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   Table of Contents - Current issue
Volume 1 | Issue 6 (Supplement)
Page Nos. 7-33

Online since Thursday, November 23, 2017

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Commitment to collaborate: The value of establishing multicenter quality improvement collaboratives in Saudi Arabia p. 7
Hanan H Edrees, Zohair Al Aseri, Yasser Mandourah, Amin Yousef, Ismael Qushmaq, Khalid A Maghrabi, Fahad Al-Hameed, Yaseen M Arabi
Healthcare organizations around the globe are increasingly turning to multicenter quality improvement collaboratives (QICs) to improve patient care and outcomes. Despite the increase in demand and popularity of establishing multi-organizational QICs, there is limited evidence of these collaboratives in Saudi Arabia and in the Middle Eastern region. This article highlights the main components of successful QICs, recommendations to ensure successful QICs, and implications for establishing future collaboratives in Saudi Arabia.
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TAME cardiac arrest: A phase III multicenter randomized trial of targeted therapeutic mild hypercapnia after resuscitated cardiac arrest p. 10
Glenn M Eastwood, Alistair Nichol, Rinaldo Bellomo, Yaseen Arabi
Cardiac arrest (CA) is a catastrophic world-wide health problem with substantial human and financial costs. Ongoing cerebral vasoconstriction and cerebral hypoxia during the early post-resuscitation period may contribute to the often poor neurological outcome in CA survivors. Arterial carbon dioxide (PaCO2) is the major determinant of cerebral blood flow and an increased PaCO2 (hypercapnia) markedly increases cerebral blood flow and oxygenation. This paper reports on the background and method of The TAME Cardiac Arrest trial (Clinicaltrials.gov (NCT03114033) which is a phase III multi-center, randomized, parallel-group, controlled trial. The trial will determine if targeted therapeutic mild hypercapnia (TTMH) (PaCO250-55mmHg) during mechanical ventilation improves neurological outcome at 6 months compared to targeted normocapnia (TN) (PaCO235-45 mmHg) in resuscitated CA patients. The intervention is cost-free and will be applied over the first 24-hours of ICU care. A total of 1700 adult resuscitated CA patients from ICUs around the world will be enrolled. When completed the TAME Cardiac Arrest trial will provide unprecedented insights that will transform the care of resuscitated CA patients admitted to the intensive care unit (ICU) around the world. Moreover, this therapy is cost free and, if shown to be effective, will improve thousands of lives, transform clinical practice, and yield major financial savings.
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Pressure ulcers in critically III patients in Saudi Arabia: An opportunity for collaborative research on an ugly disease p. 14
Hasan M Al-Dorzi
Pressure ulcers are common in critically ill patients and are associated with increased morbidity, mortality and cost. Studies on pressure ulcer prevention and management indicate the need for multifaceted care and multidisciplinary involvement. However, there are obvious deficits in pressure ulcer prevention efforts and care worldwide. Studies on pressure ulcers acquired in the intensive care unit (ICU) in Saudi Arabia are scarce. We propose a study to determine in Saudi ICUs pressure ulcer prevalence, risk factors, management and outcomes to improve the related care processes.
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Society of critical care medicine discovery: Collaborative critical care research network p. 17
Jonathan E Sevransky, Ognjen Gajic
Large-scale clinical trials networks are best suited for understanding how care is delivered, generating evidence to minimize unnecessary heterogeneity of patient care, and testing different care patterns and medications to improve clinical outcomes. Discovery, the Critical Care Research Network, was launched in 2017 as a combined effort of the United States Critical Illness and Injury Trials (USCIIT), the Critical Care Pharmacotherapy Trials Network (CCPTN), and the Society of Critical Care Medicine (SCCM). In collaboration with our colleagues we hope to contribute evidence to help improve the care of the critically ill and injured
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Knowledge gaps in the global practice of management of severe traumatic brain injury Highly accessed article p. 19
Sami Alsolamy, Farah Alotaibi, Yaseen Arabi
Traumatic brain injury (TBI) was referred to as silent epidemic, neglected epidemic, and public health crisis by the World Health Organization due to its growing incidence and global public health, social, and economic burden. Despite the massive technological progress, no definitive treatment was found to cure TBI medically.The available evidence-based protocols are primarily directed toward stabilizing the patient and preventing secondary brain injuries, and their effectiveness has been validated in in high-income countries, but they may not be applicable to low and middle-income countries due to the lack of the appropriate infrastructure and limited human resources. Therefore, discrepancies are predicted between centers in high, low and middle-income countries and further studies are needed to asses the global managment of TBI.
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The cuff leak test prior to extubation: A practice based on limited evidence p. 22
Kim Lewis, Waleed Alhazzani
Endotracheal intubation and mechanical ventilation are lifesaving interventions that are commonly performed in the intensive care unit (ICU). The trauma of endotracheal intubation itself, the prolongued pressure exerted by the endotracheal tube on the larynx, and miscellaneous factors such as fluid overload can result in laryngeal edema (LE). Extubation of a patient with undiagnosed LE can results in respiratory failure secondary to an upper airway obstruction and may require reintubation. Respiratory failure requiring reintubation is associated with morbidity and mortality. The cuff leak test (CLT) is the only method intensivists use to predict the presence of LE. Despite the CLT's first description in 1988, the correct way to interpret the results (either qualitatively or quantitatively) is unknown, and its diagnostic accuracy has been called into question. In fact, the CLT could be detrimental to patients if it has a high false positive rate (i.e. no air leak is detected indicating LE when none actually exists). Incorrectly diagnosing patients with LE may result in prolongued mechanical ventilation that predisposes patients to barotrauma, ventilator-associated infections, exposure to systemic steroids, and a prolongued stay in the ICU. Given the paucity of data, the Cuff Leak and Airway Obstruction in Mechanically Ventilated ICU Patients (COMIC) research group is conducting a survey to understand international practice surround the use of the CLT prior to extubation, as well as a randomized controlled trial that will capture the accuracy of the test and determine the bet method to measure cuff leak.
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Prevalence and outcomes of colistin-resistant Acinetobacter infection in Saudi critical care units p. 25
Ayman Kharaba
Acinetobacter baumannii is a common healthcare associated problem. It can cause a wide variety of nosocomial infections because of its tremendous ability of acquiring antibiotic resistance and to survive in hospital environments. It's associated with high morbidity and mortality. So it has been considered as one of the dangerous organisms by the Infectious Diseases Society of America. In Saudi Arabia, many studies highlighted the magnitude of Acinetobacter baumannii infections but most of the studies were small. We plan to conduct a large multicenter prospective study in major ICUs in Saudi Arabia to determine the prevalence and prognosis of Acinetobacter baumannii infection, resistant pattern, risk factors associated with resistant and outcomes.
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The bacteremia antibiotic length actually needed for clinical effectiveness research program (balance.ccctg.ca) p. 28
Nick Daneman, Asgar Rishu, Robert Fowler
A multitude of global health organizations have declared antimicrobial resistance a threat to health, based on rapidly increasing resistance rates and declining new drug development. Up to 30%–50% of antibiotic use is estimated to be inappropriate, and excessive durations of treatment are the greatest contributor to inappropriate use. A landmark trial in critically ill patients with ventilator-associated pneumonia showed that mortality and relapse rates were noninferior in patients who received 8 versus 15 days of treatment, but similar evidence is lacking for the treatment of patients with bloodstream infection, which affects 15% of critically ill patients. The Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) research program was initiated to provide evidence-based guidance on this question.
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Stress ulcer prophylaxis: Back to square one p. 31
Mohammed Alshahrani, Waleed Alhazzani
Pharmacologic prophylaxis against stress ulcer-related gastrointestinal (GI) bleeding with acid suppression has been the standard of care for decades. Worldwide, proton pump inhibitors (PPIs) are more commonly used than histamine-2-receptor antagonists. However, recent observational studies suggest that PPIs increase the risk of ventilator-associated pneumonia (VAP) and Clostridium difficile infection (CDI). Further, the incidence of GI bleeding appears to be lower than in the past, perhaps related to immediate resuscitation and enteral nutrition. a large randomized trial is needed to test the efficacy and safety of withholding PPIs in the ICU.
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