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The saudi critical care society clinical practice guidelines on the management of COVID-19 patients in the intensive care unit
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
April-June 2020, 4(2):27-44
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.
  4 10,070 574
Dynamics of SARS-CoV-2 outbreak in the Kingdom of Saudi Arabia: A predictive model
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
April-June 2020, 4(2):79-83
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.
  4 2,508 227
Exploring acute care workplace experiences of Saudi female nurses: Creating career identity
Sharifah Alsayed, Sandra West
April-June 2019, 3(2):75-84
Background: Saudi registered nurses (RNs) currently comprise 30% of Saudi Arabia's nursing workforce, and turnover/attrition rates remain problematic. No studies exploring Saudi RNs' experiences of acute care work and/or the factors that influence their decision to continue working were located. Purpose: To construct an insightful understanding of the acute care workplace experiences of female Saudi RNs and factors affecting retention. Methods: Snowball sampling was used to recruit 26 female acute care Saudi RNs who were interviewed about their workplace experiences. A constructivist grounded theory approach was used to code and categorize data to construct a shared understanding reflective of the experiences of participants and the researcher as both constructing the meanings given. Results: Shared understandings of patients' culture, religion, and language were assisting Saudi RNs to feel competent in making a unique contribution to patient care. Although participants reported negative impacts from some workplace policies, they were able to create their own identity and to find their own place by creating a career identity as Saudi-Muslim nurses. Successfully creating this unique nursing identity enhanced their motivation, work commitment, and competence; however, difficulties were encountered in accommodating work conditions and working as a minority group within a workplace largely staffed by foreign nurses. Conclusion: Saudi nurses' acute care workplace experiences were found to be complex and challenging and significantly affected by the lack of supportive policies designed to help them to keep working clinically. Implications for Nursing Policy: Workplace retention of Saudi RNs is an organizational issue that needs wide discussion to enable continuing clinical work of Saudi female nurses.
  2 3,703 309
Cross-Sectional study of the overall emotional functioning of health-care providers in Saudi
Abbas Al Mutair, Fadillah Al Obaidan, Mohammed Al-Muhaini, Khulud Al Salman, Samer Al Mosajen
July-September 2017, 1(3):80-86
Background: Health-care professionals work long hours, handle demanding patient loads, and make important decisions under conditions of uncertainty. These uncertain conditions have been shown to be associated with negative emotional and psychological outcomes for health-care professionals. In addition, they have been shown to lead to anxiety, depression, and other psychological and interpersonal strains, ultimately compromising the quality of patient care. Purpose: The purpose of this study is to evaluate the mental health issues of health-care providers including anxiety, depression, behavioral control, positive effect, and general distress. Methods: This is a cross-sectional study using a self-administered questionnaire. The questionnaire was distributed to health-care providers working at governmental and private health sectors in Saudi Arabia from January to April 2016. The questionnaire included a demographic survey and the Mental Health Inventory. Forty-five (45%) staff members completed the questionnaire. Results: Health-care professionals scored higher within the psychological distress, anxiety, depression, and loss of behavioral emotional control domains, indicating greater psychological distress. Females scored more on the depression domain than male participants. Further, physicians scored higher on the general positive effect domain than other health-care providers. Non-Saudi health-care providers scored higher on psychological distress scale than Saudi participants. Multiple regression analysis indicated that general positive effect, emotional ties, and life satisfaction were predictors of psychological well-being; on the other hand, anxiety, depression, and loss of behavioral/emotional control were predictors of psychological distress. Conclusion: High psychological distress may result from stressors associated with high work demands, workload, staff shortage, fear of infection, licensing board, fear of losing job, fear of reaction from leadership, peer, and patients and their families. Implication for Nursing Policy: Organizational supportive programs should be developed to enhance the psychological well-being of health-care professionals. These programs may decrease staff stress, anxiety, and depression and contribute to improve psychological well-being.
  2 3,213 220
Colistin monotherapy versus colistin-based combination therapy in the treatment of extensive drug-resistant Acinetobacter baumannii infections: A retrospective cohort study
Awad Al-Omari, Waleed Alhazzani, Maha F Al-Subaie, Ziad Memish, Hesham Abdelwahed, Jinhui Ma, Mohammed Abdullah Alamri, Saleem Saleh Alenazi, Haifa Al-Shammari, Hazem Aljomaah, Samer Salih, Suleiman Al-Obeid
July-September 2017, 1(3):87-94
Introduction: Acinetobacter baumannii is a Gram-negative Coccobacillus and is a frequent cause of hospital-acquired infections. Because some strains of A. baumannii are resistant to many antibiotics (i.e., extensively drug-resistant A. baumannii, or XDRAB), selecting antibiotics to treat infected patients is challenging. Clinical outcomes in critically ill patients with XDRAB infections are poor. In this study, we evaluated the clinical effectiveness of colistin as monotherapy and in combination with other antibiotics. Patients and Methods: A retrospective cohort study was performed on 94 critically ill patients (age ≥18 years) to assess the clinical effectiveness of treating XDRAB infections with colistin, either in monotherapy or combination with tigecycline, meropenem, or both. Clinical and microbiological data were obtained from patient records. We included patients suffering from XDRAB ventilation-associated pneumonia (VAP), or ventilator-associated tracheobronchitis (VAT), or VAT with bacteremia. Results: The mean age of the patients was 53.3 years (±23.7 years), and the mean Acute Physiology and Chronic Health Evaluation II score was 22.7 (standard deviation = 7.1). VAP and VAT with bacteremia were found in 84% and 16% of patients, respectively. Half (51%) of patients achieved microbiological clearance. The median Intensive Care Unit (ICU) stay was 29 days (interquartile range [IQR]: 17, 55) and the median mechanical ventilation (MV) duration was 21 days (IQR: 12, 42). MV duration and ICU length of stay were lower in the group of patients treated with colistin and meropenem than in those treated with colistin alone. Mortality was significantly lower in patients who received (colistin and tigecycline 30%) than in those who were treated with monotherapy (75%) with an odd ratio 0.03 (95% confidence interval: 0.00, 0.32; P < 0.01). Conclusions: Colistin-based combination treatment regimens mainly with tigecycline or with tigecycline and meropenem were associated with better treatment outcomes of XDRAB-induced VAP and VAT with bacteremia than colistin monotherapy.
  2 4,172 240
TAME cardiac arrest: A phase III multicenter randomized trial of targeted therapeutic mild hypercapnia after resuscitated cardiac arrest
Glenn M Eastwood, Alistair Nichol, Rinaldo Bellomo, Yaseen Arabi
2017, 1(6):10-13
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.
  2 2,978 175
Phosphate-induced hypocalcemia may have a role to play in a patient of recurrent cardiac arrest with severe hypophosphatemia
Mohammed Rizwan Jabbar, Arijit Sardar
January-March 2018, 2(1):12-14
Hypophosphatemia is a common electrolyte abnormality in our day-to-day practice in Intensive Care Unit. Severe hypophosphatemia is usually multifactorial and can lead to devastating consequences such as cardiac arrest. Phosphate replacement can be considered in severe symptomatic hypophosphatemia. We describe a patient of chronic alcoholic and diabetic who presented with diabetic ketoacidosis, right-lung pneumonia, and septic shock. Subsequently, the patient developed recurrent cardiac arrest. Both hypophosphatemia and phosphate-induced hypocalcemia were attributed to be the cause of this recurrent cardiac arrest.
  1 2,872 131
Average length of patient stay in inpatient and the emergency room
Hiba Chagla, Abbas Al Mutair
April-June 2019, 3(2):73-74
  1 2,034 174
Moving the critical care research agenda forward in Saudi Arabia
Yaseen M Arabi, Yasser Mandourah, Fahad M Al-Hameed, Khalid Maghrabi, Mohammed S ALshahrani, Musharaf Sadat
January-March 2019, 3(1):1-2
  1 2,020 202
Exploring factors affecting critical care response team service at a tertiary hospital in Riyadh: A retrospective cohort study

October-December 2020, 4(4):123-129
Background: Critical care response team (CCRT) is a proactive department of intensive care unit (ICU) that consists of an intensivist, a staff physician, a critical care nurse, and a respiratory therapist. The purpose of this team is to manage patients in their wards to avoid unnecessary ICU bed occupancies. The aim of the study is to explore factors affecting CCRT service in terms of patient disposition and mortality rate and to analyze interventions provided to the patients by the team. Materials and Methods: This is a retrospective cohort study conducted at a tertiary hospital in Riyadh. All CCRT event data collection forms from the period between February 2018 and April 2019 were reviewed. Patients meeting our criteria were included. Outcome measures were as follows: (1) patient disposition. (2) mortality rate. Factors that were tested for effect on CCRT service were patient age, activation time, and reasons for activation. All statistical analyses were done using SAS software 9.4. Results: A total of 1088 CCRT events were considered during the period of the study. Out of all deaths, the mean age was 70.90 ± 16.67 compared to the mean age of survivors 61.21 ± 20.65 (P < 0.0001). Furthermore, older patients had higher chances for ICU transfer (P = 0.0399). CCRT service was not affected by activation time as patient disposition and mortality rates were almost the same in activations during and out of work hours. The most common reason for CCRT activation was tachypnea (28.49%). Majority of patients within each reason for activation were not transferred to the ICU, except for low oxygen saturation (50.54% transferred to the ICU) (P = 0.0001), decreased level of consciousness (DLOC) (49.40% transferred to ICU) (P = 0.0001). Patients not transferred to the ICU had lower mortality rate (15.18%) than those transferred to the ICU (55.41%) (P < 0.0001). Conclusion: Given these results, increased vigilance and quick responses to CCRT calls for older patients, and those with low oxygen saturation and DLOC, must be considered. Increased vigilance is also needed for those spending more time in ICUs.
  1 1,060 106
Assessment of knowledge, attitude, and practice of hand hygiene among medical and health profession students at King Saud Bin Abdulaziz University for Health Sciences in Saudi Arabia
Mohammed Bin Humran, Khalid Alahmary
October-December 2018, 2(4):66-72
Background: In recent years, patients' safety has become high priority for health-care organizations. It has been documented that poor knowledge and compliance of health-care providers toward hand hygiene have contributed to poor patient safety outcomes. College students of health sciences may not receive adequate education and training on hand hygiene best practices. Objectives: To assess the health profession students' knowledge, attitude, and practice toward hand hygiene and to investigate the factors associated with poor hand hygiene knowledge and practice. Methods: This cross-sectional, correlational, descriptive study was conducted at King Saud Bin Abdulaziz University for Health Sciences performing clinical rotations at King Abdulaziz Medical City in Riyadh, Saudi Arabia. A proportional sampling was used to calculate the required proportions that reflect the size of student population form each of the three colleges. A total of 270 students including 140 medical, 83 nursing, and 47 respiratory therapy students who were selected using a simple random sampling method were included in the study. An adapted and validated knowledge, attitude, and practice (KAP) questionnaire was used to assess four domains: general information, knowledge, self-reported compliance to the WHO 5 Moments of Hand Hygiene, and general satisfaction on received education. Results: The overall average of knowledge score was 81.13 points out of 100. The results revealed that the knowledge score of hand hygiene was higher for nursing school (84.22 ± 12.98), followed by medical school (81.71 ± 11.31) and then respiratory therapy program (75.53 ± 11.76). The results also showed that students who took courses covering hand hygiene scored higher in knowledge score (83.28 ± 11.3) as compared to students who did not take such courses (75.16 ± 12.89). In the compliance domain, the results showed that there were no significant differences in compliance of hand hygiene between students in all categories. In terms of overall student satisfaction with hand hygiene education and training, the results showed that nursing students have higher satisfaction score (72.7%) than their counterparts in medical school (48.3%) and respiratory therapy program (49.7%). Conclusion: Hand hygiene knowledge among students was generally good, and the highest was among nursing students and the lowest among respiratory therapy students. The compliance of students toward the WHO 5 Moments of Hand Hygiene did not vary across different colleges. Improved knowledge was found to be associated with improved compliance with hand hygiene best practices. Recommendations: Increasing the academic focus on hand hygiene in both the curriculum and clinical rotations with periodic standardized educational courses and focusing on hands-on workshops could have a positive impact on the knowledge and practice of hand hygiene for current health sciences students and future health-care providers. Future studies are needed to assess the hand hygiene KAP among students in hospital settings using observation of actual practice.
  1 2,875 219
Saudi family perceptions of family-witnessed resuscitation in the adult critical care setting
Abdulaziz Alshaer, Khalid Alfaraidy, Florence Morcom, Wasaif Alqahtani, Zahra Alsadah, Atheer Almutairi
October-December 2017, 1(4):113-117
Background: During cardiopulmonary resuscitation, family members are usually pushed out of the resuscitation room. However, growing literature implies that family presence during resuscitation could be beneficial. Some health organizations worldwide such as American Heart Association and the Resuscitation Council in the UK supports family-witnessed resuscitation (FWR) and urge hospitals to develop policies to ease this process. The opinions on FWR vary widely among various cultures, and some hospitals are not applying such polices yet. This is the first study which explores the Saudi family members' opinion for family witness resuscitation in adult critical care setting. Objectives: To investigate whether patient's next of kin would like to have been present in the resuscitation room during attempted cardiopulmonary resuscitation (CPR) of their relative and their experience or knowledge of what is involved in CPR. Subjects and Methods: A retrospective, descriptive telephone survey of families of patients who had admitted in critical cares areas from January 2016 to June 2016. A family presence survey was developed to determine the desires, beliefs, and concerns about FWR. Results: Out of the 235 respondents, 143 (60.9%) wanted to be present in the room of their loved one just before death while CPR was going on. One hundred and eighty-two (77.4%) of the respondents believed that the family members should be with their loved one before death. More than half, i.e., 141 (60.0%) of the respondents believed that their presence might have eased the suffering of the deceased. One hundred and fifty-seven (66.8%) of the family members thought that their presence with the deceased in their last moments could have helped their sorrows and sadness. Conclusion: Most relatives of patients requiring CPR would like to be offered the possibility of being in the resuscitation room; this could have several benefits, so this study suggests that institutions should consider establishing programs of witnessed cardiopulmonary resuscitation for family members.
  1 4,795 216
Prevalence and outcomes of colistin-resistant Acinetobacter infection in Saudi critical care units
Ayman Kharaba
2017, 1(6):25-27
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.
  1 2,353 147
Central line-associated bloodstream infections in the Kingdom of Saudi Arabia
Raymond M Khan, Jawad Subhani, Yaseen M Arabi
January-March 2019, 3(1):43-48
Healthcare-associated infections (HAI) are a preventable cause of morbidity and mortality in the Kingdom of Saudi Arabia and internationally. They are associated with increased length of stay, mortality, antibiotics cost, and overall hospital cost. About 250,000 central line-associated bloodstream infections (CLABSI) occur in the US yearly, with a rate of 0.8 per CL-days and attributed mortality of 12%–25%. CLABSI constitutes 14.2%–38.5% of HAIs in the Kingdom, with rates varying from 2.2 to 29.7/1000 CL-days and crude device-associated mortality of 16.8%–41.9%. This article highlights the scope of the problem and outlines preventive strategies.
  1 3,926 322
Postpyloric feeding in critically ill patients: Updated systematic review, meta-analysis and trial sequential analysis of randomized trials
Fayez Alshamsi, Rucha Utgikar, Saleh Almenawer, Mustafa Alquraini, Bandar Baw, Waleed Alhazzani
January-March 2017, 1(1):6-23
Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population may result in unfavorable outcomes. However, enteral nutrition may be complicated with feeding intolerance, aspiration, pneumonia, and interruption of feeding. Objectives: We updated our systematic review and meta-analysis that compared the effect of postpyloric and gastric feeding on risk of pneumonia, duration of mechanical ventilation (MV), Intensive Care Unit (ICU) length of stay (LOS), gastrointestinal (GI) bleeding, aspiration, vomiting, and mortality. Methods: We searched MEDLINE, EMBASE, and clinical registries for data through April 2017 without language or date of publication restrictions. We included randomized controlled trials (RCTS) comparing postpyloric feeding to gastric feeding. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the Grading of Recommendations, Assessment, Development, and Evaluation methodology to assess the quality of the evidence. We used trial sequential analysis (TSA) as a sensitivity analysis to adjust for sequential testing. Results: We included 21 RCTs (1573 patients). Postpyloric feeding reduced the risk of nosocomial pneumonia (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2 = 11%; moderate quality), ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P = 0.02; I2 = 10%, moderate quality), and duration of MV (mean difference [MD] - 2.10 days, 95% CI −3.93, −0.28; P = 0.02; I2 = 67%, low quality), compared to gastric feeding. There was no difference in mortality (RR 1.07, 95% CI 0.90, 1.27; P = 0.44; I2 = 0%, moderate quality), ICU LOS (MD - 1.01 days, 95% CI −3.32, 1.3; P = 0.39; I2 = 84%, very low quality), aspiration (RR 0.81, 95% CI 0.4, 1.60, P = 0.54; I2 = 21%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P = 0.87; I2 = 33%, very low quality), and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P = 0.56; I2 = 0%, very low quality). Sensitivity analysis using TSA mirrored those of conventional analyses. Conclusions: Moderate quality evidence showed that postpyloric feeding may reduce the risk of pneumonia. Low-quality evidence yielded that duration of MV is shorter with pyloric compared to gastric feeding, with no significant impact on other outcomes. Although the results are promising further assessment in large clinical trials is warranted.
  1 3,934 200
A systematized review aimed to identify the impact of basic electrocardiogram training courses on qualified nurses
Fahad Zeed Alanezi
October-December 2018, 2(4):51-65
Aims: A systematized review aimed to identify the impact of basic electrocardiogram (ECG) training courses on qualified nurses. Background: ECG plays a crucial role in helping to diagnose, follow-up, and detect any abnormalities in patients' conditions. Nurses often work on the frontline in hospitals and are the ones who initially assess patients' conditions. According to the British Heart Foundation (n. d), 26% of all mortality in the UK is attributable to heart and circulatory diseases. Methodology: A comprehensive, systematized review was undertaken using the AMED, EMBASE, CINAHL, and MEDLINE databases. Thematic analysis was then used to synthesis the findings from the studies selected. Ten papers were selected following the application of inclusion and exclusion criteria. Conclusion: Basic ECG training courses were found to improve nurses' knowledge, compared to those who did not possess ECG training, the quality of care was seen better among nurses who had received ECG courses, and even patient outcomes were improved in the total number of myocardial infarction events in hospital which was decreased compared to before the intervention. Cardiac care nurses had better ECG interpretation skills than other nurses regardless if they took ECG courses or not.
  1 5,682 400
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