Burnout syndrome among Thai intensivists and nurses in pre-COVID19 era

Background: Burnout syndrome (BOS), a work-related constellation of symptoms and signs, causes individuals emotional stress and is associated with increasing job-related disillusionment. ICU-BOS among Thai intensivists and ICU nurses has never been clarified. Methods & materials: We performed a multicenter, prospective cross-sectional study in 17 hospitals in Thailand. BOS-related data were collected from full time ICU physicians and ICU nurses using electronic questionnaires. ICU-BOS was defined when participants exhibited at least 1 of 3 aspects (depersonalization, emotion exhaustion and personal accomplishment) regarding the Maslach Burnout Inventory. Primary outcome was prevalence of ICU-BOS among intensivists and ICU nurses, and secondary outcomes were risk factors for ICU-BOS. Results: After a total of 193 electronic surveys were sent, 171 responders (ICU physicians n=66, ICU nurses n=105) were included in this analysis (88.6%). Overall prevalence of ICU-BOS was 62.6%. Using multivariate analysis, the risk factors for ICU-BOS among intensivists were 1) income <20,000 THB, 2) feeling of quitting caring for patients in an ICU within the past year, 3) need >2 holidays/wk and 4) patient’s ICU-LOS >5 days (adjusted odd ratio (OR) of 31.5, 15.9, 7.4, 14.9; p =0.04, 0.007, 0.035, 0.004 respectively). Risk factors for ICU-BOS among ICU nurses were 1) age >40 years, 2) ICU experience >5 years, 3) patient’s ICU-LOS >5 days, 4) nurse to patient ratio lower than 1:1 5) feeling assignments in the ICU were too numerous and 6) feeling of quitting caring for patients in an ICU within the past year (adjusted OR of 15.7, 4.6, 10.0, 68.7, 4.3, 5.3; p =0.009, 0.04, 0.004, 0.004, 0.04, 0.007 respectively). Conclusion: In this study, we found a high prevalence of ICU-BOS among Thai intensivists and ICU nurses. Co-independent risk factors for BOS were patient’s ICU-LOS >5 days and feeling of quitting caring for patients in an ICU within the past year.

Role of loco-regional anesthesia for non-intubated video-assisted thoracoscopic surgery: A tertiary care hospital in northern Thailand

Background: A few studies have focused on the role of regional anesthesia for non-intubated thoracoscopic surgery (NIVATS) in Thailand. The purpose of the present study was to review the feasibility and safety of loco-regional anesthesia for NIVATS in a tertiary care hospital. Methods: All patients undergoing scheduled NIVATS under loco-regional anesthesia including thoracic epidural analgesia (TEA), intercostal nerve block (ICNB), thoracic paravertebral block, and local wound infiltration from 2018 to 2021 were assessed by a retrospective chart review. Sedation was performed with propofol infusion and bispectral index monitoring. Primary outcomes were the feasibility of surgery and safety related to loco-regional anesthesia techniques. Results: Twenty-three patients were included. The average age was 43 (26-59) years. The two most common regional anesthesia techniques in this study were TEA and ICNB. The most common surgical procedure was wedge resection (13 patients, 56.5%) followed by pleurectomy (5 patients, 21.7%). The overall median technical feasible scores were 3 (2-3). Intraoperative hypotension (62.5% for TEA vs 20% for ICNB) and urinary retention (25% for TEA vs 0 for ICNB) were found. Among four patients with severe cough, three patients received intrathoracic vagal block and one patient required general anesthesia due to severe hypoxemia. Patients with ICNB had a higher degree of incisional pain and a higher amount of postoperative morphine consumption. Conclusion: NIVATS under loco-regional anesthesia could be a feasible and safe technique. A further study is recommended to compare the efficacy and safety of TEA and ICNB for NIVATS.

The incidence of postoperative cardiac arrest and pre-resuscitation factors associated with post- cardiopulmonary resuscitation mortality: a single-center study in Thailand

Background: The author aimed to determine the incidence of in-hospital postoperative cardiac arrest requiring cardiopulmonary resuscitation (CPR), postoperative CPR mortality and pre-resuscitation factors associated with post CPR mortality. Method: A retrospective cohort study was conducted at King Chulalongkorn Memorial Hospital in Thailand from September 2018 through August 2020. A total of 34,590 adult patients underwent surgical procedures under anesthesia were recruited by electronic data recorded review. A subset of patients with postoperative CPR was collected for demographic data, comorbidities, ASA classification, operative time, functional class, types of surgery, postoperative complications, the number of deaths and survival, and SOS score at 4 hours preceding cardiac arrest. Results: A total of 34,590 adult surgical patients were recruited. In-hospital postoperative cardiac arrest incidence was 12 patients per 10,000 surgeries and predominated in emergency operation (28 per 10,000 surgeries; P< 0.0001). Risk ratio of emergency operation resulted in postoperative CPR was 3.15 (95% CI 1.72-5.77; P<0.001). Postoperative cardiac arrest patients aged 64.07 ± 16.58. The BMI was 23.46 ± 5.83. Mostly they were in ASA category 3 (44.2%). Everyone had general anesthetic procedures. The most common comorbidity was hypertension. In-hospital postoperative CPR mortality was 62.8%. Factors possibly predisposed to it were functional class < 4 METS, colorectal surgery and SOS score at 4 hours prior to cardiac arrest of at least 8. Conclusion: Incidence of in-hospital postoperative cardiac arrest and mortality after CPR in the study tended to be lower than that of previous studies. Emergency operations predisposed to cardiac arrest. SOS score was possibly valuable as a prognostication tool, ICU triage, as well as, a part of the early warning score to prevent the overwhelming crisis. Surveillance for patient’s deterioration, effective rapid response system, and comprehensive preoperative rehabilitation should be emphasized.

Physiologic cardiovascular studies in resuscitated normotensive septic shock with persistent hyperlactatemia.

Background: To study effects of increasing vasopressor dosage and fluid resuscitation on ventriculoarterial (VA) coupling and venous return (VR)-related parameters in resuscitated normotensive septic shock patients with persistent hyperlactatemia. Methods: We performed a prospective experimental study in patients with septic shock who was admitted to medical intensive care unit and still had hyperlactatemia even received initial resuscitation to maintain mean arterial pressure (MAP) >65 mmHg. All patients received incremental dose of norepinephrine (NE) to increased MAP, then NE was titrated to baseline dosage and waited for 15 mins, then fluid bolus was given. VA coupling-related parameters [arterial elastance (Ea), left ventricular end-systolic elastance (Ees), left ventricular stroke work (SW), potential energy (PE), stroke volume (SV), and Ea/Ees], and VR-related parameters [central venous pressure (CVP), mean systemic pressure analogue (Pmsa), venous return pressure (Pvr)] were measured at 4 time points including pre-increased NE phase, post-increased NE phase, pre-fluid bolus phase, and post-fluid bolus phase. Primary outcome was average of Ea/Ees. Secondary outcomes were differences in VA coupling-related parameters and VR-related parameters between pre- vs. post- interventions. Results: All 20 patients were normotensive [MAP 74 (66-80) mmHg] with elevated blood lactate [2.7 (2.4-3.6) mmol/L] at enrollment. Average Ea/Ees was 0.89 (0.61-1.16). Compared to pre-increased NE phase, post-increased NE phase had significantly higher MAP, CVP, SV, SW, PE, Pmsa, and Pvr. Likewise, compared to pre-fluid bolus phase, post-fluid bolus raised MAP, CVP, SV, Ees, SW, Pmsa, and Pvr significantly. No difference in Ea/Ees compared between before- vs. after- received both interventions. Conclusions: In resuscitated normotensive septic shock patients with persistent hyperlactatemia, we found an average Ea/Ees of 0.89. Increasing NE dosage or fluid bolus increased most of VA coupling-related parameters and VR-related parameters, but not Ea/Ees. Further large study is warranted to validate these findings.

Extracorporeal membrane oxygenation (ECMO) for COVID-19 patients

During the current outbreak of coronavirus disease 2019 (COVID-19), Extracorporeal Membrane Oxygenation (ECMO) support could be considered as the rescue treatment from life threatening condition among severe COVID-19 patients who did not respond to mechanical ventilation. We propose that veno-venous ECMO should be considered if patient has persistence PaO2:FiO2 ratio lower than 100 mmHg after appropriate mechanical ventilator adjustment, muscle relaxant and prone position. During ECMO support, treatment against cytokine storm, including non-selective immune suppression with systemic steroid, or selective interleukin-6 inhibition and Janus Kinase inhibition should be considered. Heparin infusion is still the recommended anticoagulant to maintain activated partial thromboplastin time (APTT) ratio range 1.5-2.0. The overall hospital mortality was comparable with respiratory failure patients, requiring ECMO support from other causes, which was reported about 37-50%. The decision to initiate ECMO could be depended on the individual hospital capacity and treatment availability.

Mechanical ventilator support and prone positioning in COVID-19 related pneumonia

COVID-19 is currently a global pandemic that cause high morbidity and mortality, particularly in the critical cases. The common presentation is among the common respiratory symptoms and could be deteriorated to multiple organ failure. From the previous epidemiologic study, approximate 15% of cases developed pneumonia and 5% required intensive care admission. The optimal respiratory care including oxygen support are the key for hypoxic respiratory failure from severe COVID-19. Several devices have been practically suggested for respiratory symptoms included high flow nasal cannula (HFNC), non-invasive positive pressure ventilator (NIV) via either common facial mask or helmet. However, some patients did not improve with those devices, that become more respiratory distress and eventually required intubation and mechanical ventilator support. In this brief review, the author will pay attention on the mechanical ventilator support and prone positioning for COVID-19 pneumonia.

Comparison of mean systemic pressure in patients with acute circulatory failure receiving passive leg raising vs. pneumatic leg compression

Background: Driving pressure of venous return (VR) is determined by a pressure gradient between mean systemic pressure (Pms) and central venous pressure (CVP). While passive leg raising (PLR) and pneumatic leg compression PC (PC) can increase VR, no study has explored the effects of these two procedures on Pms and VR-related hemodynamic variables. Methods: Forty patients with acute circulatory failure were enrolled in this analysis. All patients obtained both PLR and PC, and were measured for Pms, CVP, mean arterial pressure (MAP), cardiac output (CO), VR resistance (RVR), and systemic vascular resistance (SVR) at baseline and immediately after procedures. To minimize carry over effect, the patients were divided in 2 groups based on procedure sequence which were 1) patients receiving PLR first then PC (PLR-first), and 2) patients receiving PC first then PLR (PC-first). Both groups waited for a washout period before performing the 2 second procedure. Primary outcome was difference in Pms between PLR and PC procedures. Secondary outcome were differences in CVP, MAP, CO, RVR, and SVR between PLR and PC procedures. Results: No difference was found in baseline characteristics and no carry over effect was observed between the 2 groups of patients. Compared with baseline, both PLR and PC significantly increased Pms, CVP, MAP, and CO. PLR increased Pms (9.0±2.3 vs 4.8±1.7 mmHg, p<0.001), CVP (4.5±1.2 vs. 1.6±0.7 mmHg, p<0.001), MAP (22.5±5.6 vs. 14.4±5.0 mmHg, p<0.001), and CO (1.5±0.5 vs. 0.5±0.2 L/min, p<0.001) more than PC. However, PC, also significantly increased RVR (16 ± 27.2 dyn.s/cm5, p=0.001) and SVR (78.4 ± 7.2 dyn.s/cm5, p<0.001) but no difference in PLR group. Conclusion: Among patients with acute circulatory failure, PLR increased Pms, CVP, MAP, and CO more than PC.

Comparison of mean systemic pressure in patients with acute circulatory failure receiving passive leg raising vs. pneumatic leg compression

Background: Driving pressure of venous return (VR) is determined by a pressure gradient between mean systemic pressure (Pms) and central venous pressure (CVP). While passive leg raising (PLR) and pneumatic leg compression PC (PC) can increase VR, no study has explored the effects of these two procedures on Pms and VR-related hemodynamic variables. Methods: Forty patients with acute circulatory failure were enrolled in this analysis. All patients obtained both PLR and PC, and were measured for Pms, CVP, mean arterial pressure (MAP), cardiac output (CO), VR resistance (RVR), and systemic vascular resistance (SVR) at baseline and immediately after procedures. To minimize carry over effect, the patients were divided in 2 groups based on procedure sequence which were 1) patients receiving PLR first then PC (PLR-first), and 2) patients receiving PC first then PLR (PC-first). Both groups waited for a washout period before performing the 2 second procedure. Primary outcome was difference in Pms between PLR and PC procedures. Secondary outcome were differences in CVP, MAP, CO, RVR, and SVR between PLR and PC procedures. Results: No difference was found in baseline characteristics and no carry over effect was observed between the 2 groups of patients. Compared with baseline, both PLR and PC significantly increased Pms, CVP, MAP, and CO. PLR increased Pms (9.0±2.3 vs 4.8±1.7 mmHg, p<0.001), CVP (4.5±1.2 vs. 1.6±0.7 mmHg, p<0.001), MAP (22.5±5.6 vs. 14.4±5.0 mmHg, p<0.001), and CO (1.5±0.5 vs. 0.5±0.2 L/min, p<0.001) more than PC. However, PC, also significantly increased RVR (16 ± 27.2 dyn.s/cm5, p=0.001) and SVR (78.4 ± 7.2 dyn.s/cm5, p<0.001) but no difference in PLR group. Conclusion: Among patients with acute circulatory failure, PLR increased Pms, CVP, MAP, and CO more than PC.

Effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure: a cohort study

Background: Tuberculosis (TB) remains an important and evolving health problem worldwide. Acute respiratory failure, the most severe form of pulmonary tuberculosis, is associated with a high mortality rate. Adjunctive corticosteroid therapy has been reported as an effective treatment in extrapulmonary TB. The aim of this study was to investigate the effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure. Methods: This retrospective cohort study enrolled newly diagnosed pulmonary tuberculosis patients with acute respiratory failure who were admitted to Siriraj Hospital (Bangkok, Thailand) during January 2011 to December 2013. Patients that received corticosteroid as an adjunctive treatment for pulmonary TB were assigned to the steroid group. The control group consisted of patients that did not receive corticosteroid. Collected data included age, gender, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, sequential organ failure assessment (SOFA) scores, vital signs, PaO2/FiO2 ratio, chest X-ray abnormality pattern, and TB treatment strategies, including antituberculosis agents and adjunct corticosteroid treatment. The primary outcome was hospital mortality rate. The secondary outcomes were hospital length of stay and duration of mechanical ventilation. Results: Thirty-eight patients were included. There were 18 patients in the steroid group and 20 in the control group. No significant difference was observed between groups for age, gender, BMI, APACHE II score, vital signs, or PaO2/FiO2 ratio. Patients in the steroid group had a significantly higher mean SOFA score than controls (5.7±4.5 vs. 3.3±2.6, respectively; p=0.046). Almost all patients in this study (97.1%) had positive culture for M. tuberculosis from sputum. The mean corticosteroid dose was equivalent to hydrocortisone 329.7±146.0 mg/day. Patients in the steroid group had higher hospital mortality than control group patients, but the difference did not achieve statistical significance (66.7% vs. 45.0%, respectively; p=0.21). Adjunctive corticosteroid therapy did not significantly reduce hospital length of stay or duration of mechanical ventilation when compared between the steroid and control groups (12.0±13.3 vs. 14.6±19.3 days, respectively; p=0.636 and 7.2±10.6 vs. 8.0±8.3 days, respectively; p=0.801). Conclusion: Adjunctive corticosteroid therapy had no significant positive effect on outcomes in pulmonary tuberculosis patients with acute respiratory failure.

Anti-inflammatory agents other than corticosteroid in SARs-CoV-2 pneumonia

The SARs-CoV-2 results in hyperinflammation among infected patients. This condition leads to serious organ injury, especially in the lungs. Therefore, the main treatment option, in addition to anti-viral agents, is the administration of corticosteroids. However, in many cases, inadequate response to corticosteroids has been observed—other anti-inflammatory agents, such as interleukin-6 inhibitor, kinase inhibitor, etc., play an essential role in reducing this severe complication.