Thai-Shock Survey 2013: Survey of Shock Management in Thailand
Kaweesak Chittawatanarat MD, PhD*1, Boonsong Patjanasoontorn MD, FCCP, FCCM*2, Suthat Rungruanghiranya MD, FCCP*3, Thai Society of Critical Care Medicine Study group*4
Affiliation : *1 Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand *2 Department of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand *3 Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand *4 The Thai Society of Critical Care Medicine, Bangkok, Thailand
Objective : Pragmatic surveys for shock management by Thai physicians are unavailable. The objective of this study is to
identify the shock management patterns on both; the incidence of septic shock and hemorrhagic shock here in Thailand.
Material and Method: Two thousand questionnaires were sent to physicians who are called on to care for patients in shock
across Thailand. The questionnaire is composed of 58 items regarding all aspects of the management of septic and hemorrhagic
shock. A frequency scale has been defined by 5 levels of patient proportion estimates from routine practices.
Results : Between April and August, 2013, 533 of the distributed questionnaires (26.7%) were returned. In severe sepsis and
septic shock management, 406 physicians (76.2%) have reported the routine use of the quantitative resuscitation protocols.
Urine output, mean arterial pressures and central venous pressures have been more frequently used than central venous
oxygen saturation and lactate levels for the resuscitation goals. Nearly 80% of these clinicians have shown “often and
always” for the achievement of the resuscitation goals within 6 hours. Most of the physicians (65.3%) had never used
procalcitonin biomarkers. Antimicrobial empirical treatments were started within 1 hour of admission for 87.7% of these
patients and were continued for less than 5 days in 67.3% of the cases prior to de-escalating the treatments. Crystalloids have
been the common, initial fluid used for resuscitation (98.9% in sepsis, 99.3% in trauma). The most commonly used vasopressors
are norepinephrine (69.6%) for sepsis and dopamine (63.1%) for trauma. The median of the cortisol threshold level for
steroid replacement therapy is 15 mg/dL, taken from the interquartile range or IQR of 5-19 mg/dL. Nearly all the physicians
currently use hydrocortisone (96.4%). The median daily dose of hydrocortisone is 300 mg (IQR; 200-300). Approximately
50% of the physicians prescribed the hydrocortisone in divided doses to be administered every 8 hours and 31.8% ordered
the medications as a continuous infusion. Tapering the dose in reduction varied by 33.6% of the physicians over a period of
2 to 3 days. Central venous pressures (CVP) and fluid challenge tests were more frequently used in the evaluation of preload
rather than some of the newer fluid responsiveness methods. Less than 15% of the physicians continued to use pulmonary
artery catheters in their routine practices. Regarding hemorrhagic and traumatic shock, only 162 physicians (39.3%) have
been certified in Advance Traumatic Life Support (ATLS), but 311 physicians (75.6%) have reported in following with the
ATLS guidelines. In patients requiring massive transfusions, physicians used packed red cells (PRC) and fresh frozen plasma
(FFP) in a ratio of 1:1 (34.1%). Focus assessment sonography for trauma (FAST) was the most commonly used diagnostic
method in cases of traumatic shock.
Conclusion : Most physicians manage shock with the current protocols. Hemodynamic goals are preferred over tissue
perfusion targets. Early antimicrobial therapy and de-escalation are routinely practiced without the use of infective biomarkers.
Crystalloids are preferred over colloids for the initial resuscitation. CVPs and fluid challenges are still preferred over the new
fluid responsiveness methods for preload assessment. Hydrocortisone is the most common steroid prescribed for septic
shock but the threshold of initiation, frequency of use and methods of discontinuation vary.
Keywords : Septic shock, Severe sepsis, Hemorrhagic shock, Steroid use, Antimicrobial therapy
