Clinical Critical Care

The efficacy of P0.1-guided sedation protocol in critically ill patients receiving invasive mechanical ventilation: A randomized controlled trial

Natdanai Ketdao — 2024-11-14

Background: Mechanical ventilation is a lifesaving treatment in patients with acute respiratory failure. Despite optimal support, some patients still exhibit excessive respiratory drive, leading to patient self-inflicted lung injury (P-SILI) and diaphragmatic dysfunction. Sedation and muscle relaxants are commonly used to reduce respiratory efforts and manage patient-ventilator asynchrony (PVA). Conventionally, sedative drugs are adjusted based on the sedation level assessed by the Richmond Agitation-Sedation Scale (RASS), which may not correlate with the patient’s respiratory drive. Drop in airway pressure at the first 100 milliseconds of the beginning of the inspiration after the end-expiratory occlusion (P_0.1) is a simple and reliable method of respiratory drive monitoring by mechanical ventilation at the bedside and may be the more suitable sedation target.

Objectives: To assess the efficacy of a sedation protocol targeting optimal P_0.1 and RASS score compared to conventional sedation strategy in patients requiring invasive mechanical ventilation in the medical intensive care units in terms of successful extubation.

Methods: This is an open-labeled, single-center, randomized controlled trial conducted in medical intensive care units at a tertiary care hospital in Bangkok, Thailand. We randomly allocated mechanically ventilated patients in a 1:1 ratio to receive a sedation protocol targeting both optimal respiratory drive measured by P_0.1 (intervention group) and light sedation (RASS 0 to -2) or standard of care (control group targeting RASS alone). The primary outcome is the rate of successful extubation within 14 days after randomization.

Hypothesis: We hypothesize that sedation protocol targeting optimal P_0.1 and light sedation will increase the rate of successful extubation at 14 days in mechanically ventilated patients compared to conventional sedation strategy.

Conclusions: This study aims to evaluate the efficacy of a sedation protocol using P_0.1 measurement to monitor and target optimal respiratory drive, in conjunction with sedation scores, in critically ill patients receiving invasive mechanical ventilation.

Ethics and dissemination: This study protocol was approved by the Human Research Protection Unit of the Faculty of Medicine, Siriraj Hospital, Mahidol University (Certificate of Approval no. Si 915/2023).

Trial registration: NCT06203405

BASal-bolus Insulin therapy in Critically ill patients (BASIC): A randomized controlled trial protocol

Supatida Turnsaket — 2024-11-01

Background: Controlling blood glucose levels is crucial for optimizing outcomes in critically ill patients. While the sliding-scale insulin regimen is common, the efficacy of basal-bolus insulin therapy, using insulin glargine and insulin aspart, is less explored in critical care settings.

Objective: This study investigates the efficacy and safety of basal-bolus insulin therapy compared to sliding-scale insulin in managing hyperglycemia in critically ill patients in a medical intensive care unit (ICU).

Methods: The BASal-Bolus Insulin Therapy in Critically Ill Patients (BASIC) trial is a single-center, open-label randomized controlled trial at Srinagarind Hospital, Thailand. The study will enroll adult critically ill patients admitted to the medical ICU with capillary blood glucose (CBG) levels between 180 and 400 mg/dL. Participants will be randomized (1:1) to receive either basal-bolus insulin therapy or sliding-scale insulin (control). The primary endpoint is the percentage of CBG within the target range of 140–180 mg/dL. The secondary outcomes include daily mean CBG levels, glucose variability index, 28-day mortality, length of stay in the ICU, incidence of nosocomial infections, ventilator-free days within 28 days, and occurrences of hypoglycemia.

Hypothesis: Basal-bolus insulin regimen has a higher efficacy in glycemic control compared to a sliding-scale regimen in critically ill medical patients.

Discussion: Evidence regarding the effectiveness of the basal-bolus insulin regimen in critically ill patients is limited, with most existing studies focusing on non-critically ill populations. This study addresses this gap by comparing the basal-bolus approach to the conventional sliding-scale insulin regimen. This trial aims to provide valuable insights into optimizing glycemic control in critically ill patients, potentially leading to improved clinical outcomes.

Ethics and dissemination: This study obtained approval from the Center for Ethics in Human Research at Khon Kaen University (Ethics Committee number: HE661013)

Trial registration: TCTR20230410009

The sevoflurane concentration for light sedation in critically ill patients: A protocol for experimental study

Wilasinee Jitpakdee — 2024-10-21

Background: Deep-inhaled sedation is increasingly used in Thai ICUs. However, there is a lack of information regarding the level of end-tidal sevoflurane concentration during light sedation.

Objectives: The study aims to determine the effective dose (ED50 and ED95) of sevoflurane concentration for light sedation (RASS score -1 to 0) in mechanically ventilated critically ill patients.

Methods: This is a prospective experimental single-center study. Mechanically ventilated patients with RASS ≥ 1 who required sedation in the medical and surgical intensive care unit were enrolled. Using an up-and-down sequential allocation technique, the inhaled sevoflurane level of each patient was allocated based on the previous patient’s response. RASS score and hemodynamic parameters were monitored. The primary outcome was the ED50 and ED 95 of end-tidal sevoflurane concentration. The secondary outcomes included the length of intensive care unit stay, duration of ventilator day, the incidence of delirium, hemodynamic status, and respiratory variables changed during the study period.

Hypothesis: There exist specific end-tidal sevoflurane concentrations (ED50 and ED95) that will reliably induce a target RASS score of -1 to 0 in critically ill patients who are mechanically ventilated.

Conclusion: This study will provide an effective dose of inhaled sevoflurane sedation for achieving targeted light sedation levels in critically ill patients, which may have minimal effects on hemodynamics.

Ethics and dissemination: This study has been approved by the Office of Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand, on 22nd May 2023 (COA.MURA2023/390).

Trial registration: TCTR20230825001

Fluid bolus in suspected Sepsis patients with Hyperlactatemia (FISH): Study protocol for an open-labeled, randomized controlled trial

Teeraporn Chayawuttipong — 2024-08-28

Background: The adequate preload was the goal of hemodynamic optimization for sepsis resuscitation. The fluid strategy in the early phase of sepsis is unclear.

Objective: To investigate the efficacy of a fluid bolus to prevent new-onset hypotension in suspected sepsis patients with hyperlactatemia (Point-of-care serum lactate 2-4 mmol/L).

Methods: The Fluid Bolus in Suspected Sepsis Patients with Hyperlactatemia Trial (FISH) is a single-center, open-label randomized controlled trial. Participants will be patients suspected of having sepsis with hyperlactatemia (Point-of-care serum lactate 2-4 mmol/L) in the emergency department of Srinagarind Hospital, Thailand. Eligible patients will be randomized (1:1) to one of the study arms using block randomization. They will be placed in either the fluid bolus group (intervention, 30 mL/kg within 3 hours) or the standard care group (control). The primary outcome is new-onset hypotension within 24 hours after randomization. Secondary outcomes include lactate clearance, ∆SOFA at 72-hours, organ failure, and support ‘free days’ to day 28, 28-day mortality.

Hypothesis: We hypothesize that a fluid bolus will prevent new-onset hypotension in suspected sepsis patients with hyperlactatemia (point-of-care serum lactate 2-4 mmol/L).

Discussion: The optimal strategy for intravenous fluid therapy in a patient suspected of sepsis with hyperlactatemia is unknown. This is the first randomized trial examining fluid strategy in the early phase of sepsis with mild hyperlactatemia.

Ethics and dissemination: This study obtained approval from the Center for Ethics in Human Research at Khon Kaen University (Ethics Committee number: HE661012) and was registered at the Thai Clinical Trials Registry (TCTR20230502003).

Trial registration: TCTR20230502003

Relationship between strain energy and alveolar overdistension in patients with acute respiratory distress syndrome: The research protocol

Jakkrit Laikitmongkhon — 2024-08-20

Background: Energy produced during mechanical ventilation has been established as a contributor to mortality in acute respiratory distress syndrome (ARDS) patients, elucidated through ventilator-induced lung injury (VILI). However, the potential association between strain energy, an engineering-based concept, and the risk of VILI remains unexplored.

Objectives: This study aims to investigate the correlation between strain energy and alveolar overdistension and the relationship between strain energy and single-breath mechanical power (MP) calculated by a simplified formula in patients with ARDS.

Methods: A prospective observational study will be conducted on moderate to severe ARDS patients under sedation and paralysis. We will gradually reduce positive end-expiratory pressure (PEEP) by two cmH₂O every two minutes from 20 to 8 cmH₂O in pressure-controlled ventilation mode. During decremental PEEP titration, patients would be monitored simultaneously for esophageal pressure and electrical impedance tomography (EIT). Data gathered from the mechanical ventilator and EIT during the decrementing PEEP titration were focused on seven PEEP levels: 20, 18, 16, 14, 12, 10, and 8 cmH2O, providing a dataset of 7 events per patient for analysis. Strain energy and single-breath MP were calculated from ventilator parameters, while EIT provided data on alveolar overdistension.

Hypothesis: We hypothesized that strain energy and single-breath mechanical MP correlate with alveolar overdistension in ARDS patients.

Conclusions: This study aims to assess the correlation between strain energy and alveolar overdistension, as well as the correlation between strain energy and single-breath MP in ARDS patients.

Ethics and dissemination: The study protocol has been approved by the faculty of medicine ethics committee, Ramathibodi Hospital, Mahidol University (COA MURA2023/718).

Trial registration: TCTR20240320001

Comparison of guiding sedation level by respiratory effort versus usual care in mechanically ventilated patients: A randomized controlled trial protocol

Phruet Soipetkasem — 2024-06-20

Background: Critically ill patients relying on mechanical ventilation often require excessive sedation, aiming to address asynchrony and prevent ventilator-induced lung injury (VILI). Unintentionally, there may be more suppression of respiratory efforts. It is well-established that improper respiratory efforts during mechanical ventilation can cause unfavorable outcomes.

Methods: Researchers conducted a single-center randomized control trial, parallel 2 groups (1:1 ratio), with 164 participants. One intervention group employed the optimal respiratory effort (predicted ΔP_L, P_0.1), and the other control group, employed usual care to guide the adjustment of sedative levels.

Hypothesis: To compare 28-day ventilator-free day (VFD) and mortality between measuring respiratory effort as opposed to usual care and adjusting sedative level during mechanical ventilation.

Conclusions: This study will evaluate the disparity in 28-day VFD and mortality between sedative level guidance by respiratory effort and usual care.

Ethics and dissemination: The study protocol received approval from the Human Research Ethics Committee, Faculty of Medicine Ramathibodi Hospital, Mahidol University (COA No. MURA2023/642)

Trial registration: NCT06242236

Dexmedetomidine versus propofol on intestinal barrier function in patients undergoing major gastrointestinal tract surgery: A prospective randomized comparative trial protocol

Jantarat Wisawachaiwat — 2024-05-30

Background: Dexmedetomidine and propofol are recommended as sedatives for agitation management in critically ill adults. However, sedative agents always have a diversity of adverse effects, including gastrointestinal recovery. Delayed recovery of gastrointestinal motility results in prolonged hospital stays and increased medical costs for critically ill patients. The study is intended to compare the effects of dexmedetomidine and propofol on intestinal barrier function and clinical benefits in patients undergoing major gastrointestinal surgery.

Methods: In an experimental prospective randomized comparative trial, 60 patients who undergo major gastrointestinal tract surgery will be randomized into the dexmedetomidine group (n=30) and the propofol group (n=30). In the dexmedetomidine group, dexmedetomidine will be commenced at an initial concentration of 0.3 to 0.7 mcg/kg/h. In the propofol group, propofol will be commenced at an initial dose of 1.0 mg/kg/h to 4.0 mg/kg/h. Sedation is targeted at RAAS (-1)-0. Epidural analgesia will be used for pain control in both groups. The blood pressure, mean arterial pressure, heart rate, length of stay in the intensive care unit, postoperative endotracheal intubation time, and time to postoperative first defecation will be recorded. Serum D-lactate levels will be detected before the start of sedation (0 hour) and after sedation at 12, 24 hours, respectively.

Hypothesis: We hypothesize that dexmedetomidine and propofol, with optimal use for sedation, will have different effects on gastrointestinal recovery.

Ethics and dissemination: This study protocol was developed by investigators and approved by the Institutional Review Board of Faculty of Medicine of Chulalongkorn University (COA No. 0139/2023).

Trial registration: TCTR20230118002

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

Wasin Pansiritanachot — 2024-04-16

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

Nattachai Hemtanon — 2024-03-28

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)

Prasittiporn Tangjitaree — 2024-03-25

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)

Kolanya Kangwanyotsak — 2024-03-17

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.

Confronting heatstroke: Understanding, preventing and treating a deadly condition

Dujrath Somboonviboon — 2024-11-01

Heatstroke is a potentially fatal condition that occurs when the body’s thermoregulatory responses are overwhelmed by excessive heat. This review provides an overview of heatstroke, discussing risk factors, pathophysiology, and clinical presentation. Emphasis is placed on the importance of early recognition, prompt diagnosis, rapid cooling, and various cooling strategies, along with organ-supportive care, to improve patient outcomes. Additionally, the review underscores the need for increased awareness and public health initiatives to prevent and manage this life-threatening condition.

Perioperative use of high flow nasal cannula

Suharit Visuthisakchai — 2024-05-23

High flow nasal cannula (HFNC) is an innovative oxygen therapy system that has gained increasing popularity in recent decades, particularly in the field of critical care medicine. The device provides a more constant and higher FiO₂, generates low levels of PEEP, reduces dead space ventilation, and conditions the inspired gas, which collectively results in a reduction in work of breathing (WOB) and improved patient comfort. While the application of HFNC in critically ill patients is well-established and supported by a large body of evidence, studies of HFNC during the perioperative period are limited. However, the working mechanisms of HFNC align with physiological demands across various anesthetic processes. Consequently, this system could potentially serve as an alternative oxygen delivery system for surgical patients during perioperative care. In this article, we summarize the working principles and the effects provided by HFNC, review its implementation during the perioperative period, and discuss the current evidence regarding its use.

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

Panu Boontoterm — 2024-04-02

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

Nutnicha Yolsiriwat — 2024-02-24

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

Neil John Glassford — 2024-01-16

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.

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

Nobuichiro Tamura — 2024-03-22

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.

A Thai guideline summary in management of pediatric septic shock

Rujipat Samransamruajkit — 2024-04-05

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.

Atypical skin manifestation of purpura fulminans in Chikungunya infection on elderly patients: A case report

Parita Dankul — 2024-06-20

Background: Chikungunya is a vector-borne infectious disease that is usually characterized by fever, joint pain, muscle ache, headache, rash, or fatigue. Severe life-threatening complications such as septic shock, acute respiratory distress syndrome, and multiple organ dysfunction can develop during the acute phase of the disease. Purpura fulminans were rarely reported.

Case presentation: A previously healthy 69-year-old male patient with no known medical history presented with a 3-day history of fever, malaise, and arthralgia at both knees. He developed dyspnea, purpura, and hemorrhagic blebs at the right leg for 1 day. He was initially diagnosed with sepsis and oliguric renal failure with severe lactic acidosis. After fluid therapy was given to maintain stable hemodynamics, his lactate level increased rapidly. Continuous renal replacement therapy and hemoperfusion with cytokine adsorbent were then initiated simultaneously. On the second day of admission, the skin and soft tissue lesions progressed rapidly, and the patient experienced refractory shock and multiple organ dysfunction. Finally, he was diagnosed with a Chikungunya infection. Three days following the onset of edema in his extremities, he expired.

Conclusion: Purpuric skin manifestations and shock are rare but serious in Chikungunya infections. Clinicians should be aware of the potential for life-threatening complications. Aggressive management and adjunctive therapy such as hemoperfusion and intravenous immunoglobulins should be further studied.