The use of respiratory rate-oxygenation index to predict failure of high-flow nasal cannula in patients with coronavirus disease 2019-associated acute respiratory distress syndrome: A retrospective study.

Patients with mild-to-moderate coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS) can be treated with a high-flow nasal cannula (HFNC). The use of the respiratory rate-oxygenation (ROX) index, calculated as the ratio of oxygen saturation (SpO2)/fractional oxygen (FiO2) to respiratory rate, in the first few hours after HFNC initiation can help identify patients who fail HFNC therapy later. However, few studies have documented the use of the ROX index during the period of HFNC therapy. Therefore, we aimed to demonstrate the diagnostic performance of the ROX index when calculated throughout the HFNC therapy period and to determine the best cut-off point for predicting HFNC failure. We conducted a retrospective study of patients with COVID-19-associated ARDS who commenced HFNC at the Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Thailand, between April 1 and August 30, 2021. We calculated the ROX index every 4 h throughout the HFNC therapy period and defined HFNC failure as a subsequent endotracheal tube intubation. The performance of the ROX index was analyzed using the area under the receiver operating characteristic curve (AUC). We applied the ROX index ≤ 4.88 to predict HFNC failure and obtained a new ROX cut-off point using Youden's method. In total, 212 patients with COVID-19 treated with HFNC were included in the study. Of these, 81 patients (38.2%) experienced HFNC failure. The ROX index ≤ 4.88 demonstrated a reasonable performance in predicting HFNC failure (AUC, 0.77; 95% confidence interval [CI], 0.72-0.83; p<0.001). However, compared with the original cut-off point of ≤ 4.88, the new ROX index cut-off point of ≤ 5.84 delivered optimal performance (AUC, 0.84; 95% CI, 0.79-0.88; p<0.001), with a significantly better discriminative ability (p = 0.007). In conclusion, a ROX index ≤ 5.84 was found to be optimal for predicting HFNC failure in patients with COVID-19-associated ARDS.

Efficacy and safety of ivermectin in the treatment of mild to moderate COVID-19 infection: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: The emergent outbreak of coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has emphasized the requirement for therapeutic opportunities to overcome this pandemic. Ivermectin is an antiparasitic drug that has shown effectiveness against various agents, including SARS-CoV-2. This study aimed to assess the efficacy of ivermectin treatment compared with the standard of care (SOC) among people with mild to moderate COVID-19 symptoms. METHODS: In this randomized, double-blind, placebo-controlled, single-center, parallel-arm, superiority trial among adult hospitalized patients with mild to moderate COVID-19, 72 patients (mean age 48.57 ± 14.80 years) were randomly assigned to either the ivermectin (n=36) or placebo (n=36) group, along with receiving standard care. We aimed to compare the negativity of reverse transcription polymerase chain reaction (RT-PCR) result at days 7 and 14 of enrolment as the primary outcome. The secondary outcomes were duration of hospitalization, frequency of clinical worsening, survival on day 28, and adverse events. RESULTS: At days 7 and 14, no differences were observed in the proportion of PCR-positive patients (RR 0.97 at day 7 (p=0.759) and 0.95 at day 14 (p=0.813). No significant differences were found between the groups for any of the secondary endpoints, and no adverse events were reported. CONCLUSION: No difference was found in the proportion of PCR-positive cases after treatment with ivermectin compared with standard care among patients with mild to moderate COVID-19 symptoms. However, early symptomatic recovery was observed without side effects. TRIAL REGISTRATION: ClinicalTrials.gov NCT05076253. Registered on 8 October 2021, prospectively.

Perioperative outcomes of non-intubated versus intubated video-assisted thoracoscopic surgery in different thoracic procedures: a propensity score-matched analysis.

BACKGROUND: Non-intubated video-assisted thoracoscopic surgery (NIVATS) is increasingly performed in different types of thoracic procedures. Based on the anesthetic perspective, the outcomes of this method are limited. General anesthesia with intubation and controlled ventilation for video-assisted thoracoscopic surgery (IVATS) is a standard technique. The current study aimed to compare the pulmonary gas exchange between NIVATS and IVATS, with a focus on desaturation event. METHODS: This was a retrospective study conducted at Vajira Hospital. Data were collected from the hospital medical record database between January 9, 2019, and May 15, 2020. A propensity score-matched analysis was used to adjust the confounders by indications and contraindication between NIVATS and IVATS. The perioperative outcomes of VATS and NIVATS were compared by the regression analysis method. RESULTS: In total, 180 patients were included in the analysis. There were 98 and 82 patients in the NIVATS and IVATS groups, respectively. After a propensity score matching, the number of patients with similar characteristics decreased to 52 per group. None of the patients in both groups experienced desaturation. The lowest oxygen saturation of the NIVATS and IVATS groups did not significantly differ (96.5% vs. 99%, respectively; p = 0.185). The NIVATS group had a significantly higher ETCO2 peak than the IVATS group (43 vs. 36 mmHg, respectively; p < 0.001). According to the regression analysis, the NIVATS group had a significantly shorter anesthetic induction time (Mean difference (MD) = -5.135 min (95% CI = (- 8.878)- (-1.391)) and lower volume of blood loss (MD = -75.565 ml (95%CI = (- 131.08)-(- 20.65) but a higher intraoperative ETCO2 than the IVATS group (MD = 4.561 mmHg (95%CI = 1.852-7.269). Four patients in the NIVATS group required conversion to intubation due to difficulties encountered when using the surgical technique (7.7%, p = 0.041). Seven patients in the IVATS group, but none in the NIVATS group, presented with sore throat (13.5% vs. 0%, respectively; p = 0.006). Moreover, none of the patients in both groups experienced postoperative pneumonia, underwent reoperation, or died. CONCLUSIONS: The anesthetic and surgical outcomes of NIVATS were comparable to those of IVATS.

Nonintubated Video-Assisted Thoracoscopic Surgery Using Local Anesthesia for Catamenial Pneumothorax.

This report describes a case of successful catamenial pneumothorax repair using local anesthesia and sedation. A female patient presented with spontaneous pneumothorax with a persistent air leak. Preoperative computed tomography did not reveal any abnormality. Surgery was planned for exploration. In the intraoperative field, a pore was incidentally found in the diaphragm. Therefore, an apical lung wedge procedure was performed; the pore was resected at the diaphragm and covered with polypropylene mesh. The operation was performed using anesthesia with intravenous agents and an oxygen mask with a reservoir bag without endotracheal intubation. The patient was discharged 4 days postoperatively and was doing well at 1-month follow-up.

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.

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.

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

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

The Incidence, Characteristics and Outcomes of Pneumothorax in Thai Surgical Intensive Care Units (Thai-SICU Study).

Objective: To identify incidence, characteristics, and outcomes of pneumothorax among patients who specifically stayed in surgical intensive care units (SICUs). Material and Method: This was a multicenter prospective cohort study conducted in 9 University-affiliated SICUs in Thailand. Incidence of pneumothorax and its outcomes were evaluated from April 2011 to January 2013. Results: 4,652 patients who were admitted to SICU were enrolled. The incidence of pneumothorax was 0.5% (25 cases) in our study. Significant characteristics were found in the pneumothorax group, including: lower BMI, underlying malignancy and COPD, higher APACHE-II and SOFA score within 24 hours of first ICU admission, pulmonary infiltration pattern of chest imaging and usage of mechanical ventilation. In terms of outcome, there were higher SICU mortality and 28-day hospital mortality in pneumothorax than non-pneumothorax patients at 28.0% vs. 9.6%, p = 0.002 and at 44.0% vs. 13.6%, p<0.001, respectively. Conclusion: Patients admitted to surgical intensive care units who developed pneumothorax had higher risk of intensive care unit mortality and 28-day hospital mortality than non-pneumothorax patients, as well as a longer intensive care unit and hospital length of stays.

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.

The Incidence, Characteristics, and Outcomes of Stroke and Seizure In Critically Ill Surgical Patients: A Multicenter Cohort Study of Thai Surgical Intensive Care Units (THAI-SICU Study).

Objective: To explore the incidence, characteristics, and outcomes of patients affected with new onset of stroke and seizure in the surgical intensive care unit (SICU). Material and Method: This study identified new onset of stroke and seizure in 4,652 patients admitted to our multicenter prospective cohort study, a collaboration of nine university-affiliated surgical ICUs in Thailand between April 2011 to January 2013. Results: The authors found new stroke and seizure events at 0.2% and 1%, respectively. The significant characteristics found in stroke and seizure patients included: reason for ICU admission, American Society of Anesthesiologists (ASA) physical status classification, and severity of patients at ICU admission (evaluated by APACHE-II and SOFA day score in first 24 hours of ICU admission). In terms of outcomes, there was higher ICU mortality in both stroke and seizure groups than in nonstroke and non-seizure groups (18% vs. 36% vs. 9%, p<0.001, respectively). In addition, ICU length of stay among stroke and seizure patients was also longer than non-stroke and non-seizure groups (6 (4-18) vs. 10 (4-16) vs. 2 (1-4) days, p<0.001, respectively). However, multivariable regression analysis showed a statistical significance only in longer duration of ICU stay in stroke (6.07 days; 95% CI: 3.34-8.80) and seizure (3.88 days; 95% CI: 2.15-5.62) when compared with nonstroke and non-seizure patients, adjusted by ASA, APACHE-II and SOFA score). Conclusion: From Thai-SICUs study, patients admitted to surgical ICU who developed new episodes of stroke and seizure had longer ICU length of stay when adjusted by their severity score.

A multi-center Thai university-based surgical intensive care units study (THAI-SICU study): methodology and ICU characteristics.

OBJECTIVE: Although there were two large intra-operative observational studies on Thai surgical patients (THAI and THAI-AIMS), there has been no available study on critically ill surgical patients regarding their adverse events and outcomes. A THAI-Surgical Intensive Care Unit (SICU) study has been established for monitoring the occurrence of these adverse events and outcomes in the SICU. The objective of this report is to describe the methodology of the THAI-SICU study and participating SICUs' characteristics as well as the early recruitment results on patients enrolled in the present study. MATERIAL AND METHOD: The present study is designed as a multi-center, prospective, observational study. This report describes the method of case record form development and summarizes their collected parameters as well as the adverse event surveillance variables. All of nine SICU characteristics are described regarding their management systems, physicians' and nurses' work patterns. The final group of enrolled patients is reported. RESULTS: A total of nine university-based SICUs were included in the present study. All participating hospitals are residency training centers. Four of the SICUs, fulltime directors are anesthesiologists. Only one hospital's SICU is directed by a surgeon. Two SICUs were closed ICUs, three were mandatory consulting units, one was an elective consultation unit and the remaining three ICUs had no directors. Most of the participating SICUs had heterogeneity of surgical specialty patients. Six SICUs had regular resident rotations and only two of the SICUs had critical care fellowship training. There were significant differences regarding the nursing workload among the ICUs. The patient to registered nurse ratio ranged from 0.9-2.0. After a total of 19.7 months of a recruitment period, the total number of patient admissions was 6,548 (1,894 patients were excluded). A total cohort of 4,654 patients was included for further analytical processes. CONCLUSION: There were differences in ICU management systems, physician and specialist coverage, nurse burdens, nurse sparing, and types of patients admitted in the university based SICUs. This presentation is the pioneer multi-center study on Thai SICUs in which adverse events and outcomes are reported.

The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of post anesthetic reintubation: an analysis of 184 incident reports.

OBJECTIVE: The present study was a part of the Multi-centered Study of Model of Anesthesia related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective of the present study was to determine the outcomes, contributory factors and factor minimizing incident. MATERIAL AND METHOD: The present study was a descriptive research design. The authors extracted relevant data from the incident reports on reintubation after planned extubation after general anesthesia with endotracheal intubation from the Thai AIMS database during the study period January to June 2007. The cases were extensively reviewed by 3 reviewers for conclusion of anesthesia directly and indirectly related reintubation. Comparative analysis between two groups was done. RESULTS: A total 184 incidents of extubation failure according to the definition were extracted in which 129 cases (70.1%) were classified as directly related to anesthesia and 55 cases (29.9%) were indirectly related to anesthesia. Oxygen desaturation occurred in 85.9% of cases while 90.2% of patients was reintubated within 2 hours after extubation. Hypoventilation (58.1%) was the commonest cause which led to reintubation directly related to anesthesia while upper airway obstruction (39.6%) was the commonest cause in the indirectly related anesthesia group. The proportion of preventable incident was 99.2% and 54.5% in directly and indirectly related anesthesia groups, respectively. Human factors particularly including lack of experience and inappropriate decision-making were considered in 99.2%, are directly related to anesthesia reintubation group. CONCLUSION: Extubation failure and reintubation was mostly related to anesthesia. Most of directly related to anesthesia group were considered as preventable. Human factors were also claimed as contributing factors. Quality assurance activity and improvement of supervision to improve experience and competency of decision making were suggested corrective strategies.