CPR Compression Rotation Every One Minute Versus Two Minutes: A Randomized Cross-Over Manikin Study

Background. The current basic life support guidelines recommend two-minute shifts for providing chest compressions when two rescuers are performing cardiopulmonary resuscitation. However, various studies have found that rescuer fatigue can occur within one minute, coupled with a decay in the quality of chest compressions. Our aim was to compare chest compression quality metrics and rescuer fatigue between alternating rescuers in performing one- and two-minute chest compressions. Methods. This prospective randomized cross-over study was conducted at Songklanagarind Hospital, Hat Yai, Songkhla, Thailand. We enrolled sixth-year medical students and residents and randomly grouped them into pairs to perform 8 minutes of chest compression, utilizing both the one-minute and two-minute scenarios on a manikin. The primary end points were chest compression depth and rate. The secondary end points included rescuers’ fatigue, respiratory rate, and heart rate. Results. One hundred four participants were recruited. Compared with participants in the two-minute group, participants in the one-minute group had significantly higher mean (standard deviation, SD) compression depth (mm) (45.8 (7.2) vs. 44.5 (7.1), P=0.01) but there was no difference in the mean (SD) rate (compressions per min) (116.1 (12.5) vs. 117.8 (12.4), P=0.08), respectively. The rescuers in the one-minute group had significantly less fatigue (P<0.001) and change in respiratory rate (P<0.001), but there was no difference in the change of heart rate (P=0.59) between the two groups. Conclusion. There were a significantly higher compression depth and lower rescuer fatigue in the 1-minute chest compression group compared with the 2-minute group. This trial is registered with TCTR20170823001

Can base excess and anion gap predict lactate level in diagnosis of septic shock?

Werapon Pongmanee,1 Veerapong Vattanavanit2 1Department of Internal Medicine, 2Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: Lactate measurement is the key component in septic shock identification and resuscitation. However, point-of-care lactate testing is not widely used due to the lack of access to nearby test equipment. Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) are used in determining shock in patients with seemingly normal vital signs. Purpose: We aimed to determine if these biomarkers can be used interchangeably in patients with septic shock in the emergency setting. Patients and methods: A prospective observational cohort study was undertaken at a tertiary hospital in southern Thailand. Baseline point-of-care BE, AG, and serum lactate were recorded in all patients presenting with septic shock at the emergency department. Overall correlations including area under the receiver operating characteristic curve (AUROC) for both BE and AG to predict serum lactate level were calculated. Results: One hundred and fifteen patients were enrolled. Pearson correlation of serum lactate to BE was -0.59 (r2 = 0.35; 95% confidence interval [CI], -0.69 to -0.44; P &lt; 0.001) and BE to AG was -0.67 (r2 = 0.49; 95% CI, -0.76 to -0.55; P &lt; 0.001), and serum lactate to AG was 0.64 (r2 = 0.41; 95% CI, 0.52 to 0.74; P &lt; 0.001). A cut-off point of 15.8 for AG identified a lactate level &ge;2&nbsp;mmol/L (sensitivity, 71.4%; specificity, 80.7%; and AUROC, 0.76), and the best cut-off value to predict a lactate level &ge;4&nbsp;mmol/L was 18.5 (sensitivity, 64.2%; specificity, 85.5%; and AUROC 0.78). Conclusion: In patients with septic shock, lactate and AG showed a strong correlation with each other, whereas lactate and BE showed a moderate correlation with each other. Thus, these biomarkers can be used interchangeably to help determine septic shock earlier in patients. Keywords: base excess, anion gap, lactate, septic shock&nbsp

Clinical outcomes of 3-year experience of targeted temperature management in patients with out-of-hospital cardiac arrest at Songklanagarind Hospital in Southern Thailand: an analysis of the MICU-TTM registry

Veerapong Vattanavanit,&nbsp;Rungsun Bhurayanontachai Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of intensive care unit admission, which results in high hospital mortality. Targeted temperature management (TTM) was introduced several years ago and is considered to improve neurological and mortality outcomes. This management process was implemented in our hospital in 2012, which was expected to improve the standard of care in OHCA patients.Purpose: We aimed to report the clinical and mortality outcomes after TTM was introduced to our hospital in 2012.Patients and methods: An analysis of data from the Medical Intensive Care Unit-TTM registry between 2012 and 2015 was performed. After successful cardiopulmonary resuscitation, TTM was applied to all OHCA patients regardless of causes if there was no contraindication. The Cerebral Performance Category scale score and other clinical outcomes were recorded and analyzed.Results: Out of 23 patients, 87% were male and the mean age was 54.5&plusmn;18.1&nbsp;years. The causes of OHCA from cardiac etiology comprised 52.2%. The most common initial cardiac rhythm was ventricular fibrillation (47.8%). The survival rate to hospital discharge was 47.8% (11/23), but neurological outcomes were in a persistent vegetative state (8/11, 72.7%). The group with poor neurological outcomes had a significantly higher Acute Physiologic Assessment and Chronic Health Evaluation II score than the group with good neurological outcomes (22.9&plusmn;4.2 vs 16.0&plusmn;3.6, P=0.01). In the multivariate analysis, initial shockable rhythm was associated with survival at hospital discharge (odds ratio 10.1, 95% confidence interval 1.1&ndash;94.3, P=0.04).Conclusion: TTM in OHCA patients gave better mortality benefits compared to our previous records, despite poor neurological outcomes. Ventilator-associated pneumonia was the major complication of TTM. Therefore, TTM should be considered in OHCA patients, especially in shockable rhythms, after return of spontaneous circulation. Keywords: out-of-hospital cardiac arrest, targeted temperature managemen

Efficacy of Thiamine in the Treatment of Postcardiac Arrest Patients: A Randomized Controlled Study

Background. Thiamine administration has been shown to improve survival in a postcardiac arrest animal study. We aimed to evaluate the efficacy of thiamine in comatose out-of-hospital cardiac arrest (OHCA) patients following return of spontaneous circulation. Methods. A randomized, double-blinded, placebo-controlled study was conducted. Thirty-seven OHCA patients were randomly assigned to receive either thiamine 100 mg every 8 hours or a placebo. The primary outcome was 28-day all-cause mortality. Results. Over the course of 2 years, 37 patients were randomized to either receive thiamine (n = 20) or a placebo (n = 17). The primary outcome was not different between the groups: 10/20 (50%) in the thiamine group vs. 8/17 (47.1%) in the placebo group (P=0.93 by the log-rank test). There were no significant differences in secondary outcomes between the groups (good neurological outcome, lactate level, and S100B level). Conclusions. In this study, there were no significant differences in survival outcome. Further studies with a larger population are necessary to confirm these results

Timing of antibiotic administration and lactate measurement in septic shock patients: a comparison between hospital wards and the emergency department

Veerapong Vattanavanit,1 Theerapat Buppodom,2 Bodin Khwannimit1 1Department of Internal Medicine, Division of Critical Care Medicine, 2Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: The timing of intravenous antibiotic administration and lactate measurement is associated with survival of septic shock patients. Septic shock patients were admitted to the medical intensive care unit (MICU) from 2 major sources: hospital ward and emergency department (ED). This study aimed to compare the timing of antibiotic administration and lactate measurement between hospital wards and the ED.Patients and methods: Medical data were collected from adult patients admitted to the MICU with septic shock from January 2015 to December 2016. &ldquo;Time Zero&rdquo; was defined as the time of diagnosis of sepsis. The associations between the times and risk-adjusted 28-day mortality were assessed. Results: In total, 150 septic shock patients were admitted to the MICU. The median time interval (hour [h] interquartile range [IQR]) from time zero to antibiotic administration was higher in patients from the hospital wards compared to those from the ED (4.84 [3.5&ndash;8.11] vs 2.04 [1.37&ndash;3.54], P&lt;0.01), but the lactate level measurement time interval (h [IQR]) from time zero was not different between the hospital wards and the ED (1.6 [0.2&ndash;2.7] vs 1.6 [0.9&ndash;3.0], P=0.85). In multivariate analysis, higher risk-adjusted 28-day mortality was associated with antibiotic monotherapy (odds ratio [OR]: 19.3, 95% confidence interval [CI]: 2.4&ndash;153.1, P&lt;0.01) and admission during the weekends (OR: 24.4, 95% CI: 2.9&ndash;199.8, P&lt;0.01).Conclusion: Antibiotic administration in septic shock patients from the hospital wards took longer, and there was also less appropriate antibiotic prescriptions seen in this group compared with those admitted from the ED. However, neither the timing of antibiotic administration nor lactate measurement was associated with mortality. Keywords: septic shock, antibiotic administration, lactate, ward, emergency departmen

Predicting mortality among patients with severe COVID-19 pneumonia based on admission vital sign indices: a retrospective cohort study

Abstract Background Coronavirus disease 2019 (COVID-19) pneumonia remains a major public health concern. Vital sign indices—shock index (SI; heart rate [HR]/systolic blood pressure [SBP]), shock index age (SIA, SI × age), MinPulse (MP; maximum HR–HR), Pulse max index (PMI; HR/maximum HR), and blood pressure–age index (BPAI; SBP/age)—are better predictors of mortality in patients with trauma compared to traditional vital signs. We hypothesized that these vital sign indices may serve as predictors of mortality in patients with severe COVID-19 pneumonia. This study aimed to describe the association between vital sign indices at admission and COVID-19 pneumonia mortality and to modify the CURB-65 with the best performing vital sign index to establish a new mortality prediction tool. Methods This retrospective study was conducted at a tertiary care center in southern Thailand. Adult patients diagnosed with COVID-19 pneumonia were enrolled in this study between January 2020 and July 2022. Patient demographic and clinical data on admission were collected from an electronic database. The area under the receiver operating characteristic (AUC) curve analysis was used to assess the predictive power of the resultant multivariable logistic regression model after univariate and multivariate analyses of variables with identified associations with in-hospital mortality. Results In total, 251 patients with COVID-19 pneumonia were enrolled in this study. The in-hospital mortality rate was 27.9%. Non-survivors had significantly higher HR, respiratory rate, SIA, and PMI and lower MP and BPAI than survivors. A cutoff value of 51 for SIA (AUC, 0.663; specificity, 80%) was used to predict mortality. When SIA was introduced as a modifier for the CURB-65 score, the new score (the CURSIA score) showed a higher AUC than the Acute Physiology and Chronic Health Evaluation II and CURB-65 scores (AUCs: 0.785, 0.780, and 0.774, respectively) without statistical significance. Conclusions SIA and CURSIA scores were significantly associated with COVID-19 pneumonia mortality. These scores may contribute to better patient triage than traditional vital signs

High-fidelity medical simulation training improves medical students&#39; knowledge and confidence levels in septic shock resuscitation

Veerapong Vattanavanit, Jarernporn Kawla-ied, Rungsun Bhurayanontachai Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: Septic shock resuscitation bundles have poor compliance worldwide partly due to a lack of knowledge and clinical skills. High-fidelity simulation-based training is a new teaching technology in our faculty which may improve the performance of medical students in the resuscitation process. However, since the efficacy of this training method in our institute is limited, we organized an extra class for this evaluation.Purpose: The aim was to evaluate the effect on medical students&rsquo; knowledge and confidence levels after the high-fidelity medical simulation training in septic shock management.Methods: A retrospective study was performed in sixth year medical students during an internal medicine rotation between November 2015 and March 2016. The simulation class was a 2-hour session of a septic shock management scenario and post-training debriefing. Knowledge assessment was determined by a five-question pre-test and post-test examination. At the end of the class, the students completed their confidence evaluation questionnaire.Results: Of the 79 medical students, the mean percentage score &plusmn; standard deviation (SD) of the post-test examination was statistically significantly higher than the pre-test (66.83%&plusmn;19.7% vs 47.59%&plusmn;19.7%, p&lt;0.001). In addition, the student mean percentage confidence level &plusmn; SD in management of septic shock was significantly better after the simulation class (68.10%&plusmn;12.2% vs 51.64%&plusmn;13.1%, p&lt;0.001). They also strongly suggested applying this simulation class to the current curriculum.Conclusion: High-fidelity medical simulation improved the students&rsquo; knowledge and confidence in septic shock resuscitation. This simulation class should be included in the curriculum of the sixth year medical students in our institute. Keywords: medical simulation, medical students, septic shock, resuscitatio

Comparison of Race-Based and Non–Race-Based Equations for Kidney Function Estimation in Critically Ill Thai Patients for Vancomycin Dosing

Empiric antibiotic dosing frequently relies on an estimate of kidney function based on age, serum creatinine, sex, and race (on occasion). New non–race-based estimated glomerular filtration rate (eGFR) equations have been published, but their role in supporting dosing is not known. Here, we report on a population pharmacokinetic model of vancomycin that serves as a useful probe substrate of eGFR in critically ill Thai patients. Data were obtained from medical records during a 10-year period. A nonlinear mixed-effects modeling approach was conducted to estimate vancomycin parameters. Data from 208 critically ill patients (58.2% men and 36.0% septic shock) with 398 vancomycin concentrations were collected. Twenty-three covariates including 12 kidney function estimates were tested and ranked on the basis of the model performance. The median (min, max) age, weight, and serum creatinine was 69 (18, 97) years, 60.0 (27, 120) kg, and 1.53 (0.18, 7.15) mg/dL, respectively. The best base model was a 1-compartment linear elimination with zero-order input and proportional error model. A Thai-specific eGFR equation not indexed to body surface area model best predicted vancomycin clearance (CL). The typical value for volume of distribution and CL was 67.5 L and 1.22 L/h, respectively. A loading dose of 2000 mg followed by maintenance dose regimens based on eGFR is suggested. The Thai GFR not indexed to BSA model best predicts vancomycin CL and dosing in the critically ill Thai population. A 5% to 10% absolute gain in the vancomycin probability of target attainment is expected with the use of this population-specific eGFR equation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/174982/1/jcph2070_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/174982/2/jcph2070.pd