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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 61-72


Date of Web Publication30-May-2019

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2543-1854.259468

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How to cite this article:
. Abstract. Saudi Crit Care J 2019;3:61-72

How to cite this URL:
. Abstract. Saudi Crit Care J [serial online] 2019 [cited 2022 Jul 6];3:61-72. Available from: https://www.sccj-sa.org/text.asp?2019/3/1/61/259468

  Nutrition Support in Critically Ill Morbid Obsess Intensive Care Unit Patients Top

Sozan Al Qarni

E-mail: [email protected]

Purpose: The purpose is to study the (1) advantages of hypocaloric feeding; (2) macronutrients and micronutrients requirements in critically ill obese intensive care unit (ICU) patients; and (3) enteral and parenteral nutritional support guidelines. Introduction: The metabolic disorders associated with obesity present challenges to provide nutrition support, specifically as it relates to the safe and efficacious dosing of calories and protein. If not dose properly, complications such as hyperglycemia may influence outcomes of surgical procedures. It is important to discuss specific issue that should be addressed by a clinician responsible for feeding the patient in cases where enteral or parenteral nutrition are required since the mechanical, metabolic, and inflammation physiologic changes induced by obesity necessitate additional considerations of care. The benefit of selective hypocaloric feeding in this population is in reducing complications of hyperglycemia, fluid overload, and reduction of fat mass. Results: High-protein, hypocaloric regimen should be provided to reduce the fat mass, improve insulin sensitivity, and preserve lean body mass. The ideal enteral formula should have a low nonprotein calorie to nitrogen ration, and a variety of pharmaconutrient agents were added to modulate immune responses and reduce inflammation. Conclusions: Further studies are needed to determine how to optimize nutrition therapy in the critically ill morbid obese patients and to minimize morbidity and mortality related to underfeeding and overfeeding. Monitoring is the key success in nutrition support of critically ill ICU obese patients.

  Negative Impact of Enteral Nutrition Interruptions for Critical Ill Patients Top

Sozan Al Qarni

E-mail: [email protected]edu.sa

Purpose: The purpose is (1) to study the advantages of enteral nutrition (EN) feeding protocol; (2) to study how to optimize nutrition support to improve intensive care unit (ICU) outcomes; and (3) to increase the awareness of enteral nutritional support guidelines. Introduction: Interruption of EN in the ICU is frequent, and the reasons for and duration of interruption varied. It was noted that the airway procedures are associated with a relatively longer duration of interruption. Furthermore, the documentation and EN support orders were frequently missing due to lack of ICU feeding protocol. Background and Aims: Adequate nutritional support is crucial in the prevention and treatment of malnutrition in critically ill patients. Despite the intention to provide appropriate EN, meeting the full nutritional requirements can be a challenge due to interruptions. Results: The duration of EN interruption related to either patient gastrointestinal symptoms or respiratory and airway manipulations was long, and large variations found. Large variations were observed for interruptions for diagnostic tests or therapeutic interventions. EN protocols should focus on minimizing the interruption of nutrition along with enhancing administration and awareness of frequency and reasons during procedures in the ICU to reach nutrition goals. Conclusions: Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in ICU to reach the nutrition goals.

  A Rare Case of Unrepaired Adulthood Tetralogy of Fallot Presenting as Brain Abscess and Consequently as Hypoxemic Crisis Improved by Prone Positioning Top

Gultakin H. Bakirova1, Ilkin Bakirli2, Nasir N. Mahmood1, Abdulrahman Alharthy1, Ibrahim Soliman1, Dimitrios Karakitsos1,3, Hasan Bakirli2

1Department of Critical Care, Neurocritical Care Unit, King Saud Medical City, Riyadh, KSA, 2Slovak Medical University, Bratislava, Slovakia, 3Department of Critical Care, Keck School of Medicine, USC, Los Angeles, CA, USA

E-mail: [email protected]

Purpose: This observation has aimed to demonstrate the value of prone positioning (PP) in critically ill patients other than acute respiratory distress syndrome; in our case, it is unrepaired adulthood tetralogy of Fallot (ATOF). Methods: To overcome hypoxemia (P/F ratio <150) in a patient, prone position ventilation has initiated. This patient is a previously healthy 44-year-old male farmer admitted through emergency department to critical care due to recent-onset fever, diarrhea, vomiting, and depressed level of consciousness. On physical examination, he appeared to be underweight, exhibiting grade 4 fingers clubbing, no cyanosis, pansystolic murmur on cardiac auscultation, and Glasgow coma scale (GCS) 11/15. Echocardiogram showed sinus rhythm and right bundle branch block. Chest X-ray (CXR) revealed lung congestion, normal-sized heart with upturned apex, and prominent right atrial/pulmonary artery shadowing. Computed tomography (CT) brain scan complemented by CT angiography and magnetic resonane imaging showed a left parieto-occipital lesion sized 4.6 cm × 2.9 cm with midline shift and mass effect as well as signs of right lateral ventriculitis and multiple small infective lesions in the cerebella/left basal ganglia. The patient was intubated and admitted to the neurocritical care unit as a case of brain abscess and started on broad-spectrum antibiotics along with brain protective strategy measures. He underwent urgent left parieto-occipital craniotomy; while 20 cc of pus was aspirated and cultured accordingly. He was extubated 48 h postoperatively. Histopathology studies revealed acute or chronic inflammation and autolytic changes consistent with brain abscess formation. Results: Two days postextubation, he developed severe hypoxemia (GCS 15/15). He was re-intubated, while CXR, spiral CT chest, and follow-up brain CT were unremarkable. However, transesophageal echocardiography revealed TOF, ventricular septal defect, left-to-right shunt, right ventricular hypertrophy, overriding aorta, pulmonary stenosis, narrow RVO, mild MR, normal systolic function (left ventricular ejection fraction 50%), and TRmax PG 73.3 mm. Findings were consistent with unrepaired TOF. He responded dramatically to 18 h PP; subsequently, improvement of his oxygenation to steady level of SpO2 of 90% on low ventilator settings by daily PP was evident although proning is not a well-known treatment for hypoxic crisis due to unrepaired ATOF. Conclusions: PP could be considered in hypoxic crisis of unrepaired ATOF.

  Evaluation of Performance in the Intensive Care Unit Top

Waleed T. Aletreby1, Abdulrahman M. Al-Harthy1, Omar E. Ramadan1,2, Ahmed F. Madi1,3, Mohammed A. Al-Odat1, Basim M. Huwait1, Shahzad A. Mumtaz1

1Department of Critical Care, King Saud Medical City, Riyadh, KSA, 2Department of Anesthesia, Faculty of Medicine, Ein Shams University, Cairo, 3Department of Anesthesia, Faculty of Medicine, Tanta University, Tanta, Egypt E-mail: [email protected]

Purpose: The purpose is to evaluate the performance in an adult intensive care unit (ICU) in terms of effectiveness, using predefined targets for the length of stay (LOS) and standardized mortality ratio, as well as comparison to predicted values. Methods: This is a retrospective observational study, in the ICU at King Saud Medical City. All patients discharged from the ICU during the year 2017 were included in the study, with the exclusion of (1) patients of less than 18 years of age, (2) burn patients, and (3) patients with do-not-resuscitate order excluded only from the calculation of mortality rate. For every included patient, the following data were collected: (1) demographic data – age and gender; (2) source of admission to ICU; (3) broad category of admission diagnosis (medical-surgical-trauma-maternity-postoperative); (4) LOS in the ICU; (5) binary ICU outcome (dead or alive); and (6) Acute Physiology and Chronic Health Evaluation (APACHE) 4 score, predicted mortality rate, and predicted LOS. This study is a report of the mandatory requirement of continuous monitoring, evaluation, and reporting of the ICU performance, required by the total quality management department in our hospital. Results: The median LOS for all patients (5 [2–12]) was significantly higher than predicted value of 4 (2–11) days (P = 0.013), the same was observed for the LOS of acute patients (who spend less than 21 days in ICU), the actual and predicted medians were 4 (2–10) and 3 (2–6) days, respectively (P = 0.02); however, both LOS calculations were within our pre-set targets of 15 days for all and 5 days for acute patients. The actual mortality rate of 12.5% was significantly lower than that predicted by the APACHE 4 scoring system (14.6%). Using the actual and predicted mortality rates, the standardized mortality ratio was 0.86. Comparison of the year 2017 to 2016 showed a significant reduction of LOS for all patients (P = 0.03) and an insignificant trend toward reduction of mortality rate (P = 0.07). Conclusions: LOS values for all and acute patients were within targets. The mortality rate was significantly lower than predicted and lower than that reported in similar studies. With a standardized mortality ratio of <1, there is evidence of an acceptable quality of care in the ICU. There is also improvement in the performance and outcome of our ICU in 2017 as compared to 2016.

  Decision-Making and Decision Regret in Critical Care in Saudi Arabia Top

Omaimah A. Qadhi

Nursing College, King Saud University, Saudi Arabia E-mail: [email protected], [email protected]

Purpose: The purpose of this study was to explore the decision-making experience for family or surrogate decision-makers for critically ill patients in Saudi Arabia. It also tested for the occurrence or absence of regret after decision. Goal Attainment Theory by Imogene King and the Human Interacting Systems was used to guide this study. Methods: A convergent mixed methods descriptive study design was employed, including both qualitative and quantitative components from four different hospitals in Saudi Arabia. The qualitative data were collected through administering semi-structured interviews followed by collecting the quantitative data by answering the Decision Regret Scale. Results: While several themes emerged from the analysis of the data, regret was not frequently explicitly reported during the interviews. However, quantitatively, two persons scored moderate and high scores on the Decision Regret Scale. Results from both strands were integrated to better understand the phenomena of decision-making in critical care settings. Conclusions: Regret following decision-making for critically ill family members continues to be elusive and requires further study. Key factors influencing regret that may be cultural, religious, or gender based when observing Muslim and Arab communities.
Figure 1: Dynamic Conceptual Systems

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  Sustained Low-Efficiency Dialysis is Noninferior to Continuous Renal Replacement Therapy in Critically Ill Patients with Acute Kidney Injury and Hemodynamic Instabilities: A Comparative Meta-analysis Top

Sultan Al Dalbhi, Riyadh Alorf, Mohammad Alotaibi

Background: Critically ill adults with acute kidney injury (AKI) experience considerable morbidity and mortality rates up to 50%–70%. Renal replacement therapy is a proven treatment line for them. However, which of the treatment modality, that is, either continuous renal replacement therapy (CRRT) or sustained low-efficiency dialysis (SLED), performs better and is more efficient remains unanswered in the literature. Objectives: Our systematic review aimed to compare these treatment modalities based on mortality rate and renal and biochemical outcome. Methods: We carried out a systematic search of existing databases and after scrutiny by two independent researchers; 11 studies were finally shortlisted to be included in the review. Data were extracted on study design, sample size, population covered, intervention characteristics, and outcome measures. Of 11 studies, six were randomized control trials and five were prospective cohort having 1160 patients of AKI. Pooled risk ratio was the summary measure for dichotomous variables such as mortality, renal recovery, and dialysis dependence. For continuous variables, such as days of stay in the intensive care unit (ICU), fluid removal rates, and biochemical clearance rate, the standard mean difference was calculated using random effects model. Heterogeneity coefficient was also calculated for each outcome measure. Results: Meta-analysis results indicated no statistically significant difference in our primary outcomes such as mortality rate, renal recovery, and dialysis dependence. No statistically significant difference was observed for the secondary outcomes of length of ICU stay, fluid removal rate, and biochemical clearance rate for serum uric acid and serum creatinine. Conclusions: Hence, it can be concluded that there is no clear advantage for using continuous renal replacement in the hemodynamically unstable patient. Albeit, CRRT is costlier than SLED. Both the modalities are equally safe and effective in treating AKI among critically ill patients. Hence, SLED can be used in place of CRRT to cut costs as both have the same efficacy.

Keywords: Acute kidney injury, continuous renal replacement therapy, hemodynamic instability, intensive care, meta-analysis, sustained low-efficiency dialysis

  IgG4-Associated Mediastinal Fibrosis Top

Eiman Khalifa, Mohammed Khalid, Serfraz Saleemi, Masroor Hassan

E-mail: [email protected], [email protected]

Methods: This was a case report. Introduction: Internal jugular vein thrombosis (IJVT) was first described in 1912. Mediastinal compression syndrome due to IJVT is rare but potentially fatal condition. It usually arises following trauma to the internal jugular vein but also seen association with coagulopathies and advanced malignancies as part of paraneoplastic syndrome. Internal jugular and superior vena cava may get thrombosed due to compression in diffuse mediastinal fibrosis. The aim of anticoagulation therapy for IJVT is to inhibit further thrombus formation and prevent embolization. Thrombolysis either systemic or intracatheter is needed to in severe cases to maintain the patency of great veins and improve symptoms and complications. We present a case of IJVT due to mediastinal fibrosis where intracatheter thrombolysis resulted in almost complete patency of great veins. Case Presentation: We report this interesting case of a 33-year old man who presented with mediastinal compression syndrome. His condition started in 2009 when he presented with a 3-month history of progressive exertional dyspnea and was found to have constrictive pericarditis on investigations. He underwent total pericardiectomy. Pericardial histology showed evidence of granuloma, but acid-fast bacilli stain, polymerase chain reaction, and tissue culture for mycobacterial tuberculosis were negative. He was given empirical antituberculosis treatment for 9 months. He remained asymptomatic until 4 years later when he started to have dry cough and dyspnea on exertion. A chest X-ray showed speculated right hailer mass and right upper lobe infiltrates. Computed tomography (CT) scan of the chest revealed mediastinal fullness with right hilar mass and right upper lobe infiltrates. In addition, there was right paravertebral opacity and pleural thickening. Bronchoscopy did not show any endobronchial lesion, and bronchoalveolar lavage was negative for any infectious etiology. Transbronchial biopsy showed only fibrotic material with no evidence of malignancy or infection. Surgical biopsy of hilar mass and CT-guided core biopsy of paravertebral mass showed inflammatory infiltrates with background of fibrosis. A final diagnosis of fibrosing mediastinitis was established after multidisciplinary meeting. Intensive workup and special staining of biopsy indicated IgG4-related disease as the cause of fibrosing mediastinitis. The patient was started on steroids and on follow-up after 3 months showed significant improvement both clinically and radiologically. His steroids were tapered off after a year. He remained asymptomatic until a year after discontinuing steroids when he presented with progressive shortness of breath and neck swelling. Clinical examination revealed possibility of superior vena cava obstruction in view of engorged neck vein and facial swelling. A contrasted CT upper body and head showed extensive thrombosis of internal jugular veins bilaterally which extend superiorly to sigmoidal sinus and inferiorly to reaching the superior vena cava. In addition, there was worsening of mediastinal fibrosis compressing the superior vena cava. The patient was started intravenous heparin infusion. In view of worsening mediastinitis, he was given steroids and initiated on rituximab. After a detailed venogram evaluation of great veins, intracatheter thrombolysis was done and a stent placed in the superior vena cava at the site of occlusion due to mediastinal fibrosis. Subsequent venogram confirmed significant resolution of internal jugular thrombi. His symptoms improved and he was discharged on warfarin [Figure 1]. Results: In view of worsening mediastinitis, he was given steroids and initiated on rituximab. After a detailed venogram evaluation of great veins, intracatheter thrombolysis was done and a stent placed in the superior vena cava at the site of occlusion due to mediastinal fibrosis. Subsequent venogram confirmed significant resolution of internal jugular thrombi. His symptoms improved and he was discharged on warfarin. Conclusions: Mediastinal fibrosis can be treated where intracatheter thrombolysis resulted in almost complete patency of great veins.
Figure 1: Pre- and post-thrombolysis

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Figure 2: Histopathology of IgG4

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  Anemia, Blood Transfusion, and Filter Life Span in Critically Ill Patients Requiring Continuous Renal Replacement Therapy for Acute Kidney Injury: A Case–Control Study Top

Hasan M. Al-Dorzi1,2,3, Nora A. Alhumaid2,3, Nouf H. Alwelyee2,3, Nouf M. Albakheet2,3, Ramah I. Nazer2,3, Sadal K. Aldakhil2,3, Shahad A. AlSaif2,3, N. Masud2

1Intensive Care Department, Ministry of National Guard-Health Affairs, 2King Abdullah International Medical Research Center, 3College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: Continuous renal replacement therapy (CRRT) is frequently used in the intensive care unit (ICU) for the management of acute kidney injury. This study determined the incidence of anemia and blood transfusion in patients requiring CRRT and assessed the relationship between CRRT filter life and packed red blood cell (PRBC) transfusion. Methods: A case–control study was conducted at a tertiary care ICU. Ninety-six CRRT cases and 101 controls were matched for demographics and admission Acute Physiology and Chronic Health Evaluation II score. Daily hemoglobin levels, blood transfusions, and CRRT filter life span were noted. CCRT patients were categorized according to the median of the filter life (20 h). Results: Cases had lower nadir hemoglobin level compared with controls (72.8 ± 15.3 vs. 82.5 ± 20.7 g/L, P < 0.001) during the ICU stay. The incidence of anemia <70 g/L was 50% in cases versus 19% among controls (P < 0.001). Most (56.3%) cases required PRBC transfusion compared with 29.9% for controls with the number of transfused units being significantly higher in cases (2.6 ± 3.2 vs. 1.5 ± 3.2 units/patient, P = 0.03). The average number of filters/patient was 8.9 ± 10.9. Multivariable logistic regression analysis showed that lower serum creatinine on CRRT start, but neither nonprotocolized intravenous heparin use nor hemodialysis access location, was associated with longer filter life (odds ratio, 0.997; 95% confidence interval, 0.994–1.000; P = 0.04). The hemoglobin level and blood transfusion requirement were similar in shorter versus longer filter life groups. Conclusions: CRRT was associated with lower hemoglobin level during ICU stay and more PRBC transfusion. Shorter (<20 h) versus longer filter life was not associated with increased PRBC transfusion nor with nonprotocolized intravenous heparin use.

  Assessing Physicians’ Compliance with Medication-Related Clinical Decision Support Alert in the Intensive Care Unit Top

Weam T. Qattan1,2,3, Khulud Alkadi2,3, Aeshah A. Al Azmi1,2, Hend H Metwali1,2

1Ministry of the National Guard Health Affairs, King Abdulaziz Medical City, Department of Pharmaceutical Care Services, 2King Abdullah International Medical Research Center, 3College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia E-mail: [email protected]

Purpose: Clinical decision support (CDS) system is the centerpiece of the electronic health record to enhance patient care and prevent medication errors. Recent studies suggested that medication-related CDS alerts were commonly inappropriately overridden. The rate of medication errors for patients admitted to the intensive care units (ICUs) is higher than other patients, and these inappropriate overrides may affect patient care. The aim of this study is to evaluate the embedded CDS alerts and assessed physicians’ compliance with medication-related CDS alerts in the ICU. Methods: This was a retrospective chart review study included all adult who admitted to the ICUs between January 2017 and December 2017 at a tertiary care institution. The reviewer assessed physicians’ compliance with the alerts through the measured appropriateness of the CDS level 1 severity alerts and determination its category using predetermined criteria. Results: A total of 42,883 CDA alerts fired with different severity levels; Level 1 indicates as a major severity where shown 7.5%. Level 2 indicates as a moderate severity where shown 20.70%, whereas Level 3 indicates as a minor severity where shown 71.8%. A total of 3200 overridden of a major severity alters was included for physicians’ compliance evaluation. An overall appropriateness rate was 49.9% and the significance was varied by alert category (drug allergy: 66.7%, drug–drug interactions: 59.7%, drug disease: 55.4%, drug dose screening: 29%). Conclusions: Further modification should be focused to improve the CDS alerts system, and an uninformative alert must turn off. A future investigation is important to assess why physicians having a low adherence rate for utilizing the recommendation of CDS alerts.

Keywords: Alert fatigue, clinical decision support, critical care, physicians’ compliance, quality of care

  Platelet Transfusion Refractoriness: Prevalence, Risk Factors, and Outcomes among Critically Ill Patients, a Retrospective Cohort Study Top

Saeed Arabi1, Abdullah Almahayni1, Abdulrahman Alomair1, Hasan M Al-Dorzi1,2,3, Emad Masuadi1, Moussab Damlaj1,3,4

1College of Medicine, King Saud bin Abdulaziz University for Health Sciences, 2Intensive Care Department, King Abdulaziz Medical City, 3King Abdullah International Medical Research Center, 4Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: Refractoriness to platelet transfusions is an understudied phenomenon in the critical care setting. This study evaluated the prevalence, risk factors, and clinical outcomes of platelet refractoriness among patients admitted to the intensive care unit (ICU). Methods: A retrospective cohort study included all patients (age >14 years) who were admitted to a tertiary care medical-surgical ICU between 2011 and 2016 and received at least two platelet transfusions during their ICU stay. The patients were considered platelet-transfusion refractory if they had two consecutive transfusions with insufficient platelet increment (corrected count increment <5 × 109/L). Multivariable regression analysis was performed to assess predictors of refractoriness. Results: We enrolled 276 patients with median admission platelet count of 54 × 109/L (interquartile range [IQR], 28–98). Thrombocytopenia was present on admission in 88% of the patients. The study patients collectively received 1385 platelet transfusions (median of 3 transfusions/patient; IQR, 2–6). The median nadir platelet count during ICU stay was 18 × 109/L (IQR, 10–29). The median platelet increment after platelet transfusion was 6 × 109/L (IQR, 5–24). Most patients (65.5%) were found to be platelet-transfusion refractory [Figure 1]. Multivariable regression analysis showed that only the nadir platelet count was associated with increased risk of refractoriness (odds ratio, 0.98; 95% confidence interval, 0.97–0.99). Sepsis and active hematologic malignancy did not predict refractoriness. Platelet-transfusion refractoriness was associated with increased length of stay in the ICU (P = 0.03), but not with mortality. Conclusions: Platelet-transfusion refractoriness was common in critically ill patients but was not associated with increased mortality.
Figure 1: Pre- and post-transfusion platelet counts in all patients (left) and in the top five services where patients received platelet transfusions (right)

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  Impact of Critical Care Clinical Pharmacist in Tertiary Academic Hospital in Saudi Arabia Top

Moteb A. Khobrani, Dalia Ghoneim, Sultan M. Alshahrani, Abdullah Alawdah1

Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, 1Saudi German Hospital, Aseer, Saudi Arabia E-mail: [email protected]

Purpose: The purpose is to determine the impact of newly implemented clinical pharmacy services in the intensive care unit (ICU) in a tertiary academic hospital in Saudi Arabia. Methods: This was a prospective, observational study conducted in the medical and surgical/trauma ICU over 10 months. We utilized the Pharmaceutical Care Network Europe system to categorize all documented medication-related problems and pharmaceutical interventions. Results: During the study period, a total of 639 pharmaceutical interventions were documented, whereof drug selection problems accounted for 45% (n = 289), dose adjustment problems accounted for 27% (n = 170), untreated conditions were 17% (n = 109), drug monitoring-related interventions were 5% (n = 35), educational interventions were 2 % (n = 12), toxicity and adverse reactions were 1 % (n = 7), and other unclassified interventions accounted for 3% (n = 16). Five hundred and seventy-two pharmaceutical interventions were accepted (89.5). Conclusions: Critical care clinical pharmacist plays an important role as a part of healthcare professional team. The newly implemented clinical pharmacy services resulted in preventing high number of medication-related problems.

  Association between Phosphate Disturbances and Mortality among Critically Ill Patients with Sepsis or Septic shock Top

Shmeylan A. Al Harbi, Albatool M. Al Meshari1, Hani Tamim2, Hasan M. Al-Dorzi3, Sheryl Ann I. Abdukahil4, Yaseen Arabi5

Department of Pharmaceutical Care, King Saud bin Abdulaziz University for Health Science, 3King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, 4Intensive Care Department, King Abdulaziz Medical City, 5Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia, 1Saudi Food and Drug Authority, 2Department of Internal Medicine, American University of Beirut-Medical Center, Beirut, Lebanon E-mail: [email protected]

Purpose: Phosphate disturbances are one of the most common electrolyte disturbances encountered in the intensive care unit (ICU) and may lead to adverse clinical outcomes. The aim of this study is to examine the association between phosphate level on the 1st day of ICU admission and mortality in critically ill patients with sepsis and septic shock. Methods: In this retrospective cohort study, all adult patients who were admitted to the ICUs between January 2014 and September 2017 with sepsis or septic shock were categorized as having hypophosphatemia, hyperphosphatemia, or normophosphatemia based on day 1 serum phosphate values. The primary endpoints were all-cause ICU and hospital mortality. The secondary endpoints were ICU and hospital length of stay and mechanical ventilation duration. Multivariate analysis was used to show the association of phosphate levels with these outcomes. Results: Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 369 (26%) hyperphosphatemia, and 865 (61%) normophosphatemia. Hyperphosphatemia patients were associated with increased ICU and hospital mortality (adjusted odds ratio 1.6, 95% confidence interval [CI] 1.13–2.28, P = 0.008 and 1.66, 95% CI 1.21–2.29, P = 0.002, respectively) compared to normophosphatemia. Furthermore, there were no significant differences in ICU length of stay between the two groups compared to normal phosphate group. In contrast, the median hospital stay duration for hyperphosphatemia patients was lower, 17 days (7, 39) compared 22 days (12, 51) for the normophosphatemia group, P = 0.0012. Furthermore, the median mechanical ventilation duration for hyperphosphatemia was higher, 2 days (0, 6), compared to normophosphatemia group, 1 day (0, 6), P = 0.005. Conclusions: Hyperphosphatemia on the 1st day of ICU admission was associated with an increase in ICU and hospital mortality. Further studies are needed to define the causal relationship between phosphate level and mortality.

  Characteristics of Delirium in Intensive Care Units Tested by a Psychiatrist Top

Maha H. Aljuaid, Ahmad M. Deeb1, Maamoun Dbsawy2, Daniah Alsayegh3, Moteb Alotaibi4, Yaseen M. Arabi5

Nuero Critical Care Unit, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, 1King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard-Health Affairs, Departments of 2Intensive Care and 3Mental Health, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, 4Department of Mental Health, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard-Health Affairs, 5Department of Intensive Care, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia E-mail: [email protected], [email protected]

Purpose: Delirium is common in the intensive care unit (ICU) and linked to poor outcomes. Regular delirium screening of ICU patients is recommended. Yet, screening for delirium in the ICU remains sporadic and depends on the ICU clinicians’ experience. This study aims to identify the delirium characteristics in the ICU as tested by a psychiatrist according to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). Methods: This was a secondary analysis for the study conducted at a tertiary care hospital in Riyadh to test the validity and reliability of the Arabic version of the Confusion Assessment Method for the ICU. We included consecutive ICU patients who are ≥18 years and stayed in the ICU ≥24 h with Richmond Agitation-Sedation Scale ≥−2 at the time of examination. Exclusion criteria included patients with dementia, psychosis, and acute neurologic diseases. The psychiatrist assessed the patients for delirium according to the DSM-5. Information collected about delirium characteristics was acute/chronic, attention-disturbance, fluctuation of awareness, cognition disturbance, and delirium types. Results: Of 123 patients, two were excluded due to noninclusive results of the psychiatrist assessment. Among included subjects, 52.1% were males with a mean age of 62.7±17.2 years and 39.2% were mechanically ventilated. Delirium was diagnosed in 64.5%; 93.3% was acute while 6.7% was persistent. Attention-disturbance presented in 67.8% of patients, fluctuation of awareness in 58.7%, and cognition disturbance in 48.8%. Delirium types were 10.5% hyperactive, 46.1% hypoactive, and 43.4% mixed delirium. Conclusions: Delirium is common among ICU patients. Hypoactive and mixed delirium is the most common. Psychiatrist assessment for delirium is feasible in the critical care setting.

  Physical Assessment Improvement Project: Stand for Excellence Top

Alamri Samirah, Murabi Iris1, Samson Wendylyn2, Ahmadi Arwa3, Alkhalaileh Raedah4, Alpeng Lee5, Faith Nonhlanhla Ninela6, Siun Lye7, Safar Jummanah8

Pediatric Nursing Services, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 1Pediatric Nursing Services, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 2Pediatric Cardiac Pediatric Ward, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 3Pediatric Intensive Care Unit, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 4Pediatric Gastroenterology Ward, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 5Pediatric General Surgery Ward, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 6Pediatric Nephrology Ward, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 7Pediatric Chronic Ventilated Ward, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, 8Pediatric High Dependency Ward, King Abdullah Specialized Children Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: The purpose is to implement the complete head-to-toe assessment for pediatric patients who admitted in the pediatric intensive care, high dependency, and general pediatric units on admission and once per shift. Methods: The project methods were based on Plan, Do, Study, Act. Baseline data were collected and analyzed to validate the project neediness and measure the results. Clinical education provided to 100% of staff nurses; eBook and clinical guideline for physical assessment steps were made available in all units. Consequently, monthly audit was done to evaluate the compliance rate with the projects’ requirements. The results were shared with the leadership and the staff with a recommendation to enhance the projects’ outcome. Moreover, approval of modification for pediatric physical assessment electronic documentation forms was secured to ensure sustainability. In addition, pediatric physical assessment clinical competency reviewed and modified according to the best evidence base available to standardize the assessment steps. Results: Baseline data analyses showed that physical assessment was not done in consistent manner for all pediatrics patients as required by the hospital policy and procedure; however, the compliance rate increased after the project started. One hundred and forty patients have been audited, and seventy-two patients were assessed completely on admission and once per-shift. Moreover, staff nurses report the project enhanced their nursing care and promote the treatment outcome. Conclusions: Nursing physical assessment is an essential part of nursing care. Implementation of complete physical assessment increases patients safety, enhances nursing care, and enhances patients and family satisfaction.

  Extravasation and Infiltration Injury Prevention, Early Detection, and Early Management in the Pediatric Intensive Care Unit Top

Alamri Samirah, Murabi Iris, Wendylyn Samson, Ahmadi Arwa, Alkhalaileh Raedah, AlPeng Lee, Faith Nonhlanhla Ninela, Siun Lye, Safar Jummanah

1King Abdul-Aziz Medical City, 2King Abdullah Specialize Children Hospital, Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: Pediatric patients are at high risk to develop infiltration and extravasation injury due to their fragile and small veins. In 2016, we had sentinel event related to extravasation injury. This project was aimed to prevent extravasation and infiltration injury and to provide early intervention for reported cases. This project was targeted to achieve (1) zero tolerance of essential event due to extravasation injury in pediatric population; (2) 100% nurses’ attendance for clinical education; (3) 100% availability of Extravasation Management Kit in the pediatric intensive care unit (PICU) and all pediatric units; and (4) 100% compliance rate with the project clinical bundle in PICU and all other pediatric units. Methods: Extravasation team was created and initiated this project; the team used Plan, Do, Study, Act method to guide the project. They were responsible for creation of the clinical bundle based on the best evidence base available, provided the clinical education, standardized and distribute extravasation kit, and assessed the reported cases and monthly clinical audit followed by comprehensive data analysis. Results: No sentinel event occurred in 116 cases identified as infiltration and extravasation. Clinical audit showed 88% compliance rate with clinical bundle. Clinical education was attended 100% by staff nurses. In addition, the extravasation kit was updated and made available in the PICU and all pediatric units. Conclusions: Early management for all reported cases prevented any potential sentinel event, prompted patients’ safety, and enhanced patients and their families’ experience. The presence of clinical guideline, bundle, and departmental policy and procedure will guide and standardize the clinical practice.

  Effect of Using Selective Oropharyngeal Decontamination on the Rate of Infection in Pediatric Intensive Care Unit Top

A. Raja Abouelella, B. Karen Thomson, C. Joana Lumb

Freeman Hospital E-mail: [email protected]

Purpose: Respiratory tract infections are one of the common morbidities that affect ventilated patients in the intensive care unit (ICU). Prophylactic antibiotic regimens, including selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD), have been proved to reduce the prevalence of respiratory tract infections in adult population; however, the evidence of this effect in pediatrics is limited. We aim to evaluate the effect of using SOD on the rate of infection in a pediatric cardiothoracic ICU. Methods: Retrospective review of clinical outcomes before (6 months, SOD group) and after (3 months, non-SOD group) stopping the use of SOD was conducted. Patients who were expected to require intubation for >48 h were given standard SOD regimen (oral nystatin, colomycin, and neomycin). Patients were considered infected when they have positive cultures and receive antibiotic course. Patients with tracheostomy were excluded from the study. Patients’ information was all retrieved from medical notes and electronic records. Results: Both groups had matching age and RACHS scores. PICU-acquired respiratory infections occurred in 21 (40%) patients in SOD group and 8/24 (33%) patients in non-SOD group with no significant difference (P = 0.4) between both groups. The prevalence of ICU-acquired bacteremia was not significantly different between both groups (P = 0.6). There was no significant difference between mean ventilation days between SOD and non-SOD groups (10.1 ± 9.1 and 11.6 ± 10.2) (P = 0.6) and mean PICU stay (16.6 ± 13.5 and 8.4 ± 4.2) (P = 0.1). Conclusions: Our study suggests that SOD did not lead to clinically relevant reductions of infections, mechanical ventilation, and duration of PICU length of stay for pediatric cardiac patients. Further studies are warranted to determine more clinical outcomes of SDD and/or SOD and safety margins of its use in the pediatric population.

  Improved Nursing Statistic Collection in Multiple Intensive Care Units Top

Najla Al Mutairi, Sami Al Shehri, Adel Tohari, Beverly M. Cuizon, Czarina Mahinay

Prince Sultan Military Medical City E-mail: [email protected]

Purpose: The purpose of the study is to develop an electronic reporting system to improve the efficiency and accuracy of clinical reporting of statistics in a critical care environment. Methods: The intensive care nurse managers developed a flexible, user-friendly cloud-based reporting system that is capable of allowing nurses in geographically distant intensive care units (ICUs) to directly report their per-shift statistics. In addition, key performance indicator reporting was added to meet the demands of hospital administration, nursing, and intensive care department. Results: This reporting method resulted in a significant decrease in person-hours to collect routine data (actual 0.5 nursing position eliminated from data collection). In addition, data collection improved and delay between data collection and data being available to managers decreased. This improved the availability of key ICU data to decision-makers and managers. Live data are readily available to managers and physicians via a simple clinical dashboard. Conclusions: Conventional data collection methods by nurses in large disseminated intensive care units are increasingly difficult task. Demands for increased amounts of data by physicians and administrators have led to nursing resources being diverted to collection and collation of data. Electronic reporting systems improve the process of collection by removing intermediary collectors and distributing the workload among charge nurses. Data collation, which was labor intensive and error prone, was automated, removing the need to assign nursing staff to this task. Scaled outward this system could save significant hospital-wide person-hours, improve data quality, and decrease costs.

  Atypical Hemolytic Uremic syndrome: Postdelivery, Treated with Eculizumab: A Case Report Top

Ehab Ahmed

E-mail: [email protected]

Purpose: The case provides a good approach to the diagnosis and management of thrombotic microangiopathies. Methods: This was a case report of a 23-year-old female who was medically free. A mother of two healthy kid’s uneventful pregnancies last kid was born 4 months before admission. She presented to the emergency room with symptoms of abdominal pains, nausea, vomiting, and dizziness. Initial clinical examination was unremarkable, except from palar. Initial laboratory investigations revealed: blood urea 15.6 mm, serum creatinine 295 μM, total bilirubin 62 μM, direct bilirubin 12 μM, alkaline phosphates 44 U/L, alanine aminotransferase 13 U/L, albumin 35g/L, amylase 61 U/L, white blood cell 6.7, hemoglobin 9.3, mean corpuscular volume 82, and platelets 31. Blood film normocytic normochromic picture many spherocytes few fragmented red blood cells (3%–4%) marked thrombocytopenia – picture suggestive of microangiopathic hemolytic anemia. PT 14.2, activated partial thromboplastin time 29, international normalized ratio 1.1, lactate dehydrogenase (LDH) 1621 U/L, fibrinogen 2.3 g/L, Retics 155 (normal range 50–100) retics % 5.2 %. HBV, HCV, and HIV all were negative. C-reactive protein 3 mg/L ENA negative, ANCA negative, ANA positive titer 1/320, Anti-cardiolipin negative. D-dimer more than 20,000. ADAMTS-13 abs 3.8 negative ADAMTS antigen 1.2 IU normal ADAMTS activity 0.57 IU normal. Results: Initial impression microangiopathic hemolytic anemia thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) Treatment plasma pheresis 14 sessions, in addition to methylprednisolone and rituximab. Without improvement in renal function nor severe thrombocytopenia with high LDH and bilirubin. On histopathology, glomeruli show thrombotic microangiopathy, fibrinoid necrosis no evidence of vasculitis or thrombosis in arterioles interstitial edema immunofluorescence no staining. Finding in favor of atypical HUS Eculizumab 900 mg weekly was started and continue on plasma exchange and to taper steroids. The general condition improved patient, improved renal function, raised hemoglobin and features of hemolysis disappear. Conclusions: The case provides a good approach to the diagnosis of thrombotic microangiopathies. However, differentiating between TTP and aHUS is still confusing. The combination of clinical and laboratory data, activity of ADAMTS13, and response to plasma exchange allows for better differentiation between these thrombotic microangiopathies. Possibility of pregnancy as associated precipitating factor. Good clinical response to Eculizumab. Need for more research in the future.

  The Impact of a Heparinization Protocol on Filter Use during Continuous Renal Replacement Therapy Top

Hasan M Al-Dorzi, Victoria Burrows1, Amal Al-Matroud1, Renata Dousova1, Vilasini Raman Kutti1, Mohammed Melhem1

Intensive Care Department, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center and College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, 1Nursing Services, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: Anticoagulation is recommended during continuous renal replacement therapy (CRRT), to prolong the filter life and increase CRRT effectiveness. We evaluated the impact of a heparinization protocol on CRRT filter consumption. Methods: This is a before–after quality improvement project performed in two intensive care units (ICUs), Unit-A (8 beds) and Unit-B (21 beds). In the before-period (2013–2016), nonprotocolized heparinization for CRRT was as per the discretion of the treating team. In the after-period (2017–2018), a heparinization protocol was built in the computerized physician order entry system and was implemented in Unit-A and then Unit-B. It categorized patients into three risk groups depending on the coagulation profile and bleeding history. For the low-risk group, weight-based heparin bolus and infusion were given and heparin dose was titrated according to activated partial thromboplastin time. In the moderate-risk group, the heparin bolus and infusion doses were lower. For the high-risk group, neither heparin bolus nor infusion was given. We validated the protocol, educated the medical and nursing staff about it, then reinforced, and monitored its use over time. Results: Between 2013 and 2016, 1.40 filters were consumed on average per CRRT-day in both ICUs. After protocol implementation (2017–2018), 0.93 filters were consumed on average per CRRT-day (relative reduction = 0.34). [Figure 1] shows the number of CRRT filters consumed between January 1, 2016, and December 31, 2018, and demonstrates lower filter use in both units after protocol implementation. Conclusions: Protocolized heparinization for CRRT was associated with ~1/3 reduction in the number of filters consumed per CRRT-day and probably with significant cost-savings and improvement in CRRT effectiveness.
Figure 1: Number of filters per each continuous renal replacement therapy day before (2016) and after (2017–2018) heparinization protocol

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  The Accuracy of Equations That Estimate Glomerular Filtration Rate Compared with Measured Creatinine Clearance in Critically Ill Patients Top

Hasan M Al-Dorzi, Abdulmajeed A. Alsadhan, Ayman S. Almozaini1, Ali M. Alamri, Hani Tamim, Lolowa Al-Swaidan2, Yaseen M. Arabi

Intensive Care Department, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center and College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Departments of 1Internal Medicine and 2Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: The accuracy of glomerular filtration rate (GFR) estimates has been questioned. This study compared estimates of GFR by commonly used equations with creatinine clearance measured by 24-h urine collection (CrCl24h-urine) in critically ill patients. Methods: This substudy of the PermiT trial assessed the patients enrolled at King Abdulaziz Medical City, Riyadh, who had 24-h urine collection for creatinine, allowing CrCl24h-urine measurement. We estimated GFR using the Cockcroft–Gault (CG), Modification of Diet in Renal Disease Study (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. For the CG equation, we entered the actual weight in one calculation (CG actual-wt), and when BMI ≥30 kg/m2, the ideal body weight (GCideal-wt) and the adjusted body weight (GCadjusted-wt) in two calculations. We calculated the MDRD equation based on 4 (MDRD-4) and 6 variables (MDRD-6). Results: The cohort consisted of 238 patients (age 45.2 ± 20.2 years, male gender 74.4%, diabetes 31.9%, chronic renal disease 2.9%, Acute Physiology and Chronic Health Evaluation II 20.3 ± 8.1, mechanical ventilation 98.7%, and serum creatinine 214 ± 128 µmol/L). The measured CrCl24h-urine was 117.0 ± 75.0 ml/min. The correlations between the different formulae and CrCl24h-urine were all significant (P < 0.0001) and are presented in [Table 1]. CGactual-wt had the highest Pearson coefficient and MDRD-6 the lowest. CrCl24h-urine correlated best with CKD-EPI (r = 0.42) when CrCl24h-urine = 20–60 ml/min, with CGideal-wt (r = 0.29) when CrCl24h-urine = 60–130 ml/min, and with CGactual-wt (r = 0.41) when CrCl24h-urine >130 ml/min. Conclusions: There was a modest correlation between the formulae estimating GFR with CrCl24h-urine. CGactual-wt had the best correlation. The strength of correlation changed within the different ranges of CrCl24h-urine.
Table 1: Pearson correlation coefficients (r) between estimated glomerular filtration rate by commonly used equations and measured creatinine clearance by 24-h urine collection

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  Propranolol Use in Traumatic Brain Injury: A Proposal for a Randomized Controlled Trial Top

Mohammed Bawazeer, Abdulaziz Shaher1, Ahmed Alburakan2

By Surgical Critical Care Chapter, Saudi Critical Care Society King Faisal Specialist Hospital and Research Center, 1Trauma Critical Care Fellow, King Saud University, 2King Saud University E-mail: [email protected]

Background and Purpose: Traumatic brain injury (TBI) is a leading cause of death. It has been well documented that there is an exaggerated sympathetic response to TBI. Lund therapy has been proposed to blunt sympathetic response. Over the past 10 years, there were multiple retrospective reports suggesting a survival benefit with the use of beta-blockers in TBI.(1],(2],(3],(4],(5],(6],(7],(8],(9],(10],(11],(12],[13) In 2017, an updated systematic review that included nine studies was published and showed consistent findings.(14) Prospective data are limited. In 1987, a small randomized control trial (RCT) was published with high risk of bias due to unclear randomization, allocation concealment method, and incomplete outcome data.(15) Another small RCT was published in 2018, which showed significant reduction of catecholamine levels, but mortality was not reported.(16) Most recently, a large, multi-institutional, prospective observational study was published. This study included 2252 patients. They compared patients who received beta-blockers during intensive care unit (ICU) admission to patients who did not. Unadjusted and adjusted outcomes were compared and showed patients who received beta-blockers had lower mortality rates (adjusted odds ratio [AOR] 0.35, 95% confidence interval [CI] 0.26–0.4, adjusted P < 0.01). In this study, propranolol was found to be the most significant among other beta-blockers. Patients who received propranolol had much lower mortality (AOR, 0.51; 95% CI, 0.31–0.85; adjusted P = 0.010).(17) A properly designed randomized trial does not exist to date. Our aim is to study the effect of early propranolol use in patients with severe TBI on 30-day mortality. Methods: We propose a pragmatic, multicenter, double-blinded, randomized controlled trial. The experimental group (propranolol group) is all adult patients (>18 years) admitted to the ICU with severe TBI (AIS ≥3). The control group will receive placebo. For a power of 80% and to detect 4% difference in mortality, a projected sample size of 2634 (1317 in each group). Results: According to the current literature, the study is feasible. The primary outcome is 30-day mortality. The secondary outcomes will be ICU and hospital length of stay, Glasgow outcome scale-extended scale, Quality of Life after Brain Injury scale, and catecholamine levels. Analysis will be performed in intention-to-treat fashion. Multiple subgroup analysis will be performed to determine which subgroup would benefit the most. Conclusions: TBD.


  1. Arbabi S, Campion EM, Hemmila MR, Barker M, Dimo M, Ahrns KS, et al. Beta-blocker use is associated with improved outcomes in adult trauma patients. J Trauma 2007;62:56-61.
  2. Cotton BA, Snodgrass KB, Fleming SB, Carpenter RO, Kemp CD, Arbogast PG, et al. Beta-blocker exposure is associated with improved survival after severe traumatic brain injury. J Trauma 2007;62:26-33.
  3. Inaba K, Teixeira PG, David JS, Chan LS, Salim A, Brown C, et al. Beta-blockers in isolated blunt head injury. J Am Coll Surg 2008;206:432-8.
  4. Ko A, Harada MY, Barmparas G, Thomsen GM, Alban RF, Bloom MB, et al. Early propranolol after traumatic brain injury is associated with lower mortality. J Trauma Acute Care Surg 2016;80:637-42.
  5. Mohseni S, Talving P, Thelin EP, Wallin G, Ljungqvist O, Riddez L, et al. The effect of β-blockade on survival after isolated severe traumatic brain injury. World J Surg 2015;39:2076-83.
  6. Murry JS, Hoang DM, Barmparas G, Harada MY, Bukur M, Bloom MB, et al. Prospective evaluation of early propranolol after traumatic brain injury. J Surg Res 2016;200:221-6.
  7. Schroeppel TJ, Fischer PE, Zarzaur BL, Magnotti LJ, Clement LP, Fabian TC, et al. Beta-adrenergic blockade and traumatic brain injury: Protective? J Trauma 2010;69:776-82.
  8. Schroeppel TJ, Sharpe JP, Magnotti LJ, Weinberg JA, Clement LP, Croce MA, et al. Traumatic brain injury and β-blockers: Not all drugs are created equal. J Trauma Acute Care Surg 2014;76:504-9.
  9. Zangbar B, Khalil M, Rhee P, Joseph B, Kulvatunyou N, Tang A, et al. Metoprolol improves survival in severe traumatic brain injury independent of heart rate control. J Surg Res 2016;200:586-92.
  10. Salim A, Hadjizacharia P, Brown C, Inaba K, Teixeira PG, Chan L, et al. Significance of troponin elevation after severe traumatic brain injury. J Trauma 2008;64:46-52.
  11. Hadjizacharia P, O’Keeffe T, Brown CV, Inaba K, Salim A, Chan LS, et al. Incidence, risk factors, and outcomes for atrial arrhythmias in trauma patients. Am Surg 2011;77:634-9.
  12. Bukur M, Mohseni S, Ley E, Salim A, Margulies D, Talving P, et al. Efficacy of beta-blockade after isolated blunt head injury: Does race matter? J Trauma Acute Care Surg 2012;72:1013-8.
  13. Riordan WP Jr., Cotton BA, Norris PR, Waitman LR, Jenkins JM, Morris JA Jr., et al. Beta-blocker exposure in patients with severe traumatic brain injury (TBI) and cardiac uncoupling. J Trauma 2007;63:503-10.
  14. Alali AS, Mukherjee K, McCredie VA, Golan E, Shah PS, Bardes JM, et al. Beta-blockers and traumatic brain injury: A systematic review, meta-analysis, and eastern association for the surgery of trauma guideline. Ann Surg 2017;266:952-61.
  15. Cruickshank JM, Neil-Dwyer G, Degaute JP, Hayes Y, Kuurne T, Kytta J, et al. Reduction of stress/catecholamine-induced cardiac necrosis by beta 1-selective blockade. Lancet 1987;2:585-9.
  16. Ammar MA, Hussein NS. Using propranolol in traumatic brain injury to reduce sympathetic storm phenomenon: A prospective randomized clinical trial. Saudi J Anaesth 2018;12:514-20.
  17. Ley EJ, Leonard SD, Barmparas G, Dhillon NK, Inaba K, Salim A, et al. Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma Study. J Trauma Acute Care Surg 2018;84:234-44.

  Quality of Cardiopulmonary Resuscitation during Transportation Top

Ahad AlSaud, Nawaf AlKharashi1, Talal AlShaya1, Mohammed Arafat2, Nasser AlRajeh2, Nawfal AlJerian1

Department of Emergency Medicine, King Saud University, 1Department of Emergency Medicine, National Guard Health Affairs, King AbdulAziz Medical City, 2College of Medicine, King Saud Bin AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia Purpose: The purpose is to determine whether cardiopulmonary resuscitation (CPR) components are compromised during ambulance transportation. Methods: The study was randomized, cross-over, and manikin-based and compared two different environments for resuscitation: on-site and during ambulance (in-car) transportation. The parameters for assessing quality of chest compressions, such as chest compression rate, chest compression depth percentage, recoil, and number of cycles, were recorded using a True-CPRÒ device. Pearson’s correlation coefficient was used to measure the association between two variables (e.g., rate and depth). Results: Eighty qualified paramedic participants were randomized into 2-team each. The mean on-site and in-car transport chest compression rate was 142.55 and 139.98, respectively, with no statistical significant (t = −0.73, df = 78, P = 0.468). The average of adequate chest compression depth percentage was 67.8% for on-site and 58.2% for on-car with no significant difference (t = −1.57, df = 78, P = 0.120). The hands-off time was higher (mean = 3.13, confidence interval [CI] = 2.99–3.27) during in-car transport CPR than during on-site CPR (mean = 2.88, CI = 2.76–3.00). We observed that with a higher chest compression rate, the adequate chest compression depth percentage will deteriorate (Pearson’s r = −0.485, P = 0.002; n = 40). Less than half of the chest compression fractions were >80% during in-car transport CPR and on-site CPR. Conclusions: This study identified the potentially deleterious effects of transportation on (a) reducing the hands off-time and (b) decreasing the adequate chest compression depth percentage when the compression rate is high. Both may be related to the “mattress effect.” A limitation of this study is that the magnitude of the “mattress effect” was not measured. The results of this study confirm that there is an urgent need for more educational interventions targeting paramedics to follow international guidelines to enhance the quality of their chest compression skills in both on-site and in-car CPR.

  Electronic Sepsis Alert Pilot Experience in Riyadh Top

Eman Al Qasim, Ramesh K. Vishwakarma1, Ebtisam Alghamdi2, Huda Alghamdi2, Fawaz Rabeeah3, Mohammed Alkanhal3, Joan Olivier4, Kholoud Al Bishi4, Malia Ravestjin4, Ibrahim Abu Ghori4, John Alchin4, Nabeeha Tashkandi4, Angela Caswell4, Hasan M Al-Dorzi5, Yaseen Arabi5

Research Office, King Abdullah International Medical Research Center, 1Biostatisics and Bioinformatics, King Abdullah International Medical Research Center, 2Clinical Information Management Systems Department, Ministry of National Guard-Health Affairs, 3Information Systems and Informatics, Ministry of National Guard-Health Affairs, 4Nursing Department, King Abdulaziz Medical City, 5Intensive Care Department, King Abdulaziz Medical City, Riyadh, KSA E-mail: [email protected]

Purpose: The purpose is to examine the response of nurses and physicians to an electronic sepsis alert in hospital wards as part of feasibility assessment for the alert implementation across all Ministry of National Guard Health Affairs (MNGHA) hospitals. Methods: We developed an electronic alert based on qSOFA criteria (presence of 2 of 3 criteria – Glasgow coma scale <15, respiratory rate ≥22/min, and systolic blood pressure ≤100 mmHg) within a 12-h time window. When a patient has the “possible sepsis alert,” pop-up messages appear in the electronic medical record for physicians and nurses. The alert was activated in three different wards (medical xx beds, surgical xx beds, and hematology xx beds) in the MNGHA-hospital in Riyadh from January 14, 2019, to 30, 2019. We documented when patients first met the electronic alert system and when nurses and physicians acknowledged it. The physician acknowledged the alert by selecting one of the three options: sepsis, no sepsis, or unknown. The pop-up message reappeared until the presence or absence of sepsis was confirmed. Results: Fifty-five patients met qSOFA criteria and therefore had the “possible sepsis alert.” The median time to alert acknowledgment by nurses was 19 min (range: 2–402) and by physicians 16 min (range: 3–321). Twelve (21.8%) patients were confirmed by physicians to have sepsis. The median time for confirmation was around 364 min; (range: 7–1411). In addition, we found a variation in the physicians’ time to confirmation in the night shift (364 min) compared to the day shift (235 min). Conclusions: The electronic sepsis alert is feasible. The physicians’ evaluation of patients had 129 min delay in the time to physician confirmation at night shift compared to day shift. More data are needed from the other MNGHA hospitals.
Figure 1: Number of possible sepsis alert by ward

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  Engaging Sites in a National Quality Improvement Project Top

Sheryl Ann Abdukahil, Eman Al Qasim1, Abdullah A. AlZahrani2, Mohammed Al Qarni2, Basheer Abdulrahman3, Zohair Al Aseri3, John Alchin4, Navasha Singh4, Nabeeha Tashkandi4, Yaseen Arabi

Intensive Care Department, Ministry of National Guard Health Affairs, 1Research Office, King Abdullah International Medical Research Center, 2Quality and Patient Safety Department, Ministry of National Guard Health Affairs, 3King Saud Medical City, Ministry of Health, 4Nursing Services, Ministry of National Guard Health Affairs, Riyadh, KSA E-mail: [email protected]

Purpose: The aim of this national collaborative quality improvement project is to standardize and improve the care of mechanically ventilated patients throughout the kingdom. Methods: Various initiatives in the care of mechanically ventilated patients have focused on ventilator-associated pneumonia (VAP) prevention and have used the ventilator care bundle concept. Several hospitals in Saudi Arabia have published findings on successful efforts to reduce VAP. The participation of the country in the Comprehensive Unit-based Safety Program for mechanically ventilated patients (CUSP 4 MVP) in 2015 served as the groundwork for establishing cooperation between hospitals. Because of CUSP 4 MVP’s success, it was later adapted with the vision of implementing this on a national scale. Here, we describe the experience with engaging sites in NASAM project. Results: The involvement of the different sectors to collaboratively engage in this improvement project was done through multiple channels. For this project to reach its target, we first aimed to seek the nod and support from the leadership of stakeholders which involved multiple meetings and discussions. Aside from this, the project was made more visible through the Saudi Critical Care Society. A workshop was conducted in November 2018 and webinars are held twice a month. An online portal is also available not only for data entry but as a one-stop resource for educational materials and training. Currently, the project involves 6 health sectors. Of these, a total of 78 intensive care units (ICUs) from 48 hospitals in 27 cities have been onboard. The project plans to extend the implementation to a total of 100 ICUs. Conclusions: Collaborative work entails the engagement and “buy-in” of all stakeholders from the administration down to the frontline staff with the common goal of ensuring better patient outcomes as well as best clinical practices applied to all patients.

  Final-Year Students’ Knowledge, Satisfaction with Exposure to Critical Care Education, and Evaluation of Critically Ill Patients Top

Mariam AlAnsari, Ali AlBshabshe1, Layla Layqah2, Hadil AlOtair3, Emad Masuadi4, Nawaf AlKharashi5, Salim Baharoon6

Department of Adult Critical Care Medicine, King Hamad University Hospital, Al Sayh, Bahrain, 1Department of Medicine, Critical Care Division, King Khalid University, Abha, 2Research Office, King Abdullah International Medical Research Center, King AbdulAziz Medical City, 3Critical Care Department, King Saud University Medical City, 4College of Medicine, King Saud Bin AbdulAziz University for Health Sciences, 5Emergency Medicine Department, King AbdulAziz Medical City, National Guard Health Affairs, 6Intensive Care Department, King AbdulAziz Medical City, National Guard Health Affairs Riyadh, Saudi Arabia E-mail: [email protected]

Purpose: The current study evaluates how undergraduate Saudi medical school students are educated on the critical care principles and evaluate their knowledge of fundamental critical care basics. Methods: This is a cross-sectional anonymous self-administrated survey questionnaire among final-year medical students at three Saudi medical schools. The questioner consists of 6 sections acquiring the following data: medical students’ demographics data, training experience in critical care, specific questions on frequently encountered broad critical care topics, parameters, specific questions on knowledge, and experience of some critical care skills, and the last section contains questions on formal assessment of critically ill patient. Results: A total of 279 students were included. Only 6% choose critical care as a future career. Only 13% felt competent in applying principles of hypovolemic shock management, and 15% felt competent in recognizing signs of a threatened airway. There was a noticeable deficiency in identifying many thresholds of critical measures used in a formal assessment of critically ill patients. Only 29% and 13% of the students surveyed could identify the critical lactic acid value in shock and tachypnea as the early sign of critical illness, respectively. Only 1.8% of the responders could correctly answer all questions that appear in the formal basement of critically ill patients. Those who choose critical care as a career has significantly less correct answers compared to those who choose other specialties (mean score of 32.6 vs. 46.1 P < 0.001). Conclusions: Saudi medical schools undergraduates have a substantial deficiency in acutely ill patients’ assessment and exposure. Critical care was not among the preferred future career. There is a need for institutional support and endorsement of undergraduate critical care exposure and education.


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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