Clinical Critical Care

Overcoming combined shock: Hydrocortisone's role in adrenal insufficiency after unilateral adrenal gland injury - case report

Chompoonut Achavanuntakul — 2025-07-27

Introduction: Adrenal gland injury is a rare traumatic condition. Adrenal insufficiency following adrenal gland injury is even more uncommon and often overlooked, particularly in the presence of hemorrhagic shock, which is the most frequent cause of shock in trauma patients. This misdiagnosis can lead to excessive fluid resuscitation and subsequent complications.

Case presentation: A 36-year-old male sustained blunt thoracoabdominal trauma following a motor vehicle accident. Abdominal computed tomography revealed a grade II pancreatic injury, a grade II splenic injury, a grade IV kidney injury, and a left adrenal gland hematoma. During admission, the patient presented with abdominal pain and generalized guarding. An exploratory laparotomy with splenic vein repair was performed. The patient developed hypotension, and fluid resuscitation was initiated along with the administration of noradrenaline. A cortisol level was measured at 7.86 µg/dL. Therefore, hydrocortisone was infused, resulting in a gradual reduction of vasopressor support and stabilization of the patient’s hemodynamic status.

Conclusions: Severe trauma can result in combined shock. In cases of unilateral adrenal gland injury leading to low cortisol levels, prompt administration of hydrocortisone assists in improving the patient’s condition, as demonstrated in this case.

Calcium channel blocker overdose in real world practice: A case report

Adisak Chaisrima — 2025-09-18

Introduction: Calcium channel blocker (CCB) toxicity, particularly from dihydropyridine agents, like amlodipine, can cause life-threatening vasodilatory shock, bradycardia, and metabolic disturbances. In severe cases, standard resuscitative measures may be insufficient, necessitating advanced supportive and targeted therapies.

Case Presentation: A 72-year-old male presented 9 h after intentional ingestion of 200 tablets (1000 mg) of amlodipine with hypotension, metabolic acidosis, and acute kidney injury, but without hyperglycemia. Initial management included intravenous fluid resuscitation, calcium gluconate, and vasopressors. Despite this, he developed refractory shock, acute respiratory failure, and cardiac arrhythmia, requiring mechanical ventilation and intensive hemodynamic support. High-dose insulin euglycemia therapy (HIE) and methylene blue were administered. Renal function gradually improved, and vasopressors were weaned, and the patient was successfully extubated and discharged.

Conclusion: This case highlights the complexity of managing severe amlodipine overdose, emphasizing the role of early vasopressors, calcium salt administration, and adjunctive therapies such as HIE and methylene blue. Prompt recognition and a multimodal approach are critical for improving outcomes in patients with CCB toxicity.

Platypnea and orthodeoxia syndrome due to a right-to-left shunt via the foramen ovale in the absence of pulmonary hypertension after orthotopic liver transplantation: Sequelae leading to brain abscess: A case report

Suneerat Kongsayreepong — 2025-07-23

Introduction: Platypnea and orthodeoxia syndrome (POS) refers to the worsening of dyspnea and desaturation in the upright position. The most common cause of POS is a right-to-left intra-cardiac shunt. Patent foramen ovale (PFO) is a remnant of normal fetal anatomy that can continue into adulthood. Most are asymptomatic as the pressure in the left atrium is higher than in the right atrium, leading to the functional closure of the foramen ovale.

Case presentation: We report an autosomal dominant polycystic kidney and liver disease (ADPKD) patient with PFO Grade II–III, atrial septal aneurysm (ASA), and dilatation of the aortic root complicated with multiple dental caries and chronic gingivitis. He developed POS and brain abscess after liver and kidney transplantation. Right-to-left shunt was proved by the air contrast transesophageal echocardiography (TEE) review in the normal right atrium and pulmonary artery pressure. Concomitant cardiac pathology of ASA, dilatation of the aortic root, and elevation of the right hemidiaphragm after surgery might reposition the atrium septum and redirect inferior vena cava blood flow through PFO to the left atrium, causing reopening of PFO and right-to-left shunt. Multiple dental caries and chronic gingivitis might be the cause of brain abscess from paradoxical septic embolism. With the condition of complex and high-grade PFO and high Risk of Paradoxical Embolism (ROPE) score with POS, questions were raised concerning the closure of PFO either in the preoperative or especially postoperative period after POS was detected after liver transplantation to prevent paradoxical embolism. With the potential risk of complications with the closing of PFO, this issue should be addressed in a multidisciplinary approach, with the patient and family. However, aggressive treatment of intraoral infection is an important issue.

Conclusions: POS could happen in patient with underlying PFO associated with ASA undergoing orthotopic liver transplantation with elevation of right hemidiaphragm. Multidisplinary care team approach should be arranged for the decision of closure of this PFO to prevent intraoperative and serious postoperative complications.

Simultaneous extracorporeal liver and cardiorespiratory support with double plasma molecular absorption system and extracorporeal membrane oxygenation: A case report

Peerapat Thanapongsatorn — 2025-03-01

Introduction: Extracorporeal membrane oxygenation (ECMO) has emerged as a life-saving and bridging therapy for critically ill patients grappling with severe cardiopulmonary failure. However, ECMO is associated with multiple complications, including acute liver failure (ALF), which significantly worsens prognosis and mortality rates. This case report presents a unique instance of simultaneous extracorporeal liver and cardiorespiratory support.

Case presentation: A 43-year-old female with a history of infective endocarditis and prior Bentall's operation, who developed acute decompensated heart failure and cardiogenic shock due to a pseudoaneurysm compressing the left main coronary artery. She required high-dose vasopressors and was initiated on venoarterial ECMO (VA-ECMO) for circulatory and respiratory support. However, her condition worsened with the onset of hepatic encephalopathy and severe hyperbilirubinemia, indicative of acute liver failure, likely due to ischemic hepatitis, congestive hepatopathy, and ECMO-related hemolysis. To address her worsening hepatic dysfunction, we initiated the double plasma molecular absorption system (DPMAS) for three consecutive sessions as a bridge to definitive surgical repair. This intervention led to improvements in hepatic and renal function, allowing for successful ECMO weaning after 10 days. Three days after ECMO discontinuation, she underwent pseudoaneurysm repair and was subsequently discharged in stable condition.

Conclusions: To the best of our knowledge, this simultaneous management of acute liver failure and acute cardiorespiratory failure has never been reported in the literature. Our approach effectively reduced hyperbilirubinemia, improved hepatic encephalopathy, and facilitated successful bridging to cardiac surgery.

Bilateral spontaneous pneumothorax in undiagnosed asthma in an adult

Pipu Tavornshevin — 2025-01-21

Introduction: Bilateral spontaneous pneumothorax (BSP) is a rarely observed complication during an acute asthma attack. However, it can cause serious respiratory distress and must be rapidly treated.

Case presentation: A middle-aged male patient and active smoker with no previous medical illnesses presented to the emergency room, reporting severe dyspnea over the past 3 days. His vital signs were unstable, with severe desaturation (85% in room air). Physical examination revealed hyperresonance on percussion, diminished breath sounds in both lungs, and diffuse polyphonic wheezing. Chest X-ray displayed a moderate to large amount of bilateral pneumothorax with partially collapsed lungs. Thoracic computed tomography confirmed bilateral pneumothorax without evidence of cystic lung lesions or subpleural blebs. Importantly, imaging revealed diffuse mild bronchial wall thickening, indicative of chronic airway inflammation. The patient underwent treatment with bilateral tube thoracostomy and systemic corticosteroids. His treatment was maximized to control airway inflammation.

Conclusions: Acute asthma attacks can worsen due to disease progression or complications from other conditions mimicking asthma symptoms. BSP or unilateral spontaneous pneumothorax is a rare condition observed during an acute asthma attack, but it can be life-threatening. Delayed treatment and misdiagnosis may lead to serious respiratory distress and even death.

Diagnostic value of mediastinal/chest ratio in acute traumatic aortic injury

Noppon Taksaudom — 2025-10-31

Background: This study aimed to assess the diagnostic efficacy of mediastinum/chest-width ratio (MCR) derived from chest X-rays (CXR) in detecting acute traumatic aortic injury (ATAI) after blunt chest trauma. We compared MCR with standard mediastinal width for ATAI screening.

Methods: All adult patients with blunt chest trauma who underwent screening CXR due to suspected ATAI in Chiang Mai University Trauma Center between 2008 and 2022 were included. Definitive diagnosis was confirmed through computerized tomographic angiography (CTA). The diagnostic performance of MCR at the aortic knob level and carina level was evaluated using the Area under the Receiver Operating Characteristic (AuROC) curve.

Results: 421 patients were enrolled, consisting of 357 men and 64 women. 37 patients (8.7%) were diagnosed with the ATAI based on CTA findings. MCR values at the aortic knob level and carina level were significantly higher in ATAI group (0.35±0.05 vs. 0.31±0.04; p < 0.001 and 0.37±0.06 vs. 0.33±0.41; p < 0.001, respectively). The AuROC of MCR was significantly superior to that of mediastinal width at both measurement levels. AuROC further improved when considering patient age, presence of multiple organ injuries, aortopulmonary opacification on CXR, and MCR at the threshold of 0.35 for aortic knob level and 0.36 for carina level, without statistically significant difference.

Conclusions: MCR can be used as one of the complementary diagnostic tools for ATAI in blunt chest trauma. Combining MCR with other clinical predictors can further enhance its accuracy. However, it cannot replace direct measurement of mediastinal width as a standard screening tool for blunt ATAI cases.

Effect of positive end-expiratory pressure on intracranial pressure in post cranial surgery using ultrasonic imaging measurement the optic nerve sheath diameter

Nuttapon Lertkankasuk — 2025-07-01

Background: While positive end-expiratory pressure (PEEP) is beneficial for oxygenation, it may potentially increase intracranial pressure (ICP): especially in post-cranial surgical patients. The optic nerve sheath diameter (ONSD) is the non-invasive method of ICP measurement. Our study focuses on the association between PEEP and intracranial pressure (ICP) in post-cranial surgery patients using optic nerve sheath diameter (ONSD) as a surrogate marker.

Method: A prospective non-randomized interventional study was conducted on post-cranial surgical patients who required mechanical ventilation with ages 16-80 years, initial PEEP at 5 mmH₂O were included in this study. Patients with intracranial hypertension (defined as ICP 22 mmHg), a history of traumatic brain injury, or cardiopulmonary disease at enrollment were excluded from the study. ONSD measurement was performed at varying PEEP levels from 5 to 20 cmH₂O.

Result: In adult (18-60 years) patients who had post-cranial surgery within 72 hours and required a mechanical ventilator, ONSD corresponding to ICP significantly increased when PEEP exceeded 13 cmH₂O. PEEP more than 15 cmH₂O resulted in a significant increase in ONSD exceeding 5.5 mm (corresponding to ICP > 22 mmHg); Mean arterial pressure (MAP) significantly decreased with an increase in PEEP value (p < 0.001). PEEP 20 cmH₂O reduced MAP to below 65 mmHg.

Conclusion: PEEP less than 15 cmH₂O can be safely applied to post-cranial surgical patients, whereas PEEP more than 20 cmH₂O may be harmful due to both ICP elevation and MAP decrement for these patients.

End expiratory occlusion test and tidal volume challenge test for assess fluid responsiveness in prone patients

Thanadate Sirithanasarn — 2025-05-07

Background: Assessing fluid responsiveness in patients in the prone position with low tidal volume ventilation presents challenges when utilizing pulse pressure variation (PPV) and the inferior vena cava (IVC) distensibility index. These challenges stem from the use of low tidal volume and the difficulty of conducting IVC assessment in the prone position. Consequently, an alternative method for predicting fluid responsiveness in these patients is imperative.

Method: This study comprises a prospective investigation that was carried out on hypotensive patients positioned in the prone posture and undergoing lung-protective ventilation at Bhumibol Adulyadej Hospital. Prior to the administration of a 500 ml fluid bolus, end-expiratory occlusion (EEO) and tidal volume challenge (TVC) tests were conducted. Initial recordings of cardiac output, cardiac index, and PPV were documented, followed by subsequent recordings after each procedure.

Result: Among the 20 participants in the prone position study, 4 patients developed severe acute respiratory distress syndrome (ARDS) while 16 patients were in that position for surgical reasons. Of these, 7 patients exhibited a positive response to fluid administration, while 13 patients did not. An increase in cardiac index (CI) of more than 5% during EEO is indicative of fluid responsiveness with a sensitivity of 100% and specificity of 92.3%. Moreover, a 3.5% absolute increment in PPV during TVC suggests fluid responsiveness with a sensitivity of 57.1% and specificity of 92.3%. We observed an interrater reliability (kappa) of 0.894 for EEO and 0.529 for PPV.

Conclusion: In the case of hypotensive patients undergoing prone positioning and receiving low tidal volume ventilation, both EEO for 15 seconds and TVC methodologies can be employed to evaluate fluid responsiveness. It is important to note that EEO demonstrates greater reliability in this context.

The development of clinical nursing practice guideline (CNPG) for patients undergoing coronary artery bypass graft surgery

Nipaporn Chuntratip — 2025-04-05

Background: The current clinical nursing practice guideline (CNPG) for coronary artery bypass graft (CABG) patients lacks comprehensive coverage across all phases of care, leading to postoperative complications and increased readmissions. Therefore, the development of a new CNPG is essential to ensure continuity and quality of care.

Methods: This research and development study was conducted from August 2024 to January 2025 and involved two sample groups: (1) 32 patients undergoing CABG surgery, compared with a retrospective chart review of patients with similar characteristics treated within six months prior to CNPG implementation, and (2) 52 nurses providing care for CABG patients. Research instruments included: (1) a nursing questionnaire, (2) a demographic questionnaire, (3) a newly developed CNPG covering all phases of care from preoperative to discharge, (4) a nurse satisfaction survey on CNPG use, and (5) a CABG care knowledge assessment for nurses. Data were analyzed using descriptive statistics, independent t-test, and Chi-square test.

Results: All patients underwent CABG surgery as scheduled, with no postponements due to unpreparedness. There were no significant differences in baseline characteristics between the control and intervention groups. The intervention group demonstrated significant reductions in intubation time, ICU stay, hospitalization duration, and post-discharge complications (p < .05), with durations decreasing from 7.28 ± 2.75 to 6.66 ± 2.15 days, 8.88 ± 1.90 to 8.63 ± 2.15 days, and 1.56 ± 0.72 to 1.16 ± 0.45 days, respectively. Nurse’s knowledge of CABG care significantly improved after CNPG implementation (p < .01). Overall, nurses reported the highest level of satisfaction with the CNPG (Mean = 4.73 ± 0.27).

Conclusions: This developed CNPG for patients undergoing CABG can be effectively implemented by nurses covering preoperative, intraoperative, postoperative, and discharge periods.

Metaraminol in critical care and anesthesia: A safe alternative for hypotension management?

Camila Gomes Dall’Aqua — 2025-11-05

Metaraminol, a synthetic sympathomimetic amine with predominant alpha-1 adrenergic agonist activity, is increasingly used to manage arterial hypotension in critical care and anesthesia. Its pharmacological effects include peripheral vasoconstriction and indirect stimulation of norepinephrine release, producing effective hemodynamic support through intravenous bolus or infusion. Compared with norepinephrine, metaraminol may offer advantages such as reduced arrhythmogenic potential, improved coronary and renal perfusion, and suitability for peripheral administration, minimizing risks associated with central venous access. However, evidence supporting its broader use outside obstetric anesthesia remains limited, largely derived from small observational studies. Uncertainties persist regarding optimal dosing, pharmacokinetic variability, and dose equivalence with norepinephrine. Reported adverse effects include prolonged hypertension, tissue ischemia, and reflex bradycardia. Despite these gaps, surveys indicate widespread clinical use, reflecting its practicality for rapid hemodynamic stabilization. Current data suggest non-inferiority to norepinephrine in obstetric anesthesia, but robust randomized trials are needed to define efficacy, safety, and pharmacodynamic profiles across patient populations. Standardization of dosing strategies and further evaluation in critical care settings are essential to clarify metaraminol’s role as a safe and effective vasopressor alternative.

Effect of dynamic arterial elastance and assisted fluid management software guided resuscitation in septic shock: Pilot study

Nuwara Pornawalai — 2025-10-06

Background: Hypotension in septic shock patients increases mortality and organ dysfunction risks, which is characterized by vasodilation and fluid loss. Therefore, precise fluid and vasopressor therapy is needed. A new monitoring device (Hemosphere®) using parameters of dynamic arterial elastance (Ea_dyn) and stroke volume change prediction (∆SV_predict) may safely guide treatment, improving outcomes compared to standard care.

Objections: to investigate the benefit of using the assist fluid management and dynamic arterial elastance (AFM-Ea_dyn) guide resuscitation and vasopressor therapy in septic shock resuscitation for mechanically ventilated patients compared with standard of care.

Methods: This randomized, controlled, experimental clinical medical device pilot trial included patients older than 18 years with a diagnosis of sepsis or septic shock in medical ICU with onset of shock in less than 24 hours assigned in a 1:1 ratio to receive the assist fluid management and dynamic arterial elastance (AFM-Ea_dyn) guide resuscitation and the standard of care.

Hypothesis: We hypothesize that AFM-Ea_dynguide resuscitation in patients with sepsis-induced hypotension would result in less time to shock reversal compared to the standard of care.

Ethics and dissemination: The study protocol was approved by the Siriraj Institutional Review Board with the certificate of approval number Si 895/2567

Trial registration: NCT06937918 (ClinicalTrial.gov ID)

Effects of nasal continuous positive airway pressure compared with high flow nasal cannula on the coordination between swallowing and breathing in post-extubation patients, a randomized crossover study

Sawita Cowawintaweewat — 2025-08-31

Background: Coordination between swallowing and breathing is essential to prevent aspiration. Swallowing during expiration (E-E swallow) is considered the most protective pattern [1,2]. High-flow nasal cannula (HFNC) and continuous positive airway pressure (CPAP) may promote this pattern by increasing the proportion of E-E swallows [3-5], but their comparative effects in post-extubation patients remain unclear.

Objectives: To compare the effects of nasal CPAP and HFNC on swallowing-breathing coordination patterns in post-extubation patients and to identify factors influencing this coordination

Methods: This randomized, controlled, crossover trial includes patients who received invasive mechanical ventilation for ≥ 48 hours and were extubated within 48 hours prior to enrollment. Patients with dysphagia (modified water swallowing test score < 4) were excluded. Eligible patients are randomly assigned to Group A (CPAP → HFNC) or Group B (HFNC → CPAP). Each intervention is applied for 5 minutes, followed by three continuous water swallowing tests. Swallowing and respiratory phases are recorded using surface EMG and ECG-derived respiration. A 5-minute washout with low-flow nasal oxygen is provided between interventions. Swallowing–breathing coordination is classified into four patterns: E–E, I–E, E–I, and I–I. The primary outcome is the percentage of E-E swallows. Secondary outcomes include other patterns, swallowing frequency, expiratory time, and respiratory rate. All outcomes are analyzed using linear mixed-effects models.

Hypothesis: CPAP and HFNC may differ in their effects on swallowing–breathing coordination, particularly in promoting the E–E pattern.

Conclusion: This study explores how nasal CPAP and HFNC affect swallowing–breathing coordination and their potential impact on airway protection after extubation.

Ethics and dissemination: Approved by the IRB, Faculty of Medicine, Chulalongkorn University. Results will be disseminated via peer-reviewed journals and conferences.

Trial registration: TCTR20210607003

The treatment and monitoring of aneurysmal subarachnoid hemorrhage in critically ill patients

Panu Boontoterm — 2025-07-10

Purpose: To review the treatment and monitoring strategies for aneurysmal subarachnoid hemorrhage (aSAH) in critically ill patients, emphasizing the need for a multidisciplinary approach to stabilize the patient, prevent secondary brain injury, and manage complications.

Methods: The review focuses on targeted management of key cerebral parameters, including intracranial pressure (ICP), pressure reactivity index (PRx), cerebral autoregulation (CA), and the integration of non-invasive modalities such as near-infrared spectroscopy (NIRS). These tools are utilized to prevent rebleeding, control ICP, manage cerebral vasospasm, and support systemic homeostasis.

Important results: Despite advancements in continuous neuromonitoring and multidisciplinary care, current therapeutic strategies must span the entire treatment continuum from diagnosis and preoperative stabilization to intraoperative management and postoperative recovery. Securing the aneurysm via clipping or coiling remains central to reducing complications and improving neurologic outcomes.

Conclusions: Optimal management of aSAH demands individualized and dynamic neuromonitoring strategies. Patients with preserved consciousness may benefit from non-invasive monitoring to detect early deterioration, while those who are comatose or severely impaired require comprehensive invasive monitoring to guide cerebral resuscitation and prevent secondary injuries. Equally important is the strict prevention of systemic complications such as dysglycemia, anemia, hyperthermia, hypoxemia, dysnatremia, and infection, which are critical for maximizing neurologic recovery and survival.

Irritant and asphyxiant gases

Pitirat Panpruang — 2025-10-08

Both irritant and asphyxiant gases are hazardous substances that, when inhaled, can cause a spectrum of respiratory complications, ranging from mild irritation to life-threatening respiratory failure. These gases are classified into three main categories based on their mechanisms of toxicity: pulmonary irritants, simple asphyxiants, and chemical asphyxiants. Pulmonary irritants, such as chlorine, phosgene, and ammonia, cause direct injury to the respiratory mucosa, leading to inflammation, bronchospasm, and pulmonary edema. Simple asphyxiants, including nitrogen, methane, and carbon dioxide, displace oxygen in the environment, resulting in hypoxia and potentially fatal respiratory depression. Chemical asphyxiants, such as carbon monoxide, hydrogen cyanide, and hydrogen sulfide, interfere with oxygen transport or cellular respiration, causing systemic hypoxia at the mitochondrial level.

Diagnosis of the gas exposure relies on a detailed history of exposure, clinical symptoms, and laboratory investigations, including arterial blood gas analysis, pulse oximetry, and carboxyhemoglobin or methemoglobin levels. Management involves immediate removal from the toxic environment, decontamination, oxygen supplementation, and supportive treatment. Specific antidotes, such as hydroxocobalamin for cyanide poisoning and methylene blue for methemoglobinemia, may be required in severe cases. Given the potential for rapid deterioration, early recognition and prompt intervention are essential in preventing morbidity and mortality. This review provides an in-depth analysis of the toxicology, pathophysiology, and management strategies associated with asphyxiant gas exposure.

Diaphragmatic ultrasound: A clinical perspective on diaphragm function in the ICU

Nonpisit Tangkitkiatkul — 2025-04-01

Mechanical ventilation (MV) is a critical component in managing respiratory failure in critically ill patients. While lifesaving, prolonged MV can induce ventilator-induced diaphragmatic dysfunction (VIDD), characterized by decreased diaphragmatic function, atrophy, and loss of contractility. These complications exacerbate weaning challenges, extend ICU stays, and escalate mortality rates. Diaphragmatic ultrasound (DUS) offers a non-invasive, real-time evaluation tool that has revolutionized the monitoring and management of diaphragm function. This review delves into the pathophysiology of VIDD, evaluates its clinical impacts, and the integral role of DUS in implementing protective ventilation strategies to optimize outcomes for both lung and diaphragm health.

Diagnosis of brain death

Pawarisa Chaisuthikun — 2025-03-28

Brain death (BD), or death by neurological criteria (DNC), defined as the irreversible cessation of all cerebral and brainstem activities, has been a medically and legally accepted formulation of death. This review article summarizes the clinical criteria and diagnostic protocols for determining brain death. Emphasis is placed on the integration of clinical examination findings, such as the absence of brainstem reflexes and apnea testing, alongside ancillary tests when required. Key guidelines are discussed to ensure a standardized and legally sound diagnosis, including approaches to confounding factors such as drug intoxication, metabolic disturbances, or hypothermia. Furthermore, the article highlights advancements in imaging techniques and electrophysiological monitoring that supplement traditional assessments. This review aims to provide a comprehensive understanding of brain death diagnosis, ensuring accuracy and consistency in clinical and legal practices worldwide.

Viscoelastography interpretation

Karuna Chavalertsakul — 2025-03-28

The application of viscoelastography, which includes both Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM), has become increasingly prominent across various clinical disciplines. Its utility is well-documented in surgical settings, trauma care, postpartum care, and critical care medicine, where patients often experience complex and dynamic disturbances in hemostasis. Viscoelastic testing offers a rapid, real-time, point-of-care evaluation of the entire coagulation process, providing valuable insights into the distinct phases of clot initiation, clot strength, and subsequent fibrinolysis. The understanding and timely interpretation of viscoelastography results enhance the precision of hemostatic management by guiding the judicious use of appropriate blood components and hemostatic agents. This targeted approach reduces the risks associated with transfusion-related complications and contributes to improved overall clinical outcomes.

Management of critically ill obstetric patients

Touchapong Taksinwarajarn — 2025-03-28

Pregnant patients requiring intensive care management present unique challenges due to physiological adaptations and pregnancy-specific conditions. While many aspects of critical care remain similar to non-pregnant patients, modifications in fluid resuscitation, medication selection, ventilatory support, and anticoagulation strategies are important to balance maternal stabilization with fetal safety. A multidisciplinary team approach, including obstetricians, intensivists, anesthesiologists, and neonatologists, is necessary for the effective management of critically ill pregnant patients. This review outlines key considerations in the critical care of pregnant patients, including hemodynamic, respiratory, and airway management, as well as sedation, thromboprophylaxis, and nutritional support. Additionally, pregnancy-related complications such as preeclampsia, pulmonary embolism, amniotic fluid embolism, and air embolism require specialized diagnostic and therapeutic approaches to ensure optimal maternal and fetal outcomes.

Electrical impedance tomography in critical care: Advancing bedside respiratory monitoring and ventilation management

Jitanong Sootlek — 2025-03-13

Electrical Impedance Tomography (EIT) is a transformative, non-invasive imaging tool in critical care, providing real-time, continuous monitoring of lung function. Originally applied to assess ventilation distribution in mechanically ventilated patients. EIT's scope has expanded significantly. It now encompasses a wide range of applications, including positive end-expiratory pressure (PEEP) titration, spontaneous breathing assessment, air trapping detection, alveolar recruitment guidance, and ventilation-perfusion (V/Q) matching. EIT supports personalized respiratory management across a range of therapies, including mechanical ventilation, high-flow nasal cannula (HFNC), and non-invasive ventilation (NIV), by identifying ventilation heterogeneity and preventing ventilator-induced lung injury (VILI). The ability of EIT to quantify regional lung mechanics, detect changes due to therapeutic interventions like suctioning and bronchodilation, and visualize complex phenomena such as pendelluft underscores its role in optimizing ventilation strategies and enhancing patient outcomes in critical care. Despite some technical challenges, EIT's integration into respiratory monitoring protocols is advancing, supporting data-driven, individualized management approaches that improve safety and outcomes for critically ill patients.

Diastolic shock index: Its importance and application in critically ill patients: A narrative review

Natthida Owattanapanich — 2025-02-14

A recently developed method to measure vasodilatation is the diastolic shock index (DSI), which can be calculated by dividing heart rate by diastolic blood pressure. The DSI plays a significant role in many medical conditions. The focus of this review is to determine the evidence-based data of diastolic shock index in various conditions. Current trials recommend adding norepinephrine when diastolic arterial pressure is below 40 mmHg or diastolic shock index is more than 3. Besides, recent trials have studied the diastolic shock index in myocardial infarction, the peri-intubation period, the intraoperative period, and emergency department triage. Higher diastolic shock index value at presentation of severe cases of sepsis could identify patients who might benefit from early vasopressors and predict the progression of septic shock in emergency department triage. Moreover, it could help as a tool to identify a higher risk of death in myocardial infarction and peri-intubation period hypotension. However, the cut-off points for the diastolic shock index vary across different conditions.

Assessment of sleep quality in the Intensive Care Unit: A comprehensive review of tools and techniques

Suchanun Lao-amornphunkul — 2025-02-13

Sleep disturbances are common among critically ill patients, significantly impacting recovery and overall health outcomes. Sleep in the Intensive Care Unit (ICU) is often fragmented, with reduced deeper sleep stages and disrupted circadian rhythms. This review explores a range of tools for assessing sleep quality in ICU settings, including both objective and subjective methods. Objective tools, such as polysomnography (PSG), Bispectral Index (BIS), and actigraphy, provide quantifiable data on sleep patterns but vary in their practicality and accuracy. PSG is considered the gold standard due to its comprehensive measurement of sleep stages; however, its use is limited in ICU settings due to high costs, complexity, and the need for trained personnel. BIS and actigraphy offer more feasible alternatives, but their validity and accuracy compared to PSG can vary. Subjective approaches, like patient questionnaires and nurse observation tools, offer valuable insights into perceived sleep quality but may be influenced by patient condition and cognitive status. This review evaluates the advantages, limitations, validity, and reliability of these tools, emphasizing their potential roles in clinical practice. The findings suggest the need for more tailored approaches to sleep assessment in ICU patients, acknowledging that no single tool is without limitations. Further research is needed to develop novel, reliable, and cost-effective sleep assessment methods specifically suited for the ICU, which could improve patient outcomes through better-targeted interventions for sleep disturbances.

Publications in 2024 and reviewers in 2021 - 2024 on Clinical Critical Care and indexing in Thai-Journal Citation Index - Tier 1 (valid 2025 - 2029)

Kaweesak Chittawatanarat — 2025-02-06

In its 33^rd year of publication under the Thai Society of Critical Care Medicine and entering its 5^th year as Clinical Critical Care, the journal has reached another milestone by being indexed in the Thai-Journal Citation Index (TCI) Tier 1. This editorial will highlight the published works of the journal, along with expert reviews from various fields, whose insights and critiques have contributed to refining and enhancing the quality of the published research.

Remembering Professor Emeritus Lady Dr. Putipannee Vorakitpokatorn: A visionary anesthesiologist and ICU pioneer

Chaianan Sodapak — 2025-01-23

We mourn the loss of Lady Dr. Putipannee Vorakitpokatorn or “Ajahn Tam”, beloved wife, mother, teacher, a remarkable anesthesiologist, critical care physician, and a mentor who dedicated her life to improve patient care in Thailand Ajahn Tam passed away peacefully on October 11^st, 2023, her unwavering passion and compassion touched the lives of countless individuals.

Benefit of inodilators in septic shock patients: A systematic review and network meta-analysis

Nutnicha Suntornlekha — 2025-04-05

Background: The efficacy of inodilator agents, including dobutamine, levosimendan, and milrinone, in patients with septic cardiomyopathy on mortality outcomes is still a controversial issue. This systematic review and network meta-analysis aimed to assess the impact of inodilator agents on mortality outcomes and hemodynamic data when utilizing these inodilators compared to placebo.

Method: We conducted a network meta-analysis and searched PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov for randomized controlled trials and prospective cohort studies examining the use of levosimendan, dobutamine, or milrinone in patients with septic shock. The primary outcomes were short-term mortality. The secondary outcome were ICU length of stay, and hemodynamic parameters.

Results: Fourteen studies involving 1164 participants were included in the analysis. In terms of short-term mortality, levosimendan ranked the highest with a relative risk (RR) of 0.93 (95% CI 0.77-1.13) compared to placebo. The second and third rankings were milrinone (RR of 0.91; 95% CI 0.65-1.27) and dobutamine (RR of 1.12; 95% CI 0.84-1.51), respectively. Regarding ICU length of stay, Levosimendan ranked the first with a mean difference (MD) of -0.83 (95% CI -2.58 to 0.93), while dobutamine, ranking second, demonstrated a MD of 0.30 (95% CI -2.45 to 3.05) compared to placebo. In terms of heart rate, levosimendan was the first ranking with a MD of 0.25 (95% CI -4.57 to 5.07) compared to placebo, followed by milrinone with a MD of 0.00 (95% CI -10.14 to 10.14), and dobutamine with a MD of 1.43 (95% CI -4.59 to 7.45). All results had very low certainty of evidence.

Conclusions: There were no statistically significant differences in short-term mortality, length of ICU stays, and tachyarrhythmia among septic shock patients treated with inodilator agents. The application of these agents in clinical practice should be tailored to individual patient characteristics. Further randomized controlled trials with larger sample sizes are necessary to establish more definitive evidence.