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Background: Delirium in intensive care units increases morbidity and mortality risk. The incidence and risk factors of delirium vary among studies. This study therefore aimed to determine the incidence and risk factors of delirium in Thai university-based surgical intensive care units. Methods: A multi-center, prospective cohort study was conducted. All patients who had been admitted to surgical intensive care units (SICU) between April 2011 and January 2012 were enrolled. Delirium was diagnosed using the Intensive Care Delirium Screening Checklists (ICDSC). The univariable and multivariable risk regression analyses were analyzed and presented as risk ratio (RR) and 95 % confidence interval (CI). Results: The overall incidence of delirium was 3.6 % (162 of 4450, 95 % CI 3.09-4.19 %) whilst the incidences of delirium for patients being admitted ⩽48 and >48 h were 0.7 % (21 of 2967, 95 % CI 0.41-1.01 %) and 8.3 % (141 of 1685, 95 % CI 7.04-9.68 %), respectively. The incidence of delirium on each study site was significantly different (range between 0 and 13.9 %, P < 0.001). Delirious patients had a significantly higher age (65.3 ± 15.6 versus 61.8 ± 17.3 years, P = 0.013), higher Acute Physiology and Chronic Health Evaluation II score (APACHE II score) (16 (12-23) versus 10 (7-15), P < 0.001), and higher sequential organ failure assessment score (5 (2-8) versus 2 (1-5), P < 0.001). The median duration of delirium was 3 (1-5) days. Delirious patients had significantly longer duration of ICU stay (8 (5-19) versus 2 (1-4), P < 0.001) and higher ICU mortality rate (23.5 versus 8.1 %, P < 0.001). Sepsis (RR = 3.70, 95 % CI 2.33-5.90, P < 0.001), exposure to sedative medications (RR = 3.54, 95 % CI 2.13-5.87, P < 0.001), higher APACHE II score (RR = 2.79, 95 % CI 1.98-3.95, P < 0.001), thoracic surgery (RR = 1.74, 95 % CI 1.09-2.78, P = 0.021), and emergency surgery (RR = 1.70, 95 % CI 1.09-2.65, P = 0.019) were independent risk factors of delirium in SICU. Conclusions: Sepsis, exposure to sedative medications, higher APACHE II score, thoracic surgery, and emergency surgery were independent risk factors of delirium in Thai university-based surgical intensive care units. [ABSTRACT FROM AUTHOR]

ABSTRACT Background and Objective: Interleukin-8 (IL-8) is a central chemokine in acute respiratory distress syndrome (ARDS), and the IL-8 gene contains a functional single nucleotide polymorphism (SNP) −251A/T in its promoter region. We hypothesized that IL-8 −251A/T SNP is associated with PaO2/FiO2 in critically ill patients. Methods: We conducted genetic-association studies in intensive care units at academic teaching centres using a derivation septic shock cohort (vasopressin and septic shock trial (VASST), n = 467) and a validation post-cardiopulmonary bypass surgery cohort (CPB, n = 739) of Caucasian patients. Patients in both cohorts were genotyped for IL-8 −251A/T. The primary outcome variable in both cohorts was the fraction of patients who had a PaO2/FiO2 < 200. IL-8 mRNA expression was measured in genotyped lymphoblastoid cells in vitro. Results: The frequency of the patients with PaO2/FiO2 <200 was significantly greater in patients who had the AA genotype of −251A/T than in patients who had the AT or TT genotypes in both VASST (AA = 60.8% vs AT and TT = 53.8% and 48.0%, P = 0.038) and the CPB cohort (AA = 37.0% vs AT and TT = 27.0% and 26.0%, P = 0.039). Patients having the AA genotype had a higher probability to remain on mechanical ventilation ( P = 0.047) in the first 14 days. Lymphoblastoid cells having the AA genotype had significantly higher IL-8 mRNA expression than cells having the AT or TT genotype ( P = 0.022). Conclusions: Critically ill Caucasian patients who had the AA genotype of IL-8 −251A/T had an increased risk of PaO2/FiO2 <200. The AA genotype was associated with greater IL-8 mRNA expression than the AT or TT genotypes. [ABSTRACT FROM AUTHOR]

Objective: To investigate the prevalence of overweight and obesity, and their impacts in patients admitted to a surgical intensive care unit (SICU) in Thailand., Material and Method: We conducted an analysis using the THAI-SICU database. All 4,579 patients who had weight and height measured were classified into four groups using body mass index (BMI) based on the World Health Organization criteria, which were 1) underweight (BMI <18.5 kg/m2), 2) normal BMI (BMI 18.5-24.9 kg/m2), 3) overweight (BMI 25-29.9 kg/m2), and 4) obese (BMI >30 kg/m2) groups. Primary outcome was prevalence of overweight and obesity. Secondary outcomes were 28-day survival, and SICU outcomes between four patient groups., Results: There were 768 (16.8%) of underweight, 2,624 (57.3%) of normal BMI, 858 (18.7%) of overweight, and 329 (7.2%) of obese patients. Compared to other three patient groups, obese had the highest 28-day survival (log-rank, p<0.001), lowest incidence of systemic inflammatory response syndrome (SIRS) (underweight 41.1%, normal BMI 35.6%, overweight 34.5%, and obese 29.5%; p = 0.001), and lowest incidence of new infection (underweight 27.3%, normal BMI 23.3%, overweight 24.5%, and obese 20.4%; p = 0.047). After adjustment for related confounding factors, we found that every one unit increasing of BMI associated with lower risk of hospital mortality [odds ratio, OR, 0.97(95% confidence interval, CI, 0.94-0.99); p = 0.04], higher risk of acute respiratory distress syndrome (ARDS) [OR 1.06 (95% CI 1.03-1.08); p<0.001], and higher risk of intra-abdominal hypertension (IAH) [OR 1.06 (95% CI 1.03-1.09); p<0.001]., Conclusion: The prevalence of overweight and obesity in Thai critically ill surgical patients were 18.7% and 7.2%, respectively. Compared to patients with lower BMI, patients with higher BMI had significantly lower mortality but greater risk of ARDS and IAH.

Objective: Cigarette smoking is not only has detrimental effects on the respiratory system but also contributes to development of atherosclerosis and inflammatory vascular reactions. We hypothesized whether smoking is associated with increased risk of acute respiratory distress syndrome (ARDS), systemic inflammatory response syndrome (SIRS), sepsis, distant organ dysfunctions, and the increase of total cost of surgical intensive care unit (SICU) in critically ill surgical patients., Material and Method: We performed analysis using the THAI-SICU data, a prospective, observational, multicenter study in patients who admitted to SICU in nine university-based hospitals in Thailand. The patients were categorized into 3 groups based on their smoking histories, which were 1) never smoked, 2) former smoker, and 3) current smoker. The primary outcome was probability of ARDS and the secondary outcomes included incidences of SIRS, sepsis, distant organ dysfunction (included acute kidney injury (AKI) and acute myocardial infarction (AMI)), total SICU cost, and 28-day mortality, Results: A total of 4,652 patients had complete data of smoking and were analyzed. The smoking status was never smoked (2,947 patients), former smokers (1,148 patients), and current smokers (557 patients). Compared to current smokers and former smokers, patients who had never smoked had significantly lower proportion of patients with chronic obstructive pulmonary disease (p<0.01) and had significantly higher PaO2/FiO2 ratio on SICU admission (p = 0.02). Compared to patients who had never smoked and former smokers, current smokers had significantly higher probability of ARDS (p = 0.003), higher incidence of SIRS (p = 0.006), and AKI (p<0.001), after adjustment for age, gender, APACHE II score, and patients’ pre-existing diseases. We found that every 1-pack year of cigarette smoking increased risk of ARDS with a hazard ratio of 1.02 (95% CI 1.01-1.03, p = 0.001). There was no difference in incidence of sepsis, AMI, and 28-day mortality among three groups of patients. Current smokers had significantly higher SICU cost, followed by former smokers, and patients who had never smoked (p = 0.02)., Conclusion: In critically ill surgical patients, we found dose-response association between smoking pack year and risk of ARDS. Compared to patients who had never smoked and former smokers, current smokers had significantly higher probability of ARDS, higher incidence of SIRS, AKI, and higher total SICU cost. Our findings demonstrated harm of cigarette smoking in critically ill surgical patients who admitted to SICU.

Objective: In patients receiving inappropriate empirical antimicrobial agents, delaying of time to report positive hemoculture (TRH) may cause delay switching from inappropriate antimicrobial agents to appropriate antimicrobial agents, and thus may increase mortality. We hypothesized that the patients with septicemia from different types of pathogens may have differ duration of TRH, and duration of TRH may had an impact on hospital mortality., Material and Method: We performed observational study on the patients who were reported to have bacteremia or fungemia and admitted to the surgical intensive care unit, Phramongkutklao Hospital during a 2-year period. Type of pathogens grew in blood cultures and the sensitivities to antimicrobial agents were collected from blood culture reports. Patients were categorized into three groups based on their blood culture reports which were gram-positive (GP) bacteria, gram-negative (GN) bacteria, and fungus. Primary outcome was duration of TRH and secondary outcome was hospital mortality among the three groups of patients., Results: There were 9, 32, and 7 patients for whom growth of GP bacteria (18.8%), GN bacteria (66.7%), and fungus (14.6%) were reported in their blood cultures respectively. Patients with fungemia had the longest TRH (130 hours, interquartile range (IQR) 100-137 hours), followed by patients with GN (64 hours, IQR 48-78 hours), and GP bacteremia (55 hours, IQR 42-71 hours) (p = 0.001). There was no difference in hospital mortality (GP 89%, GN 66%, fungus 71%, p = 0.4). TRH was found significantly longer in survivors (n = 14) (81 hours, IQR 56-105 hours) than non-survivors (n = 34) (64 hours, IQR 48-71 hours) (p = 0.035). In multivariate analysis, we found that every 1-hr increasing of TRH was associated with lower risk of hospital mortality with adjusted odd ratio of 0.95 (0.92-0.99, p = 0.01)., Conclusion: Patients with fungemia had significantly longer TRH than patients with GP and GN bacteremia. TRH was found significantly longer in patients with septicemia who survived than non-survivors.

Objective: Acute kidney injury (AKI) is one of the most common problems in critically ill patients. AKI associates with poor outcome in ICU. The recognition of the prevalence and risk factors of AKI is important. This could lead to the prevention of AKI and improve patient’s outcome. This study aims to identify the prevalence, outcomes and independent risk factors of AKI in Thai surgical intensive care units., Material and Method: We conducted the prospective cohort study from nine university-based SICUs. The patients were diagnosed AKI by Acute Kidney Injury Network (AKIN) classification. The types of RRT and outcomes including mortality were collected. The risk factors of AKI were identified., Results: A total cohort of 4,652 patients was included for the present study. AKI was diagnosed in 786 (16.89%) patients. The ICU mortality was higher in patients with AKI (29.90% vs. 5.48%, p-value <0.001). Among patients with AKI staging, we found that those with AKIN III had higher ICU mortality compared to patients with AKIN II and AKIN I respectively (47.66% vs. 26.67% vs. 14.69%, p-value <0.001). Patients with AKI had higher 28 day-mortality compared with those without AKI (37.53% vs. 8.98%, p-value <0.001). The independent risk factors of AKI were higher APACHE II scores (OR 1.04, 95% CI 1.01-1.06, p-value = 0.001), lower serum albumin (OR 0.82, 95% CI 0.70-0.97, p-value = 0.020), organ failures which were in the gastrointestinal system (OR 1.53, 95% CI 1.13-2.08, p-value = 0.007), cardiovascular system (OR 1.95, 95% CI 1.34-2.83, p-value <0.001), neurological system (OR 1.37, 95% CI 1.02-1.85, p-value = 0.038) and urinary system (OR 7.00, 95% CI 5.21-9.40, p-value <0.001)., Conclusion: Acute kidney injury associates with poor outcomes including increased ICU and 28-day mortality. Independent risk factors of AKI in the present study were higher APACHE II scores, lower serum albumin and organ failures on admission.

Objective: Surgical intensive care units (SICUs) are special units for critically ill surgical patients both in the pre and postoperative period. There is little aggregated information about surgical patients who are admitted to the Thai surgical ICU. The objective of this report was to describe patient characteristics, outcomes of ICU care, incidence and outcomes of adverse events in the SICU in the participating SICUs., Material and Method: This multi-center, prospective, observational study of nine university-based SICUs was done. All admitted patients with ages >18 years old were included. Information about patient characteristics, underlying medical problems, indication and type of ICU admission, severity score as ASA physical status in operative patients, APACHE II score and SOFA score, adverse events of interest, ventilator days, ICU and 28 days mortality. The association of outcome and predictors was reported by relative risk (RR) with 95% confidence interval (95% CI). Statistical significant difference was defined by p<0.05., Results: During April 2011-January 2013 of total cohort time, a total of 4,652 patients from nine university-based SICUs were included in this study. Mode of patient age was 71-75 year old for both sexes. Median (IQR) of APACHE II scores and SOFA scores were 10 (7-10) and 2 (1-5), respectively. Seventy eight percent of patients were postoperative patients and 50% of them were ASA physical status III. The median of ICU stay was 2 (IQR 1-4) days. Each day of ICU increment was associated with increased 1.4 days of a hospital stay. Three percent of survived at discharge were clinically inappropriate discharge resulting in ICU readmission. Sixty-five percent were discharged home after ICU admission. ICU and 28 days mortality was 9.6% and 13.8%. The seven most common adverse events were sepsis (19.5%), acute kidney injury (AKI) (16.9%), new cardiac arrhythmias (6.2%), acute respiratory distress syndrome (ARDS) (5.8%), cardiac arrest (4.9%), delirium (3.5%) and reintubation within 72 hours (3.0%), respectively. Most of the adverse events occurred in the first five days, significantly less occurred after 15 days of ICU admission. The association between adverse events and 28 days mortality were significant for cardiac arrest (RR, 9.5; 95% CI, 8.6-10.4), respiratory failure [acute respiratory distress syndrome (ARDS) (RR, 4.6; 95% CI, 3.9-5.3), acute lung injury (ALI) (RR, 2.7; 95% CI, 2.1-3.6)], acute kidney injury (AKI) (RR, 4.2; 95% CI, 3.7-4.8), sepsis (RR, 3.6; 95% CI, 3.2-4.2), iatrogenic pneumothorax (RR, 3.2; 95% CI, 2.1-5.1), new seizure (RR, 3.1, 95% CI, 2.2-4.4), upper GI hemorrhage (RR, 3.0, 95% CI, 2.1-4.1), new cardiac arrhythmias (RR, 2.9; 95% CI, 2.4-3.5), delirium (RR, 2.1; 95% CI, 1.7-2.8), acute myocardial infarction (RR, 2.1; 95% CI, 1.4-3.1), unplanned extubation (RR, 2.1; 95% CI, 1.4-3.1), intra-abdominal hypertension (RR, 1.8; 95% CI, 1.2-2.7) and reintubation within 72 hours (RR, 1.5; 95% CI, 1.1-2.1)., Conclusion: This is the first large study of surgical critical care in Thailand, which had a systematic patient follow-up program. Most of the patients were elderly. Adverse events were most frequent during the first 5 days of admission and were associated with ICU and 28 days mortality.

Objective: Delirium in intensive care units (ICU) increases risks in prolonged mechanical ventilation, hospitalization, and mortality rate. The purpose of this study is to determine if delirium in the surgical intensive care units (SICU) is an independent predictor of clinical outcomes during hospitalization., Material and Method: A multi-center, prospective cohort study was conducted between April 2011 and January 2013. All patients who were admitted to nine university-based SICU were enrolled. Delirium was diagnosed by using the Intensive Care Delirium Screening Checklists. The clinical outcomes of study included length of mechanical ventilation, length of hospital stay, ICU and 28 day mortality. Cox proportional hazard regression model was used to assess the effects of delirium on ICU and 28 day mortality., Results: A total of 4,652 patients were included. One hundred and sixty-three patients were diagnosed delirium (3.5%, 163 of 4,652). Patients who experienced delirium during ICU admission were significantly older (65.0+15.8 years versus 61.6+17.3 years, p = 0.013), had higher American Society of Anesthesiologists physical status (24.3% versus 12.2%, p<0.001), higher Acute Physiology and Chronic Health Evaluation II score (16 (12-23) versus 10 (7-15), p<0.001), and higher Sequential Organ Failure Assessment score (5 (2-8) versus 2 (1-5), p<0.001) compared to non-delirium. Delirious patients also had higher ventilator days (7 (4-17) versus 2 (1-4), p<0.001, longer length of hospital stay (22 (14-34) versus 15 (9-26), p<0.001) and higher ICU mortality (24% versus 9%, p<0.001), and 28-day mortality (28% versus 13%, p<0.001). Patients who developed delirium in the intensive care unit were associated with increased 28-day mortality (adjusted HR = 2.47, 95% CI: 1.13-5.41, p = 0.023)., Conclusion: Delirium in an ICU was a major predictor of hospital mortality after adjusted for relevant covariates. Routine monitoring of delirium, early detection, and implementation of preventive strategy are recommended.

Health information technology (IT) has become an important part of current medical practice, especially in critical care services. One significant advance is the use of telemedicine which was initiated in Thailand nearly two decades ago. Telemedicine is also used in the intensive care unit or what has been termed the "Tele-ICU". It has evolved as an alternate paradigm linking the intensivist and critical care specialists to critically ill patients in remote areas. In this article, the author has reviewed the evidence of health IT on critical care services in Thailand, focusing on telemedicine, as well as the concept of the 'Tele-ICU' and its challenges. These factors may assist intensivists to reach more critically ill patients in remote areas.

Objective: Although there were two large intra-operative observational studies on Thai surgical patients (THAI and THAI-AIMS), there has been no available study on critically ill surgical patients regarding their adverse events and outcomes. A THAI-Surgical Intensive Care Unit (SICU) study has been established for monitoring the occurrence of these adverse events and outcomes in the SICU. The objective of this report is to describe the methodology of the THAI-SICU study and participating SICUs' characteristics as well as the early recruitment results on patients enrolled in the present study., Material and Method: The present study is designed as a multi-center, prospective, observational study. This report describes the method of case record form development and summarizes their collected parameters as well as the adverse event surveillance variables. All of nine SICU characteristics are described regarding their management systems, physicians' and nurses' work patterns. The final group of enrolled patients is reported., Results: A total of nine university-based SICUs were included in the present study. All participating hospitals are residency training centers. Four of the SICUs, fulltime directors are anesthesiologists. Only one hospital's SICU is directed by a surgeon. Two SICUs were closed ICUs, three were mandatory consulting units, one was an elective consultation unit and the remaining three ICUs had no directors. Most of the participating SICUs had heterogeneity of surgical specialty patients. Six SICUs had regular resident rotations and only two of the SICUs had critical care fellowship training. There were significant differences regarding the nursing workload among the ICUs. The patient to registered nurse ratio ranged from 0.9-2.0. After a total of 19.7 months of a recruitment period, the total number of patient admissions was 6,548 (1,894 patients were excluded). A total cohort of 4,654 patients was included for further analytical processes., Conclusion: There were differences in ICU management systems, physician and specialist coverage, nurse burdens, nurse sparing, and types of patients admitted in the university based SICUs. This presentation is the pioneer multi-center study on Thai SICUs in which adverse events and outcomes are reported.

Objective: To evaluate the performance of arterial pressure-based cardiac output (APCO) and pulse wave transit time-based cardiac output (esCCO) monitors in Thai patients undergoing cardiac surgery with cardiopulmonary bypass., Material and Method: The authors studied fifty Thai surgical patients undergoing coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass and requiring pulmonary artery catheters and radial artery catheter placement as a standard of clinical care. All patients were measured for APCO using the Vigileo/FloTrac and esCCO using the esCCO monitoring system. The data were compared to thermodilution cardiac output (TDCO) monitoring as a reference method, simultaneously at pre-induction of anesthesia, post-induction, and every 30 minutes thereafter until the completion of the surgery. The bias and precision were assessed using Bland-Altman analysis., Results: 310 pairs of simultaneous measurements of APCO vs. TDCO and 303 pairs of esCCO vs. TDCO were obtained from fifty patients. Both APCO (R = 0.53, p < 0.0001) and esCCO values (R = 0.56, p < 0.0001) were correlated with TDCO values. Either of the changes in APCO (R = 0.63, p < 0.0001) or any changes in esCCO (R = 0.60, p < 0.0001) were correlated with changes in TDCO. For APCO relative to TDCO, the bias, precision, and the limits of agreement were 0.70, +/- 1.63, and -2.5 to 3.9 L/min while of esCCO were 1.20, +/-1.59 and -1.9 to 4.3 L/min, respectively. Comparisons of the bias of APCO and esCCO revealed a level of significance of p < 0.001., Conclusion: Despite the overestimation of CO measurements, APCO and esCCO calibrated with patient information has shown an acceptable trend as compared to TDCO in Thai patients undergoing CABG with cardiopulmonary bypass. Compared to esCCO, APCO demonstrated no significant differences ofprecision however; a lower mean bias was exhibited.

Background and Objective: Interleukin-8 (IL-8) is a central chemokine in acute respiratory distress syndrome (ARDS), and the IL-8 gene contains a functional single nucleotide polymorphism (SNP) -251A/T in its promoter region. We hypothesized that IL-8 -251A/T SNP is associated with PaO(2)/FiO(2) in critically ill patients., Methods: We conducted genetic-association studies in intensive care units at academic teaching centres using a derivation septic shock cohort (vasopressin and septic shock trial (VASST), n = 467) and a validation post-cardiopulmonary bypass surgery cohort (CPB, n = 739) of Caucasian patients. Patients in both cohorts were genotyped for IL-8 -251A/T. The primary outcome variable in both cohorts was the fraction of patients who had a PaO(2) /FiO(2) < 200. IL-8 mRNA expression was measured in genotyped lymphoblastoid cells in vitro., Results: The frequency of the patients with PaO(2)/FiO(2) <200 was significantly greater in patients who had the AA genotype of -251A/T than in patients who had the AT or TT genotypes in both VASST (AA = 60.8% vs AT and TT = 53.8% and 48.0%, P = 0.038) and the CPB cohort (AA = 37.0% vs AT and TT = 27.0% and 26.0%, P = 0.039). Patients having the AA genotype had a higher probability to remain on mechanical ventilation (P = 0.047) in the first 14 days. Lymphoblastoid cells having the AA genotype had significantly higher IL-8 mRNA expression than cells having the AT or TT genotype (P = 0.022)., Conclusions: Critically ill Caucasian patients who had the AA genotype of IL-8 -251A/T had an increased risk of PaO(2)/FiO(2) <200. The AA genotype was associated with greater IL-8 mRNA expression than the AT or TT genotypes., (© 2012 The Authors. Respirology © 2012 Asian Pacific Society of Respirology.)

Objective: To evaluate the effectiveness and accuracy of three dynamic indices, currently available in intensive care monitoring devices, which are pulse pressure variation (PPV), stroke volume variation (SVV) and pulse oximetry plethysmographic waveform variation (POPV) in septic patients., Material and Method: This prospective clinical trial was conducted in 20 deeply sedated septic patients 18 years of age and older who had invasive blood pressure monitoring with an intraarterial cannula. PPV, SVV and POPV (%) were calculated using five consecutive snapshots from every patient's monitor. Statistical analysis compared using linear regression, paired t-test or student t-test, and receiver operating characteristic (ROC) curve analysis., Results: The authors found that, strong correlation existed of PPV for the detection of percent cardiac index change (r2 = 0.794, p < 0.001). A respiratory variation in POPV exceeding 14% (sensitivity of 72%, specificity of 90%), SVV exceeding 11% (sensitivity 90%, specificity 92%) allowed detection of PPV exceeding 12% (sensitivity 84%, specificity 96%)., Conclusion: Comparing of PPV, SVV and POPV, PPV is the most correlate with percent change in cardiac index and the most effective dynamic index for predict fluid responsiveness in adult septic critically ill patients who are on controlled mechanical ventilator, followed by SVV and POPV.