Clinical Critical Care

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

Nipaporn Chuntratip, Piyatida Borvornsudhasin, Sudarat Tippinit — Sat, 05 Apr 2025 00:00:00 +0700

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.

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

Sat, 05 Apr 2025 00:00:00 +0700

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.

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

Nonpisit Tangkitkiatkul, Taweevat Assavapokee — Tue, 01 Apr 2025 00:00:00 +0700

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, Kittikorn Kittirukwarakorn, Nattanon Pornchaisakuldee — Fri, 28 Mar 2025 00:00:00 +0700

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, Jakkrit Laikitmongkhon — Fri, 28 Mar 2025 00:00:00 +0700

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, Tananchai Petnak — Fri, 28 Mar 2025 00:00:00 +0700

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, Ranistha Ratanarat — Thu, 13 Mar 2025 00:00:00 +0700

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, Natyada Boonchana — Fri, 14 Feb 2025 00:00:00 +0700

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, Nattaya Raykateeraroj, Nuanprae Kitisin — Thu, 13 Feb 2025 00:00:00 +0700

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.

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

Peerapat Thanapongsatorn, Massupa Krisem, Sahaporn Wathanawanichakun — Sat, 01 Mar 2025 00:00:00 +0700

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, Napplika Kongpolprom — Tue, 21 Jan 2025 00:00:00 +0700

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.

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, Suthat Rungruanghiranya — Thu, 06 Feb 2025 00:00:00 +0700

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 — Thu, 23 Jan 2025 00:00:00 +0700

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.