Clinical Critical Care

Retrospective comparison of the frequency of Do Not Intubate orders among patients diagnosed with sepsis in the emergency room between 2017 and 2022

2024-03-19T10:04:26+07:00

Background: This study retrospectively evaluated the frequency of "Do Not Intubate" (DNI) orders in patients with sepsis diagnosed in the emergency room in 2017 and 2022. The objective was to understand the longitudinal adoption of the Advanced Care Planning (ACP) concept over a 5-year span.

Methods: We included patients primarily diagnosed with sepsis by emergency physicians at Kurashiki Central Hospital in 2017 and 2022. The primary outcome was the frequency of DNI orders, whereas the secondary outcomes were morbidity and length of hospital stay. We compared the outcomes between 2017 and 2022. Additionally, patient characteristics, such as age, sex, presence of co-resident family members, malignancy status, source of infection, and degree of official care certification were collected.

Results: We included 82 and 77 patients with sepsis in 2017 and 2022, respectively. Regarding the primary outcome, 39% (95% confidence interval [CI]: 27-49%) (31/82) of patients with sepsis in 2017 had DNI orders, compared to 44% (95% CI: 33-56%) (34/77) in 2022. There were no significant differences in the primary and secondary outcomes between the two years. The only significant difference noted was in the degree of official care certification among patient characteristics.

Conclusion: The frequency of DNI orders remained relatively stable between 2017 and 2022. This suggests that the ACP concept has not yet been widely integrated into the decision-making process for treatment strategies for patients with sepsis.

Neuromonitoring in neurocritical care for traumatic brain injury in the Thai context

2024-03-19T10:00:21+07:00

The purposes of this review were to identify the incidence and types of traumatic brain injury (TBI) in Thailand, and recommend neuro-monitoring for limited resources in Thai patients. The monitoring methods focus on the targeted and personalized management in severe TBI such as intracranial pressure (ICP), pressure reactivity index (PRx), regional cerebral saturation (rSO₂), cerebral autoregulation (CA), as well as noninvasive methods for example near-infrared spectroscopy (NIRS) and optic nerve sheath diameter (ONSD). These monitors are aimed to optimize brain oxygen delivery and prevent further neurologic deterioration in terms of increased ICP and decreased cerebral perfusion pressure (CPP). Some of these were implemented in neurological monitoring protocol and clinical practice guidelines for severe TBI. However, cost - effectiveness is concerned. Even though considering CA and the advance monitoring methods in continuous assessment are widely used, current therapeutic interventions which appear entirely to bedside approach for correct dysregulated CA are limited. In addition, understanding of basic molecular and cellular pathways involved in cerebral homeostasis ( brain oxygen delivery, cerebral blood flow, CA and cerebral vascular reactivity to oxygen and carbon dioxide) as well as secondary brain injury prevention are still necessary for improving TBI outcomes. In summary, further study in Thailand is required to determine optimal cerebral physiologic-based technology, monitoring parameters, and individualized thresholds to optimize CA and potentially improve neurologic outcomes across a spectrum of TBI patients, which focus in Thai rural areas where invasive monitoring is not routinely performed due to resources limitation. Encourage and training of non invasive methods might solve these issues.

Inotropic drugs in septic shock

2024-02-19T14:57:39+07:00

Septic shock is a life-threatening condition characterized by a complex underlying mechanism that requires a multidimensional treatment approach. Sepsis-induced cardiomyopathy plays a significant role in the development of multiple organ failure. The focus of this review is to determine the evidence-based data of the commonly used inotropic drugs in the management of septic shock during clinical hypoperfusion and reduced myocardial performance. Current guidelines recommend adding dobutamine to norepinephrine or using epinephrine alone in septic-induced cardiomyopathy, while suggesting against the use of levosimendan. Although dobutamine increases cardiac contractility and heart rate, it also decreases systemic vascular resistance. Epinephrine has a greater potency than dobutamine but does not demonstrate a clinical difference in hemodynamic improvement. Milrinone is preferred for cases involving pulmonary hypertension and right ventricular failure but should be avoided in the presence of renal dysfunction. Levosimendan improves cardiac performance and promotes coronary blood flow, but later evidence mentioned significant arrhythmia compared to other inotropic agents. Due to the narrow therapeutic window of these agents, precise therapeutic targets are crucial.

Sedation management in the post-COVID era: A personalised, patient-orientated approach

2023-11-02T20:14:14+07:00

Intensive care patients are older, frailer, and more co-morbid than ever before, and remain at risk of a variety of adverse outcomes, both in ICU, and after discharge. Sedation and delirium play an intricate role in this complex system, and it can be difficult to determine if they are a contributor or consequence in any given situation. During the COVID-19 pandemic, the increased frequency of complex ventilatory management, including prone ventilation and neuromuscular blockade, necessitated deep sedation in many cases. In concert with infection control concerns and staffing pressures, the delivery of precision symptom- and patient-oriented sedation has waned in favour of strategies felt to be globally safe. Using the SPICE III study as a lens to understand both the importance of exploring heterogeneity of effect in large, complex RCTs of critically ill patients, and the importance of an individualised approach to sedation in the intensive care unit, we demonstrate the evolution of our understanding of sedation in this challenging environment. By following the principles that define the cornerstones of best contemporary sedation practice we can once more grow beyond the boundaries of clinical practice guidelines in the provision of personalised, patient-orientated sedation in the post-COVID intensive care unit.

Early intravenous hydrocortisone in sepsis: A randomized control trial (Protocol)

2024-03-25T20:33:30+07:00

Background: The evidence of the appropriate timing of hydrocortisone is still weak and controversial. Observational studies showed a trend towards greater benefits when hydrocortisone was given earlier in the course of septic shock resuscitation. This study evaluates the effects of early intravenous low-dose hydrocortisone administered at the beginning of the onset of sepsis-induced hypotension compared with standard care.

Methods: This study is a single-center, parallel-group, double-blinded, randomized control trial, conducted in a non-trauma emergency department. Adult patients with sepsis-induced hypotension will be included. Patients will be randomly assigned in a 1:1 ratio to receive early intravenous low-dose hydrocortisone or standard care. Blood inflammatory biomarkers at baseline will be collected. The primary outcome is 28-day mortality. Resuscitation-related secondary outcomes and safety outcomes will also be observed. Outcomes will be compared between groups. Subgroup analyses considering inflammatory biomarker levels will also be performed to evaluate the effect of early intravenous hydrocortisone, especially in patients with hyperinflammation.

Hypothesis: We hypothesize that early intravenous low-dose hydrocortisone administration in patients with sepsis-induced hypotension would result in less mortality and improve resuscitation outcomes, especially in subgroup of patients with hyperinflammation.

Ethics and dissemination: The study protocol was approved by the Siriraj Institutional Review Board with the certificate of approval number Si 917/2023.

Trial registration: Clinicaltrial.gov NCT06217939

Change in cardiac index during Trendelenburg maneuver as a predictor of fluid responsiveness among patients under mechanical ventilation with spontaneous breathing activity: A protocol for prospective observational study

2024-02-19T14:33:32+07:00

Background: Optimal fluid management in surgical intensive care units (SICUs) is challenging, with under or over-resuscitations linked to increased mortality and extended ICU stays. Dynamic parameters like stroke volume variation and pulse pressure variation are unreliable in intubated patients with spontaneous breathing activity. The passive leg raise (PLR), which relies on translocation of the patient’s intravascular volume, is effective in identifying fluid responsiveness, but it still has some limitations. Regarding limitations, another potential method, using the same principle, known as the Trendelenburg maneuver (TM), has been introduced. This study aims to assess the diagnostic performance of TM in mechanically ventilated patients with spontaneous breathing activity, focusing on changes in cardiac index in relation to fluid administration.

Methods: In this single-center, prospective observational study conducted in a surgical ICU, we enrolled 68 patients with inadequate tissue perfusion who had spontaneous breathing while receiving mechanical ventilation to evaluate the diagnostic ability of TM in fluid responsiveness prediction. The patients were classified as fluid responders when the change in cardiac index, measured by the FloTrac™ sensor with the HemoSphere™ advanced monitoring platform, increased by more than 10% after fluid administration.

Hypothesis: We hypothesize that TM has the ability to predict fluid responsiveness in mechanically ventilated patients with spontaneous breathing activity.

Ethics and dissemination: This trial received approval from the Siriraj Institutional Review Board. We plan to present the result in peer-reviewed publications in critical care medicine.

Trial registration: TCTR20230704005

The comparison of circuit lifespan between integration and separation approach in extracorporeal membrane oxygenation (ECMO) patient requiring continuous renal replacement therapy (CRRT) support, (E-CRRT Trial)

2024-01-15T15:25:18+07:00

Background: The estimated incidence of acute kidney injury requiring continuous renal replacement therapy (CRRT) in patients necessitating extracorporeal membrane oxygenation (ECMO) is approximately 50%. Currently, two well-known techniques—integration and separation—are utilized for combining CRRT and ECMO circuits. The efficacy of these two techniques is still unknown. Therefore, this study aimed to compare the circuit lifespan of CRRT between the integration and separation techniques.

Methods: A multicentered randomized controlled study with an unblinded design will be conducted to determine circuit lifespan differences between integration and separation techniques.

Hypothesis: We hypothesize that the integration technique will yield a longer circuit lifespan for CRRT compared to the separation technique.

Trial registration: NCT05036616

Composite adverse events compared early versus conventional cessation of hydrocortisone in patients with septic shock: Randomized-controlled trial (The CESSHYDRO study)

2024-02-22T11:02:20+07:00

Background: Intravenous hydrocortisone has benefits in the treatment of septic shock patients, but there are adverse events mentioned in the secondary outcomes of several studies, such as hyperglycemia, hypernatremia, secondary infection, and muscle weakness. In addition, there are no recommendations regarding the precise duration and steps to discontinue hydrocortisone administration. The CESSHYDRO trial evaluates the adverse outcomes of intravenous hydrocortisone between early cessation versus conventional cessation of hydrocortisone in septic shock patients.

Methods: The CESSHYDRO trial is a single-center, double-blind, randomized controlled clinical trial conducted at Siriraj Hospital. One hundred and eighty septic shock patients receiving vasopressors and hydrocortisone at least 200 mg/day with hemodynamic stability will be included. The patients are randomized into 2 groups: intervention A (early cessation of hydrocortisone) and intervention B (conventional cessation). The primary outcomes were composite adverse events, including hyperglycemia, hypernatremia, muscle weakness, and new infections.

Hypothesis: We hypothesize that early cessation of hydrocortisone in patients with septic shock would reduce composite adverse events including hyperglycemia, hypernatremia, muscle weakness, and the new onset of infection.

Ethics and dissemination: The trial receives ethical approval from Siriraj Hospital, Mahidol University (COA No.SI012/2023).

Trial registration: ClinicalTrials.govNCT05818826. Registered on April 19, 2023.

A Thai guideline summary in management of pediatric septic shock

2024-01-26T08:40:05+07:00

Sepsis-associated organ dysfunction, particularly septic shock, is a prevalent critical illness characterized by increased morbidity and mortality, particularly in children. Recognizing the imperative to enhance outcomes, a septic shock guideline tailored for pediatric patients was formulated. This guideline strives to establish an evidence-based framework for the effective management of septic shock and sepsis-associated organ dysfunction in Thai children. Key components encompass the prompt identification and stabilization of patients, meticulous titration of fluids and vasoactive agents, initiation of empirical antimicrobial therapy, judicious infectious source control, respiratory support, administration of sedation and analgesia, blood and blood product transfusion, correction of electrolyte imbalances, management of metabolic derangements, renal replacement therapy, and the implementation of multimodal monitoring. The objective is to optimize management, achieving therapeutic goals while continuously reassessing the patient's condition. Additionally, this guideline demonstrates adaptability by tailoring its suggestions to the resources available in Thailand’s medical facilities. Recognizing the diverse capabilities of healthcare institutions, the guideline endeavors to ensure its implementation is practical and feasible.