Chairat Permpikul

Effectiveness of Chlorhexidine Wipes for the Prevention of Multidrug-Resistant Bacterial Colonization and Hospital-Acquired Infections in Intensive Care Unit Patients: A Randomized Trial in Thailand

OBJECTIVE To determine the effectiveness of daily bathing with 2% chlorhexidine-impregnated washcloths in preventing multidrug-resistant (MDR) gram-positive bacterial colonization and bloodstream infection. METHODS A randomized, open-label controlled trial was conducted in 4 medical intensive care units (ICUs) in Thailand from December 2013 to January 2015. Patients were randomized to receive cleansing with non-antimicrobial soap (control group) or 2% chlorhexidine-impregnated washcloths used to wipe the patients body once daily (chlorhexidine group). Swabs were taken from nares, axilla, antecubital, groin, and perianal areas on admission and on day 3, 5, 7, and 14. The 5 outcomes were (1) favorable events ( all samples negative throughout ICU admission, or initially positive samples with subsequent negative samples); (2) MDR bacteria colonization-free time; (3) hospital-acquired infection; (4) length of ICU and hospital stay; (5) adverse skin reactions. RESULTS A total of 481 patients were randomly assigned to the control group (241) or the chlorhexidine group (240). Favorable events at day 14 were observed in 34.8% of patients in the control group and 28.6% in the chlorhexidine group (P=.79). Median MDR bacteria colonization-free times were 5 days in both groups. The incidence rate of hospital-acquired infection and the length of the ICU and hospital stay did not differ significantly between groups. The incidence of adverse skin reactions in the chlorhexidine group was 2.5%. CONCLUSION The effectiveness of 2% chlorhexidine-impregnated washcloths for the prevention of MDR gram-negative bacteria colonization and hospital-acquired infection in adult patients in ICU was not proven. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01989416.

Hyperglycemia and glycemic variability are associated with the severity of sepsis in nondiabetic subjects

Purpose: The purpose was to compare glucose variability (GV) obtained via continuous glucose monitoring between nondiabetic sepsis patients and healthy subjects and to seek associations between GV and sepsis severity in nondiabetic sepsis patients. Methods: Nondiabetic sepsis inpatients and healthy controls received a 72‐hour continuous glucose monitoring (iPro2, Medtronic) postadmission and post–oral glucose tolerance test, respectively. The mean glucose level (MGL) along with GV represented by standard deviation (SD) and the mean amplitude of glycemic excursion (MAGE) were calculated at 24 and 72 hours. Sepsis severity was evaluated with the Sepsis‐related Organ Failure Assessment Score (SOFA). MGL and GV in patients with SOFA ≥9 and <9 were compared. Results: Thirty nondiabetic sepsis and 10 healthy subjects were recruited. No differences were found between groups except for higher patient age in sepsis patients. The MGL and MAGE72h of sepsis patients were significantly higher than those of healthy subjects. MGL and GV24h were higher in patients with SOFA ≥9 than in patients with SOFA <9 (MGL24h 195 ± 17 vs 139 ± 27, P < .001; SD24h 32 [28, 36] vs 19 [5, 58], P = .02; and MAGE24h 94 [58, 153] vs 54 [16, 179], P = .01). Conclusion: Nondiabetic sepsis patients had higher MGL and GV values than healthy subjects. MGL and GV24h were associated with sepsis severity. HighlightsTo evaluate glucose variability from continuous glucose monitoring in sepsis without diabetes mellitus.The nondiabetic sepsis patients had higher glucose variability than the control group.Glucose variability during first 24 hours was associated with severity of sepsis.

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Emergency Department Patients With Cardiogenic Pulmonary Edema: A Randomized Controlled Trial

Study objective: High‐flow nasal cannula is a new method for delivering high‐flow supplemental oxygen for victims of respiratory failure. This randomized controlled trial compares high‐flow nasal cannula with conventional oxygen therapy in emergency department (ED) patients with cardiogenic pulmonary edema. Methods: We conducted an open‐label randomized controlled trial in the ED of Siriraj Hospital, Bangkok, Thailand. Patients aged 18 years or older with cardiogenic pulmonary edema were randomly assigned to receive either conventional oxygen therapy or high‐flow nasal cannula. The primary outcome was the respiratory rate 60 minutes postintervention. Results: We enrolled 128 participants (65 in the conventional oxygen therapy and 63 in the high‐flow nasal cannula groups). Baseline high‐flow nasal cannula and conventional oxygen therapy mean respiratory rates were 28.7 breaths/min (SD 3.2) and 28.6 breaths/min (SD 3.5). Mean respiratory rates at 60 minutes postintervention were lower in the high‐flow nasal cannula group (21.8 versus 25.1 breaths/min; difference 3.3; 95% confidence interval 1.9 to 4.6). No significant differences were found in the admission rate, ED and hospital lengths of stay, noninvasive ventilation, intubation, or mortality. Conclusion: In patients with cardiogenic pulmonary edema in the ED, high‐flow nasal cannula therapy may decrease the severity of dyspnea during the first hour of treatment.

Factors predicting failure of noninvasive ventilation assist for preventing reintubation among medical critically ill patients

Purpose: Reintubation after failed extubation is associated with high mortality. Noninvasive ventilation (NIV) has been used to prevent reintubation, but the results have been inconclusive. We investigated the factors predicting failure of NIV‐assisted extubation among medical critically ill patients. Materials and methods: This retrospective cohort study enrolled patients who were admitted to medical intensive care units at Siriraj Hospital between March 2012 and August 2015 who required more than 48 hours of mechanical ventilation and who received NIV after endotracheal extubation. NIV was considered to have failed if the patient required reintubation during intensive care unit admission. Results: A total of 105 patients (57 male; mean age, 63.3 ± 17.9 years) were enrolled. The reintubation rate was 45.7%. Univariate analysis identified pre‐NIV Sepsis‐related Organ Failure Assessment score >3.5, respiratory failure caused by pneumonia, heart rate after NIV for 1 hour of more 100 beats per minute, fluid accumulation greater than 100 mL/kg, and NIV duration more than 96 hours as factors associated with reintubation. However, multivariate analysis identified pneumonia as the only predictive factor for failure of NIV‐assisted extubation among critically ill patients. Reintubated patients had significantly higher hospital mortality than successfully extubated patients. Conclusions: Respiratory failure caused by pneumonia is predictive of failure of NIV‐assisted extubation.

Hydrocortisone in treatment of severe sepsis and septic shock with acute respiratory distress syndrome: a randomised controlled trial.

and improve PaO2/FiO2 ratio at the 3 rd day after treatment (273.9+126.9 vs 227.6+110.3, P = 0.007). The incidence of hyperglycemia was also higher in the study group. Mortality in the study group was lower although statistical difference was not reached (25.5% vs 31.3%, P = 0.37). Conclusions Hydrocortisone improved outcomes; namely organ support-free days, vasopressor-dependent days and oxygenation, in severe sepsis or septic shock patients with ARDS. There was a trend toward mortality reduction in the study group but the statistical significant was not reached. (ClinicalTrials.gov number, NCT01284452)

Serum potassium levels and outcomes in critically ill patients in the medical intensive care unit

Objective To compare the outcomes of patients with and without a mean serum potassium (K+) level within the recommended range (3.5–4.5 mEq/L). Methods This prospective cohort study involved patients admitted to the medical intensive care unit (ICU) of Siriraj Hospital from May 2012 to February 2013. The patients’ baseline characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, serum K+ level, and hospital outcomes were recorded. Patients with a mean K+ level of 3.5 to 4.5 mEq/L and with all individual K+ values of 3.0 to 5.0 mEq/L were allocated to the normal K+ group. The remaining patients were allocated to the abnormal K+ group. Results In total, 160 patients were included. Their mean age was 59.3±18.3 years, and their mean APACHE II score was 21.8±14.0. The normal K+ group comprised 74 (46.3%) patients. The abnormal K+ group had a significantly higher mean APACHE II score, proportion of coronary artery disease, and rate of vasopressor treatment. An abnormal serum K+ level was associated with significantly higher ICU mortality and incidence of ventricular fibrillation. Conclusion Critically ill patients with abnormal K+ levels had a higher incidence of ventricular arrhythmia and ICU mortality than patients with normal K+ levels.

Clinical characteristics of newly diagnosed tuberculosis patients with respiratory failure

Respiratory failure from tuberculosis is not as common as other community acquired infection. Delay in diagnosis of tuberculosis thus poses significant impact on disease management and ICU infection control. We report here the clinical characteristics of this condition in order to render better diagnosis and early management.