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Background: Due to the pivotal role of inflammatory cytokines in sepsis, hemoperfusion with cytokine adsorbents may lead to better outcomes. Although previous studies showed inconclusive results, proper patient selection and timing of hemoperfusion may lead to improved survival. Objectives: To examine whether patients with septic shock requiring high-dose vasopressors undergoing add-on hemoperfusion with a cytokine adsorbent have better clinical outcomes than those treated with standard treatment alone. Methods: This is a multi-center, randomized controlled study in 2 tertiary care centers. 206 patients with septic shock receiving norepinephrine of 0.2 mcg/kg/min or higher are randomized to receive either standard treatment combined with 3-hour sessions of hemoperfusion with cytokine adsorbent for two consecutive days (HP group) or standard treatment alone (ST group). The primary outcome is 28-day mortality. Secondary outcomes include hospital and ICU mortality, shock reversal, vasoactive-inotropic score (VIS), organ support-free days, interleukin-6 levels, as well as safety data. Conclusions: This study will provide information to guide the use of hemoperfusion with a cytokine adsorbent in patients with septic shock.

BACKGROUND: Treatments for ARDS that improve patient outcomes include use of lung-protective ventilation, prone ventilation, and conservative fluid management. Implementation of ARDS protocols via educational programs might improve adherence and outcomes. The objective of this study was to investigate the effects of an ARDS protocol implementation on outcomes and adherence with ARDS guidelines. METHODS: This was a single-center, interventional, comparative study before and after protocol implementation. Staff education for the ARDS protocol was implemented between June 2014 and May 2015. A retrospective cohort analysis was conducted during between January 2012 and May 2014 (pre-protocol) and between June 2015 and June 2017 (post-protocol). A total of 450 subjects with ARDS were included. After propensity score matching, 432 subjects were analyzed. Of those, 330 subjects were treated after protocol implementation. RESULTS: The median (interquartile range [IQR]) plateau pressure and tidal volume over the first 3 d decreased significantly after protocol implementation (30.5 [IQR 24.2–33] vs 25.5 [IQR 21.7–30], P = .01 and 7.65 vs 7.4 mL/kg predicted body weight, P = .032, respectively). The percentage of subjects with unsafe tidal volume (> 10 mL/kg predicted body weight) decreased (14.4% vs 5.8%, P = .02). The percentage of subjects with safe plateau pressure (≤ 30 cm H(2)O) increased (47.4% vs 76.5%, P < .001). PEEP deviation from the ARDSNet PEEP/ [Formula: see text] table was significantly lower after the implementation. Mortality at 28 and 90 days improved after implementation (53.9% vs 41.8% and 61.8% vs 48.2%, respectively). Adjusted odds ratios for 28-d and 90-d mortality were 0.47 (95% CI 0.28–0.78) and 0.45 (95% CI 0.27–0.76), respectively. CONCLUSIONS: ARDS protocol implementation was associated with improved survival and rate of adherence.

Introduction: The impact of coexisting chronic obstructive lung disease (COPD) in patients with stroke remains unclear. This study aims to investigate the effect of COPD on survival and hospital outcomes among stroke patients. Methods: The outcomes of patients with stroke between fiscal years 2005 and 2017 from Thailand’s Universal Coverage Scheme database were compared between COPD and non-COPD patients using propensity score matching and flexible parametric survival model. Results: A total of 805,561 patients were admitted with stroke during the study period, 12,650 (1.92%) of whom had been diagnosed with COPD. Participants with COPD were significantly older, were more likely to be male, and had higher prevalences of pre-existing atrial fibrillation, ischemic heart disease, and heart failure and a higher incidence of ischemic stroke (p < 0.001). The propensity score-matched groups were well balanced in terms of all observed covariates. Participants with COPD had higher incidences of pneumonia (odds ratio [OR] 1.98, 95% confidence interval [CI]: 1.83–2.15), urinary tract infection (OR 1.27, 95% CI: 1.14–1.42), sepsis (OR 1.50, 95% CI: 1.32–1.70), cardiac arrest (OR 1.50, 95% CI: 1.19–1.88), respiratory failure (OR 1.82, 95% CI: 1.69–1.96), acute kidney injury (OR 1.29, 95% CI: 1.14–1.46), and in-hospital death (OR 1.21, 95% CI: 1.13–1.30) than those without. The impact of COPD on mortality was highest at day 93 (hazard ratio [HR] 1.73, 95% CI: 1.60–1.87) and nonsignificant at day 965 of follow-up (HR 1.08, 95% CI: 1.00–1.16). Conclusions: COPD was associated with respiratory, cardiac, renal, and infectious complications and significantly impacted survival for up to 2.6 years.

There have been no published studies examining the epidemiology of Guillain-Barre syndrome (GBS) in large populations in Thailand. This study aimed to explore the incidence, patient characteristics, seasonality, treatments, and outcomes of GBS in Thailand. The National Health Security Office (NHSO) provided data on in-patient admission between fiscal year 2005 and 2017. We selected all patients with a primary diagnosis of GBS. We retrieved data regarding the total population from the Department of Provincial Administration. A total of 4521 patients with GBS were included. The median age was 42 years (IQR 22-56), and 61.5% were male. The incidence rate increased from 0.48 to 0.93 per 100 000 population over the 13 years. The incidence was increased with age and a male-to-female ratio of 1.6:1. There was seasonal variation in the rate of admission for GBS, with significantly more patients admitted in rainy vs summer (IRR 1.94, 95%CI 1.80-2.10, P

Background: Acute kidney injury (AKI) is frequently encountered around 40% in critically ill patients and associate with a high mortality particularly in AKI patients requiring renal replacement therapy (RRT). The objective of this study was to assess the clinical predictors for 28-day mortality in AKI patients requiring RRT.Methods: This is a retrospective cohort study from prospectively collected data over a year (2014-2015). AKI patients requiring RRT were included. We collected demographic and laboratory data of AKI patients requiring RRT within 24 hours before initiation of RRT. We excluded patients with pre-existing chronic kidney disease stage 5 and AKI patients requiring peritoneal dialysis. We compared clinical characteristics and analyzed the predictors of mortality of survivors and non-survivors according to 28-day mortality.Results: We included 122 AKI patients requiring RRT. Mortality rate at day 28 and 90 after AKI diagnosis were 59% (95% confidence interval [CI] 49.7-67.8) and 72.1% (95%CI 63.3-79.9). On multivariable analysis, clinical predictors for 28-day mortality were baseline serum creatinine (hazard ratio [HR] 0.57, 95% CI 0.36-0.90), SOFA score before initiation of RRT (HR 1.08, 95%CI 1.01-1.15), presence of vasopressors before initiation of RRT (HR 3.04, 95%CI 1.12-8.25), serum lactate > 4 mmol/L before initiation of RRT effect 4 mmol/L before initiation of RRT effect ≥10 days of survival time (HR 1.31, 95%CI 0.47-3.60).Conclusion: A lower baseline serum creatinine was associated with the mortality in AKI patients requiring RRT. SOFA score, presence of vasopressors, and a higher serum lactate before initiation of RRT are useful clinical predictors for the 28-day mortality.

BACKGROUND There have been no published studies examining the epidemiology of Guillain-Barré syndrome (GBS) in large populations in Thailand. OBJECTIVE This study aimed to explore the incidence, patient characteristics, seasonality, and geographical distribution of GBS in Thailand. METHODS The National Health Security Office (NHSO) provided data on inpatient admission between 2005 and 2017. We selected all in-patients with a primary diagnosis of GBS based on the International Classification of Disease-10 (ICD-10) codes. The ICD-9 codes were used for plasmapheresis and intravenous immunoglobulin (IVIg). We retrieved data regarding the total population in Thailand from the Department of Provincial Administration. RESULTS A total of 5,688 patients with GBS were included. The median age was 42 years, and 61.6% were male. The incidence rate increased from 0.54 to 1.22 per 100,000 population over the 13 years. The incidence was higher in late rainy season and early winter, although no pattern of seasonality was observed (P = .53). Overall in-hospital mortality was 3.2% and was significantly higher in elderly patients (5.4%) than in younger adults (3.4%) and children (1.4%; P < .001). Treatment with IVIg increased from 4.72% through 25.12% over the 13-year period (P < .001). CONCLUSIONS The incidence rate of GBS gradually increased over the study period, especially in elderly patients, who also had a higher rate of mortality than patients in other age groups. There was no seasonal variation in the incidence of GBS in Thailand. Treatment with IVIg drastically increased over time and was more common than treatment with PE.

BACKGROUND: Obese subjects are at higher risk of development and progression of ARDS. There are limited data regarding mechanical ventilation practices and use of adjunctive therapies in subjects with ARDS across different obesity classes. We hypothesized that the adherence to lung-protective ventilation would be worse with rising body mass index class in patients with ARDS. METHODS: We conducted a retrospective observational study of subjects with ARDS. We evaluated the differences in ventilator settings, airway pressures, gas exchange, use of rescue therapies, length of hospital stay, and mortality among subjects based on the obesity classes of the WHO. RESULTS: The study included 613 subjects with ARDS: 21.4% were normal weight, 25% were overweight, and 53.7% were obese; 33.3% of the obese subjects met criteria for class I–II obesity, while 20.4% were class III obese (morbid obesity). On day 1, 53% of subjects with class III obesity had tidal volumes > 8 mL/kg, compared to 26% of the subjects with normal weight. In addition, 48% of the morbidly obese subjects received at least one rescue therapy as compared to 37% of normal weight subjects and 36% of overweight subjects. There were significant differences in the use of rescue therapies among the groups. In a multivariable model, subjects with class III obesity were significantly more likely to receive tidal volume > 8 mL/kg predicted body weight on day 1 when compared with subjects with normal weight (odds ratio 3.14, 95% CI 1.78–5.57). There was no difference in length of stay in ICU or hospital, duration of mechanical ventilation, or adjusted ICU or hospital mortality among the 4 groups. CONCLUSIONS: In this study, the risk of exposure to higher tidal volumes and the need for specific rescue therapies rose with higher classes of obesity in subjects with ARDS. More research is needed to identify how to better implement lung-protective ventilation in patients with obesity.

Panita Limpawattana,1 Wannaporn Aungsakul,2 Chomchanok Suraditnan,2 Anupol Panitchote,3 Boonsong Patjanasoontorn,3 Anakapong Phunmanee,3 Nittaya Pittayawattanachai4 1Division of Geriatric Medicine, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 3Division of Critical Care, Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 4CPR Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand Background: There are limited data available regarding long-term survival and its predictors in cases of in-hospital cardiac arrest (IHCA) in which patients receive cardiopulmonary resuscitation.Purpose: The objectives of this study were to determine the 1-year survival rates and predictors of survival after IHCA.Patients and methods: Data were retrospectively collected on all adult patients who were administered cardiopulmonary resuscitation from January 1, 2013 to December 31, 2014 in Srinagarind Hospital (Thailand). Clinical outcomes of interest and survival at discharge and 1 year after hospitalization were reviewed. Descriptive statistics and survival analysis were used to analyze the outcomes.Results: Of the 202 patients that were included, 48 (23.76%) were still alive at hospital discharge and 17 (about 8%) were still alive at 1 year post cardiac arrests. The 1-year survival rate for the cardiac arrest survivors post hospital discharge was 72.9%. Prearrest serum HCO3

Purpose Cholangiocarcinoma (CCA) is the second most common primary malignant hepatic tumor originating from bile duct epithelia. Bone metastasis is uncommon and less documented. The aim of this study was to characterize the imaging features of bone metastasis from CCA. Methods A retrospective descriptive imaging characteristics in 199 patients (1465 lesions) diagnosed as CCA with bone metastasis were evaluated based on plain radiography, computed tomography (CT), magnetic resonance imaging (MRI) and Tc-99 m methylene diphosphonate bone scan. Results The common vertebral metastatic sites were lumbar spines (94 [47.2 %], 95 %CI 40.1–54.4), upper thoracic spines (89 patients [44.7 %], 95 % CI 37.7–51.9), and lower thoracic spines (80 [40.2 %], 95 % CI 33.3–47.4). On plain radiograph, most of lesions had osteolytic pattern (68 %) with pedicular destruction (45.3 %) whereas on CT had mixed osteolytic and osteosclerotic destruction (40.8 %). The common non-vertebral metastatic sites were ribs and pelvis (80 patients [40.2 %], 95 % CI 33.3–47.4 and 60 [30.2 %], 95 % CI 23.9–37). On plain radiograph, in the long bones, usually had permeative destruction (58.9 %), whereas on CT showed mixed osteolytic and osteosclerotic (34.6 %). On bone scan, increased-uptake was the common pattern, found in the vertebral and non-vertebral sites (93.6 % and 92.4 %). Conclusions Bone metastasis from CCA usually occurred in the axial skeleton. The common patterns of destruction were osteolytic or mixed osteolytic and osteosclerotic. Periosteal reaction was scant in the appendicular long bones. On bone scan commonly had increased-uptake.

Table S1. Percentage of missing data of potential full model variables. Table S2. Baseline characteristics of survivors by renal recovery. Table S3. Ventilator settings, arterial blood gases averaged on day 1â 3 and other therapies in survivors. Table S4. Patterns of acute kidney injury reversal in survivors with acute respiratory distress syndrome. Table S5. Factors associated with renal non-recovery in all patients (non-imputed data. Table S6. Factors associated with renal non-recovery in survival patients (non-imputed data. Figure S1. The bar graphs show pattern of renal recovery by staging of acute kidney injury in 128 survivors. (DOC 170 kb)

Additional file 1. Supplementary tables and figures.

Delirium is a common condition in older adults which can have devastating outcomes. The studies about delirium in intensive care units (ICU) are relatively rare compared to studies in the non-ICU setting. This study aimed to study the prevalence, incidence, and risk factors of delirium among older Thai adults in ICU.Participants were older patients who were admitted to the ICU of Srinagarind Medical School, KhonKaen, Thailand from May 2013 to August 2014. Baseline characteristics were collected. Delirium was rated by trained clinical researchers using the Confusion Assessment Method for the ICU (CAM-ICU). Demographic data were analyzed using descriptive statistics. Regression analyses were used to analyze the outcomes.Delirium occurred in 44 of 99 patients (44.4%) with an incidence rate of 22.2% (22/99). The prevalence of delirium in mechanically ventilated patients was 62.5% (30/48). The majority of the patients had delirium within five days of ICU admission. Seven independent predisposing factors were identified using bivariate regressions: age, functional status, disease severity, having pneumonia, cognitive impairment, depression, or previous stroke. Numbers of additional drugs, bed changes, physical restraints, sleep deprivation, use of bladder catheters, and patients with mechanical ventilators were independent precipitating factors. For multivariate regressions, previous stroke, multiple bed changes, and physical restraints were the significant factors.The prevalence and incidence of delirium of older adults in the ICU setting in this study was high and comparable to prior studies. There are several significant risk factors associated with delirium which could be modified. These factors should be considered when designing effective preventive strategies of delirium.

Nurses have the key roles to detect delirium in hospitalized older patients but under-recognition of delirium among nurses is prevalent. The objectives of this study were to identify the under-recognition rate of delirium by intensive care nurses (ICU) using Confusion Assessment Method for the ICU (CAM–ICU) and factors associated with under-recognition. Participants were older patients aged ≥65 years who were admitted to the ICU of Srinagarind Medical School, Khon Kaen, Thailand from May 2013 to August 2014. Baseline characteristics were collected. Delirium was rated by a trained clinical researcher using the CAM–ICU. Demographic data were analyzed using descriptive statistics. Univariate and multiple logistic regressions were used to analyze the outcomes. Delirium occurred in 44 of 99 patients (44.4 %). Nurses could not identify delirium in 29.6 % of patients compared with researchers. Pre-existing dementia and depression were found in 47.7 % of patients. Pneumonia or other causes of respiratory failure were the most common causes of admission to ICU (47.7 %). Independent factors associated with under-recognition by nurses were identified—heart failure [adjusted odds ratio (OR), 77.8; 95 % confidence interval (CI) 2.5–2,543, p = 0.01] and pre-existing taking treatment with benzodiazepines (adjusted OR, 22.6; 95 % CI 1.8–85, p = 0.01). Under-recognition of delirium is a frequent issue. New independent factors associated with under-recognition were identified. Awareness of delirium in the patients with these factors is recommended. This study supports the finding of high under-recognition rates of delirium among hospitalized older adults in ICU. Patients with heart failure and receiving benzodiazepines were identified as barriers of recognition of delirium.

Energy expenditure in severe sepsis/septic shock patients was measured by indirect calorimetry and the correlation of energy expenditure between indirect calorimetry and predictive equations was determined.This was a prospective, observational analytical study. Severe sepsis or septic shock patients were measured for energy expenditure over 72 hours by indirect calorimetry that was measured by a mechanical ventilator (EngströmCarestation, GE Healthcare). Predictive equations for energy expenditure by the Harris-Benedict equation (HBE), Ireton-Jones 1992 equation (IRE) and ACCP equation (ACCP) were calculated and then correlations and agreement between indirect calorimetry and predictive equations were tested.The 16 patients had a mean age of 71.6±5.5 years and a mean APACHE II score of 26.9±4.0. The average energy expenditure by indirect calorimetry over 72 hours per kilogram body weight was 26.7±5.3 kcal/kg/day. For predictive equations, IRE was moderately significantly correlated with indirect calorimetry over 72 hours (intraclass correlation 0.46, 95% CI -0.01 to 0.77, p=0.028), but the HBE and ACCP equations were not significantly correlated (intraclass correlation for HBE -0.52, 95% CI -0.8 to -0.06, p=0.985 and intraclass correlation for ACCP 0.29, 95% CI -0.21 to 0.68, p=0.121).Energy expenditure over 72 hours in severe sepsis or septic shock was about 26.7±5.3 kcal/kg/day. The use of predictive equations should be further examined in future studies.

To determine the effectiveness of a non-return catheter valve vs. the standard urine bag for prevention of catheter-associated urinary tract infections (CAUTI) in critically ill patients.This was a pilot, randomized, stratified, open-label controlled trial (ClinicalTrials.gov, number NCT01963013). Ninety-six critically illpatients requiring indwelling urinary catheter were assigned with either a non-return catheter valve or the standard urine bag. Symptoms and signs of CAUTI before and after enrollment for all patients were recorded. If CAUTI was suspected, urine for microbiological testing was collected The primary outcome was the incidence density rate of symptomatic CAUTI and bacteriurial presence.The 96 patients were randomized into two groups. Baseline patient characteristics were similar in both groups except for the sex distribution. The incidence rate ratio was 0.71 for symptomatic CAUTI in the non-return catheter valve group (95% CI 0.25-1.98, p-value = 0.51). The crude incidence rate ratio of bacteriuria in the non-return valve group was 0.66 (95% CI 0.3-1.46, p-value = 0.31). The sex-adjusted incidence rate ratio of bacteriuria in the non-return catheter valve group was 0.64 (95% CI 0.29-1.41, p-value = 0.27).Using a non-return catheter valve might not prevent CA UTI among critically ill patients.

Post-stroke seizures in Thailand have not been studied. Thus, the authors' main objective was to assess the prevalence of post-stroke seizures and the secondary objective was to determine the factors associated with post-stroke seizures and mortality after stroke.This was a retrospective, descriptive study. The population included stroke patients admitted to Srinagarind Hospital between 2000 and 2004. The patients were 15 years of age and older. The authors reviewed medical records, mailed out a questionnaire, and conducted telephone interviews.The present study included 372 patients with stroke; of whom 15.6% had the seizures after the stroke. The length of follow-up was at least 5 years. Generalized tonic-clonic seizures were the most common type of post-stroke seizures. The time from the onset of stroke to the seizures was mostly (60.3%) less than 2 weeks (i.e., early post-stroke seizures). The associated factors of post-stroke seizures were non-dyslipidemia (p = 0.0007), intracerebral hemorrhage (p = 0.015), and lesions at cortical area (p = 0.05). The overall mortality rate at the time of the present study was 39.5%, 7.5% at 30 days and 22.8% at 1 year.The prevalence of post-stroke seizures was higher than in previous studies but the associated factors of post-stroke seizures were similar.

The epidemiology of DVT in critically ill medical patients has not been studied in Thailand. The aim of this study was to assess the prevalence and incidence rate of proximal DVT in these patients and to determine the factors associated with the development of this condition.