18.66-33.67) in the smaller vs. 36.67 mmHg (23.34-43.34) in the larger abdominal circumference group, p=0.004; percentage decrease: 31.41% (22.74-39.22) in the smaller vs. 38.47% (28.00-44.81) in the larger abdominal circumference group, p=0.022). CONCLUSIONS: Large abdominal circumference in pregnancy is associated with greater decreases in mean arterial pressure from baseline. However, the incidence of hypotension defined by standard criteria did not differ between larger and smaller abdominal circumference groups.

Acute kidney injury risk prediction score for critically-ill surgical patients.

BACKGROUND: There has been a global increase in the incidence of acute kidney injury (AKI), including among critically-ill surgical patients. AKI prediction score provides an opportunity for early detection of patients who are at risk of AKI; however, most of the AKI prediction scores were derived from cardiothoracic surgery. Therefore, we aimed to develop an AKI prediction score for major non-cardiothoracic surgery patients who were admitted to the intensive care unit (ICU). METHODS: The data of critically-ill patients from non-cardiothoracic operations in the Thai Surgical Intensive Care Unit (THAI-SICU) study were used to develop an AKI prediction score. Independent prognostic factors from regression analysis were included as predictors in the model. The outcome of interest was AKI within 7 days after the ICU admission. The AKI diagnosis was made according to the Kidney Disease Improving Global Outcomes (KDIGO)-2012 serum creatinine criteria. Diagnostic function of the model was determined by area under the Receiver Operating Curve (AuROC). Risk scores were categorized into four risk probability levels: low (0-2.5), moderate (3.0-8.5), high (9.0-11.5), and very high (12.0-16.5) risk. Risk of AKI was presented as likelihood ratios of positive (LH+). RESULTS: A total of 3474 critically-ill surgical patients were included in the model; 333 (9.6%) developed AKI. Using multivariable logistic regression analysis, older age, high Sequential Organ Failure Assessment (SOFA) non-renal score, emergency surgery, large volume of perioperative blood loss, less urine output, and sepsis were identified as independent predictors for AKI. Then AKI prediction score was created from these predictors. The summation of the score was 16.5 and had a discriminative ability for predicting AKI at AuROC = 0.839 (95% CI 0.825-0.852). LH+ for AKI were: low risk = 0.117 (0.063-0.200); moderate risk = 0.927 (0.745-1.148); high risk = 5.190 (3.881-6.910); and very high risk = 9.892 (6.230-15.695), respectively. CONCLUSIONS: The function of AKI prediction score to predict AKI among critically ill patients who underwent non-cardiothoracic surgery was good. It can aid in early recognition of critically-ill surgical patients who are at risk from ICU admission. The scores could guide decision making for aggressive strategies to prevent AKI during the perioperative period or at ICU admission. TRIAL REGISTRATION: TCTR20190408004, registered on April 4, 2019.

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

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

Effects of nutrition factors on mortality and sepsis occurrence in a multicenter university-based surgical intensive care unit in Thailand (THAI-SICU study).

OBJECTIVES: The aim of this study was to demonstrate the role of nutrition factors on a 28-d mortality outcome and sepsis occurrence in surgical intensive care unit. METHODS: The data was extracted from a THAI-SICU study that prospectively recruited participants (≥18 y of age) from three Thai surgical intensive care units (SICUs) of university-based hospitals. The demographic data and nutrition factors at SICU admission included energy delivery deficit, weight loss severity, route of energy delivery, and albumin and nutrition risk screening (NRS-2002). The outcomes were 28-d hospital mortality and sepsis occurrence. The statistical analysis was performed using Cox regression. RESULTS: The study included 1503 eligible patients with a predominantly male population. The 28-d mortality and sepsis occurrences were 211 (14%) and 452 (30%), respectively. Regarding multivariable analysis, for mortality outcome, the protective effects of nutrition variables were higher body mass index (BMI; hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.99; P = 0.039), tube feeding (HR, 0.46; 95% CI, 0.26-0.83; P = 0.010), and a combination of enteral and parenteral nutrition (HR, 0.24; 95% CI, 0.07-0.77; P = 0.016). The harmful effects were severe weight loss (HR, 1.61; 95% CI, 1.16-2.22; P = 0.004), albumin ≤2.5 (HR, 2.15; 95% CI, 1.20-3.84; P = 0.010), and at risk according to NRS-2002 (HR, 1.34; 95% CI, 0.98-1.85; P = 0.071). For the sepsis occurrence, only tube feeding had a protective effect (HR, 0.58; 95% CI, 0.39-0.88; P = 0.009), and only albumin ≤2.5 had a harmful effect (HR, 1.71; 95% CI, 1.20-2.45; P = 0.003). CONCLUSION: Nutrition factors affecting the mortality or sepsis occurrence in this study were BMI, enteral feeding or combination with parenteral nutrition, severe weight loss, preadmission albumin ≤2.5, and at risk according to NRS-2002.

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

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

A Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study): Outcome of ICU Care and Adverse Events.

Objective: Surgical intensive care units (SICUs) are special units for critically ill surgical patients both in the pre and postoperative period. There is little aggregated information about surgical patients who are admitted to the Thai surgical ICU. The objective of this report was to describe patient characteristics, outcomes of ICU care, incidence and outcomes of adverse events in the SICU in the participating SICUs. Material and Method: This multi-center, prospective, observational study of nine university-based SICUs was done. All admitted patients with ages >18 years old were included. Information about patient characteristics, underlying medical problems, indication and type of ICU admission, severity score as ASA physical status in operative patients, APACHE II score and SOFA score, adverse events of interest, ventilator days, ICU and 28 days mortality. The association of outcome and predictors was reported by relative risk (RR) with 95% confidence interval (95% CI). Statistical significant difference was defined by p<0.05. Results: During April 2011-January 2013 of total cohort time, a total of 4,652 patients from nine university-based SICUs were included in this study. Mode of patient age was 71-75 year old for both sexes. Median (IQR) of APACHE II scores and SOFA scores were 10 (7-10) and 2 (1-5), respectively. Seventy eight percent of patients were postoperative patients and 50% of them were ASA physical status III. The median of ICU stay was 2 (IQR 1-4) days. Each day of ICU increment was associated with increased 1.4 days of a hospital stay. Three percent of survived at discharge were clinically inappropriate discharge resulting in ICU readmission. Sixty-five percent were discharged home after ICU admission. ICU and 28 days mortality was 9.6% and 13.8%. The seven most common adverse events were sepsis (19.5%), acute kidney injury (AKI) (16.9%), new cardiac arrhythmias (6.2%), acute respiratory distress syndrome (ARDS) (5.8%), cardiac arrest (4.9%), delirium (3.5%) and reintubation within 72 hours (3.0%), respectively. Most of the adverse events occurred in the first five days, significantly less occurred after 15 days of ICU admission. The association between adverse events and 28 days mortality were significant for cardiac arrest (RR, 9.5; 95% CI, 8.6-10.4), respiratory failure [acute respiratory distress syndrome (ARDS) (RR, 4.6; 95% CI, 3.9-5.3), acute lung injury (ALI) (RR, 2.7; 95% CI, 2.1-3.6)], acute kidney injury (AKI) (RR, 4.2; 95% CI, 3.7-4.8), sepsis (RR, 3.6; 95% CI, 3.2-4.2), iatrogenic pneumothorax (RR, 3.2; 95% CI, 2.1-5.1), new seizure (RR, 3.1, 95% CI, 2.2-4.4), upper GI hemorrhage (RR, 3.0, 95% CI, 2.1-4.1), new cardiac arrhythmias (RR, 2.9; 95% CI, 2.4-3.5), delirium (RR, 2.1; 95% CI, 1.7-2.8), acute myocardial infarction (RR, 2.1; 95% CI, 1.4-3.1), unplanned extubation (RR, 2.1; 95% CI, 1.4-3.1), intra-abdominal hypertension (RR, 1.8; 95% CI, 1.2-2.7) and reintubation within 72 hours (RR, 1.5; 95% CI, 1.1-2.1). Conclusion: This is the first large study of surgical critical care in Thailand, which had a systematic patient follow-up program. Most of the patients were elderly. Adverse events were most frequent during the first 5 days of admission and were associated with ICU and 28 days mortality.

Hazards and Intensive Care Unit Economic Burden of Cigarette Smoking on Critically Ill Surgical Patients: Analysis of the THAI-SICU Study.

Objective: Cigarette smoking is not only has detrimental effects on the respiratory system but also contributes to development of atherosclerosis and inflammatory vascular reactions. We hypothesized whether smoking is associated with increased risk of acute respiratory distress syndrome (ARDS), systemic inflammatory response syndrome (SIRS), sepsis, distant organ dysfunctions, and the increase of total cost of surgical intensive care unit (SICU) in critically ill surgical patients. Material and Method: We performed analysis using the THAI-SICU data, a prospective, observational, multicenter study in patients who admitted to SICU in nine university-based hospitals in Thailand. The patients were categorized into 3 groups based on their smoking histories, which were 1) never smoked, 2) former smoker, and 3) current smoker. The primary outcome was probability of ARDS and the secondary outcomes included incidences of SIRS, sepsis, distant organ dysfunction (included acute kidney injury (AKI) and acute myocardial infarction (AMI)), total SICU cost, and 28-day mortality Results: A total of 4,652 patients had complete data of smoking and were analyzed. The smoking status was never smoked (2,947 patients), former smokers (1,148 patients), and current smokers (557 patients). Compared to current smokers and former smokers, patients who had never smoked had significantly lower proportion of patients with chronic obstructive pulmonary disease (p<0.01) and had significantly higher PaO2/FiO2 ratio on SICU admission (p = 0.02). Compared to patients who had never smoked and former smokers, current smokers had significantly higher probability of ARDS (p = 0.003), higher incidence of SIRS (p = 0.006), and AKI (p<0.001), after adjustment for age, gender, APACHE II score, and patients' pre-existing diseases. We found that every 1-pack year of cigarette smoking increased risk of ARDS with a hazard ratio of 1.02 (95% CI 1.01-1.03, p = 0.001). There was no difference in incidence of sepsis, AMI, and 28-day mortality among three groups of patients. Current smokers had significantly higher SICU cost, followed by former smokers, and patients who had never smoked (p = 0.02). Conclusion: In critically ill surgical patients, we found dose-response association between smoking pack year and risk of ARDS. Compared to patients who had never smoked and former smokers, current smokers had significantly higher probability of ARDS, higher incidence of SIRS, AKI, and higher total SICU cost. Our findings demonstrated harm of cigarette smoking in critically ill surgical patients who admitted to SICU.

Prevalence and Impact of Overweight and Obesity in Critically Ill Surgical Patients: Analysis of THAI-SICU Study.

Objective: To investigate the prevalence of overweight and obesity, and their impacts in patients admitted to a surgical intensive care unit (SICU) in Thailand. Material and Method: We conducted an analysis using the THAI-SICU database. All 4,579 patients who had weight and height measured were classified into four groups using body mass index (BMI) based on the World Health Organization criteria, which were 1) underweight (BMI <18.5 kg/m2), 2) normal BMI (BMI 18.5-24.9 kg/m2), 3) overweight (BMI 25-29.9 kg/m2), and 4) obese (BMI >30 kg/m2) groups. Primary outcome was prevalence of overweight and obesity. Secondary outcomes were 28-day survival, and SICU outcomes between four patient groups. Results: There were 768 (16.8%) of underweight, 2,624 (57.3%) of normal BMI, 858 (18.7%) of overweight, and 329 (7.2%) of obese patients. Compared to other three patient groups, obese had the highest 28-day survival (log-rank, p<0.001), lowest incidence of systemic inflammatory response syndrome (SIRS) (underweight 41.1%, normal BMI 35.6%, overweight 34.5%, and obese 29.5%; p = 0.001), and lowest incidence of new infection (underweight 27.3%, normal BMI 23.3%, overweight 24.5%, and obese 20.4%; p = 0.047). After adjustment for related confounding factors, we found that every one unit increasing of BMI associated with lower risk of hospital mortality [odds ratio, OR, 0.97(95% confidence interval, CI, 0.94-0.99); p = 0.04], higher risk of acute respiratory distress syndrome (ARDS) [OR 1.06 (95% CI 1.03-1.08); p<0.001], and higher risk of intra-abdominal hypertension (IAH) [OR 1.06 (95% CI 1.03-1.09); p<0.001]. Conclusion: The prevalence of overweight and obesity in Thai critically ill surgical patients were 18.7% and 7.2%, respectively. Compared to patients with lower BMI, patients with higher BMI had significantly lower mortality but greater risk of ARDS and IAH.

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

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

Outcomes of Nutrition Status Assessment by Bhumibol Nutrition Triage/Nutrition Triage (BNT/NT) in Multicenter THAI-SICU Study.

Objective: The objective of the study is to evaluate the nutrition assessment tool used by Bhumibol Nutrition Triage/Nutrition Triage (BNT/NT) for patient outcomes in a surgical intensive care unit (SICU). Material and Method: All data were retrieved from the THAI-SICU database. A total of 1,685 patients from three medical centers were participants in the nutrition project and were enrolled onto this study. The parameters needed for BNT/NT scoring were recorded including body mass index (BMI), weight change, energy delivery, age, and disease severity. The BNT/NT calculation was classified into 4 groups as BNT/NT I to IV. An adjusted odds ratio (OR) with 95% confidence interval (CI) of mortality and sepsis occurrence were reported. Results were classed as being statistically significant at p<0.05. Results: Regarding the nutrition assessment classification, the patients admitted to SICU were classified as BNT/NT class I48.6%, class II 30.0%, class III 9.3%, and class IV 12.1%. There were statistically significant differences between classes in terms of BMI, weight change, energy delivery and disease severity. In addition, the BNT/NT classification was also significantly associated with ICU mortality [OR (95% CI): 1.51 (1.25-1.83); p<0.001], 28 day mortality [1.47 (1.23-1.74); p<0.001], and sepsis occurrence [1.41 (1.25-1.60); p<0.001]. Conclusion: Most of the patients admitted to SICU had a low nutrition risk BNT/NT class I and II. The higher BNT/NT scores were associated with mortality and sepsis occurrence in SICU.

Prevalence, Outcomes and Risk factors of Acute Kidney Injury in Surgical Intensive Care Unit: A Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study).

Objective: Acute kidney injury (AKI) is one of the most common problems in critically ill patients. AKI associates with poor outcome in ICU. The recognition of the prevalence and risk factors of AKI is important. This could lead to the prevention of AKI and improve patient's outcome. This study aims to identify the prevalence, outcomes and independent risk factors of AKI in Thai surgical intensive care units. Material and Method: We conducted the prospective cohort study from nine university-based SICUs. The patients were diagnosed AKI by Acute Kidney Injury Network (AKIN) classification. The types of RRT and outcomes including mortality were collected. The risk factors of AKI were identified. Results: A total cohort of 4,652 patients was included for the present study. AKI was diagnosed in 786 (16.89%) patients. The ICU mortality was higher in patients with AKI (29.90% vs. 5.48%, p-value <0.001). Among patients with AKI staging, we found that those with AKIN III had higher ICU mortality compared to patients with AKIN II and AKIN I respectively (47.66% vs. 26.67% vs. 14.69%, p-value <0.001). Patients with AKI had higher 28 day-mortality compared with those without AKI (37.53% vs. 8.98%, p-value <0.001). The independent risk factors of AKI were higher APACHE II scores (OR 1.04, 95% CI 1.01-1.06, p-value = 0.001), lower serum albumin (OR 0.82, 95% CI 0.70-0.97, p-value = 0.020), organ failures which were in the gastrointestinal system (OR 1.53, 95% CI 1.13-2.08, p-value = 0.007), cardiovascular system (OR 1.95, 95% CI 1.34-2.83, p-value <0.001), neurological system (OR 1.37, 95% CI 1.02-1.85, p-value = 0.038) and urinary system (OR 7.00, 95% CI 5.21-9.40, p-value <0.001). Conclusion: Acute kidney injury associates with poor outcomes including increased ICU and 28-day mortality. Independent risk factors of AKI in the present study were higher APACHE II scores, lower serum albumin and organ failures on admission.

Acute Kidney Injury in Elderly Patients in Thai-Surgical Intensive Care Units (THAI-SICU) Study.

Objective: To demonstrate prevalence, characteristics and outcomes of the elderly patients who were diagnosed with acute kidney injury (AKI) in surgical intensive care units (ICUs). Material and Method: AKI data were extracted from multicenter prospective cohort study conducted in 9 university-affiliated surgical ICUs in Thailand (THAI-SICU study) from April 2011 to January 2013. The elderly group was defined as those over 65 years old. Statistical analysis was done comparing baseline characteristics and outcomes between the elderly with AKI and those without. Results: A total of 2,310 elderly patients (49.7%) were identified in our surgical ICUs from a total 4,652 cases. Of this elderly group, AKI was diagnosed in 445 cases (19.3%). The differences in the baseline characteristics of the elderly with AKI group were: older, higher number of males, greater number of smokers, and greater disease severity evaluated with APACHE-II and SOFA score than the elderly without AKI. The ICU mortality and 28-day hospital mortality were higher in the elderly with AKI than those without (28.1% vs. 5.2%, p<0.001 with RR = 5.401, 95% CI 4.231-6.895 and 35.7% vs. 9.4%, p<0.001 with RR = 3.786, 95% CI 3.138-4.569, respectively). Using multivariable logistic regression analysis and after adjustment of covariates, independent potential risk factors of developing AKI in the SICU included: older age, higher APACHE-II and SOFA score, smoking history, emergency surgery, concurrent sepsis, cardiac complications, delirium, and requiring respiratory support during ICU stay. Conclusion: Geriatric patients made up almost half of our surgical ICU population and nearly one-fifth of them suffered AKI. Once they had AKI, ICU mortality and 28-day hospital mortality were higher than those without AKI.

Pain Management in Surgical Intensive Care Units: A Multi-Center Prospective Observational Study (THAI-SICU Study).

Objective: This study is a part of the multi-center Thai university-based Surgical Intensive Care Unit Study (THAI-SICU Study). It aimed to evaluate the patterns of pain management in patients admitted to surgical intensive care units. Material and Method: Case record forms (CRFs) were created by the working group. Data regarding pain management in the ICUs were documented on the daily record form. These included types of analgesics used (opioids and non-opioids), routes of administration (oral, intravenous, intramuscular, epidural and intrathecal) and methods of administration (continuous infusion, regular intermittent, as needed, patient-controlled analgesia and patient-controlled epidural analgesia). Results: Data were gathered from 4,652 patients. The majority of the patients received analgesics (85.2%). The main stay analgesics were morphine (52.3%) and fentanyl (27%). Analgesics were frequently administered via the intravenous route (76.5%) on an as needed basis (48.6%). Conclusion: Analgesics were commonly given to patients in the surgical intensive care units. The analgesics of choice were strong opioids, and the most preferred route and method of administration was the intravenous route and the as needed basis, respectively.