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   Table of Contents - Current issue
April-June 2020
Volume 4 | Issue 2
Page Nos. 27-87

Online since Wednesday, July 1, 2020

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The saudi critical care society clinical practice guidelines on the management of COVID-19 patients in the intensive care unit Highly accessed article p. 27
Waleed Alhazzani, Faisal A Al-Suwaidan, Zohair A Al Aseri, Abbas Al Mutair, Ghassan Alghamdi, Ali A Rabaan, Mohmmed Algamdi, Ahmed F Alohali, Ayed Y Asiri, Mohammed S Alshahrani, Maha F Al-Subaie, Tareq Alayed, Hind A Bafaqih, Safug Alkoraisi, Saad M Alharthi, Farhan Z Alenezi, Ahmed Al Gahtani, Anas A Amr, Abbas Shamsan, Zainab Al Duhailib, Awad Al-Omari
Background: Although recent international guidelines have been published on the management of critically ill patients with the novel coronavirus disease 2019 (COVID-19), there is a vital need to develop clinical practice guidelines tailored to the context of Saudi Arabia. Methods: The Saudi Critical Care Society (SCCS) is the sponsor for this guideline. The expert panel consisted of 19 members. All members completed the World Health Organization Conflict of Interest Form. The expert panel formulated questions on the management of critically ill patients in the intensive care unit with COVID-19. Panel members identified relevant studies. The panel used the categories of Grading Recommendations, Assessment, Development, and Evaluation (GRADE) to assess the confidence in the evidence. Results: The SCCS expert panel issued 53 statements; of which 7 were strong recommendations, 9 were best practice statements, 32 were weak recommendations, and we were not able to issue recommendations in 5 instances. The statements covered different aspects of the critical illness in COVID-19 patients, including: infection control; therapeutic interventions; supportive care; and crisis management. Conclusion: The SCCS guidelines on the management of critically ill COVID-19 patients have been based on the best available evidence and tailored to the context of Saudi Arabia. These guidelines will be updated periodically to incorporate new evidence.
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COVID-19: What we all intensivists should know p. 45
Srikant Behera, Simant Kumar Jha, Nitesh Kumar Singh, Gopi Chand Khilnani, Anurag Mahajan, Shiv Kumar, Alok Kumar, Sudhanshu Sant
Coronaviruses were identified as a viral family in the 1960s and are known to infect both humans and animals. Novel strain of coronavirus was identified when some cases of pneumonia began to arise in Wuhan province of China without any apparent cause. Later, this novel strain was called as coronavirus disease 2019 (COVID-19). Since 2002, coronavirus has been known to cause two widespread outbreaks in humans: severe acute respiratory syndrome coronavirus in 2003 and Middle East respiratory syndrome-CoV in 2012. The present crisis began to arise in late November of 2019 and then rapidly grew to become a pandemic. The present medical crisis resulted because high virulence of this virus simultaneously infected large number of patients. Although only a small proportion of COVID-19-infected patients require hospitalization, mortality is significantly higher in elderly and in patients with preexisting diseases. Patients with COVID-19 can present with an array of symptoms such as fever, dry cough, myalgia, vomiting, and loose motions. In later stages, it can progress to breathing difficulty. High virulence of COVID-19 puts the health-care workers (HCWs) at extreme risks of contacting this infection. COVID-19 is mainly diagnosed on the basis of clinical symptoms along with reverse-transcription polymerase chain reaction (RT-PCR). However, sensitivity of RT-PCR is 67% in the first 7 days and subsequently it falls to below 50% from the 2nd week onward. Total antibody has also been used to diagnose COVID-19. They have a lower sensitivity in initial days, but their sensitivity increases to 90% above from the 2nd week onward. Currently, management of COVID-19 is focused on supportive treatment as no drug till date has proven efficacy against novel coronavirus. Current trials have shown some promise with remdesivir. Although hydroxychloroquine rose to fame with earlier studies, its role in the management of COVID-19 was not established in further research. Current focus of the world to control this pandemic is on prevention through social distancing, use of face mask, regular hand washing, cough etiquette, and isolation of suspicious and confirmed cases. This article deals with nature, progression, and possible outcomes of this infection along with necessary steps that must be taken by a HCW to preventing himself from catching COVID-19.
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Thirty-day outcomes among intensive care unit patients with septic shock with versus without preadmission chronic renal disease p. 58
Haifa Mesfer Algethamy, Yasmin Sharton, Ayman Morish
Background: Considerable research indicates that experiencing acute kidney injury (AKI) during hospitalization from sepsis increases patients' risk of death, but few data exist on whether preexisting renal disease, irrespective of the need for dialysis, also increases mortality. Objectives: The objectives of this study were to identify if preexisting renal disease alters outcomes in patients admitted to a Saudi Arabian, tertiary-care intensive care unit (ICU) for septic shock. Materials and Methods: All patients ≥14 years old admitted to the ICU for septic shock from December 2015 to January 2017 were enrolled prospectively and followed for a minimum of 30 days or until death or hospital discharge. Patients with versus without preexisting renal disease were compared regarding demographic and baseline clinical characteristics, details of their infection and treatment, and outcomes. Results: Among 161 patients (mean age: 61.6; male:female = 1:1), 33 had some documented, preexisting renal disease, among whom 17 required regular dialysis. Among the 128 without preexisting renal disease, 66 (52%) died in hospital, versus 11 of 17 (65%) and 9 of 16 (56%) with kidney disease requiring and not requiring dialysis, respectively. Both the presence of renal dysfunction and the development of new-onset AKI were borderline linked to increased, inhospital mortality (P = 0.051 and 0.080, respectively). However, the presence of preexisting renal disease, with or without the need for dialysis, was nonsignificantly (P = 0.58) linked to increased, inhospital mortality. Conclusions: In our sample of 161 patients with septic shock, the presence of preexisting renal disease was not associated with increased mortality, but new-onset AKI and the presence of renal dysfunction in the ICU both were associated with increased mortality.
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Critical care pharmacy services in the Western Region of Saudi Arabia p. 66
Ohoud A Aljuhani
Background: The value of critical care pharmacists (CCPs) in intensive care units (ICUs) has been well documented, and various studies have demonstrated the positive impacts of CCPs. Despite growing evidence supporting the contributions of clinical pharmacists in general and CCPs in particular in improving patient outcomes, many hospitals in the Kingdom of Saudi Arabia (KSA) still lack clinical pharmacy services. Most studies that have measured the impacts of CCPs in ICU settings have been conducted outside Saudi Arabia, with a significant gap in the literature related to CCP-related impacts, needs and obstacles in Saudi Arabia. Objective: To evaluate the current status of CCP services and the CCP services that are needed in Saudi Arabia as well as the barriers to establishing these services. Setting: Governmental and non-governmental hospitals in the western region of the KSA. Method: This was a cross-sectional survey-based study conducted in the western region of the KSA. The questionnaire included questions investigating current CCP services, which include clinical, educational, administrative and research services. Additional questions assessed the obstacles, needs and limitations related to the development of CCP services. Main Outcome Measures: The primary outcome is to describe the current status of ICU pharmacists in the KSA. Secondary outcomes of interest are the evaluation of the need for CCP services and the identification of the main barriers to establishing these services. Results: Of the 130 hospitals with ICUs to which surveys were emailed, 94 (72%) responded. Forty-three percent of responding hospitals had an ICU multidisciplinary team structure that included a pharmacist who visited the unit during medical rounds. Up to 54% of the hospitals with CCP services had one dedicated pharmacist present at bedside and during medical rounds. Approximately 78% of the ICU pharmacists performed one or more clinical activities. Training pharmacy interns was one of the major educational activities provided by ICU pharmacists. Clinical services (42%) were the most needed services, followed by educational (14%) activities. Limited job availability was the main barriers to having CCP services among hospitals. Conclusion: Critical care pharmacists in the western region of the KSA mainly provide fundamental clinical services, with limited engagement in desirable and optimal services such as research activities. The limited CCP services in the KSA are due to several barriers that warrant national efforts from the Ministry of Health (MOH) and the Saudi Commission for Health Specialists (SCFHS).
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Human T lymphotropic virus antibodies seroprevalence among healthy blood donors and high risk groups at Riyadh regional laboratory in Riyadh, Saudi Arabia p. 73
Fadel Hassan Al-Hababi, Ibrahim Mohammed Al-Deailej, Hussein Ali Al-Sulatan, Yasser Abdullah Al-Ghamdi, Kamel Mohammed Al-Dossari
Aims: Transmission of human T lymphotropic viruses (HTLV) testing performed as routine pretransfusion screening. In Riyadh city the prevalence of HTLV1/2 among healthy volunteers in Riyadh city more than two decades. In addition, no information available related to the HTLV1/2 infections in HIV/AIDS patients. This study first aims to determine the prevalence of HTLV1/2 infections among healthy volunteers in Riyadh city. Second, as HTLV1/2 transmission similar as HIV routes, we assess rates of HTLV1/2 coinfection among patients infected with HIV. Materials and Methods: A retrospective study depends on the data obtained from Riyadh Regional Laboratory (RRL) for 3 years, 2017–2019. The samples enrolled in study consist of 114638 healthy blood donors and 243 patient samples referred to RRL virology samples. In addition, 474 HIV-infected patients were included. All serum samples tested to detect infection with HTLV1/2 by commercial CMIA or enzyme-linked immunosorbent assay kits and any positive results confirmed and differentiated by western blot. Results: Among of 114638 blood donations were tested, only two confirmed HTLV1 positive found from two (0.002%) donors, one of them is Saudi female and the second donor was expatriates. None was positive for anti-HTLV2. The overall HTLV1 prevalence was 1.7/100,000 donations during the 3 years tested. In addition, none of the referred sample was positive for anti-HTLV1/2. In addition, a large number of HIV-positive individual population enrolled none tested positive for HTLV1/2. Conclusions: HTLV seroprevalence is very low among healthy blood donors population in Riyadh city, which reflects the situation in the general population. However, screening for HTLV1/2 blood donors for the first donation from endemic countries donors would keep safe blood donation in Saudi Arabia.
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Dynamics of SARS-CoV-2 outbreak in the Kingdom of Saudi Arabia: A predictive model p. 79
Waleed Tharwat Aletreby, Abdulrahman Mishaal Alharthy, Fahad Faqihi, Ahmed Fouad Mady, Omar Elsayed Ramadan, Bassim Mohammad Huwait, Mohammed Ali Alodat, Abdullah Ba Lahmar, Nasir Nasim Mahmood, Shahzad Ahmad Mumtaz, Waseem Alzayer, Dimitrios Karakitsos
Background: COVID-19 is a worldwide pandemic that was first reported in China, and has spread to almost all nations. Measures of containment and control practiced by governments and authorities may benefit from prediction of the extent and peaks of spread to properly prepare to face the pandemic. Aim: The aim of the study was to predict the peak numbers of mortality, intensive care unit (ICU) admission, hospitalization, and positive cases and the time of their occurrence. Settings and Design: The study design is of a mathematical prediction model of prediction of spread of infectious disease, based on data from Saudi Arabia. Materials and Methods: We utilized a SEIR predictive model that divides the population into compartments and utilizes mathematical equations to predict the dynamics of the infection and its peak. The model exploited data from reliable sources on the Internet, and is – by design – based on certain assumptions. Statistical Analysis: Predefined mathematical equations that incorporate different parameters and assumptions were used for statistical analysis. Results: We estimated an R 0 value for our model of 2.2, and the model predicted a peak incidence of the pandemic around July 26, 2020. The peak mortality was predicted at 99,749 persons, predicted peak ICU admission of 70,246 patients, and peak hospitalization of 11,997,936 patients; all these predicted values were out of a total of predicted 14,049,104.83 COVID-19-positive cases. Conclusion: The COVID-19 pandemic in Saudi Arabia is predicted to peak by the end of July 2020, and may pose a serious burden on health-care systems already in shortage. Proper crisis management and effective resource utilization is crucial to safely overcome the pandemic, in addition to continuing control measures at least till the predicted peak time is over.
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Prevention of thrombosis in patients with severe COVID-19 p. 84
Hasan M Al Dorzi, Yaseen Arabi
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