Background: Recent attempts were made to identify early indicators of acute kidney injury (AKI) in order to accelerate treatment and hopefully improve outcomes. This study aims to assess the value of ...urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a predictor of AKI, severe AKI, and the need for renal replacement therapy (RRT). Methods: We conducted a prospective study and included adults admitted to our intensive care unit (ICU) at King Abdulaziz University Hospital (KAUH), between May 2012 and June 2013, who had at least 1 major risk factor for AKI. They were followed up throughout their hospital stay to identify which potential characteristics predicted any of the above 3 outcomes. We collected information on patients’ age and gender, the Acute Physiology And Chronic Health Evaluation, version II (APACHE II) score, the Sepsis-Related Organ Failure Assessment (SOFA) score, serum creatinine and cystatin C levels, and uNGAL. We compared ICU patients who presented with any of the 3 outcomes with others who did not. Results: We included 75 patients, and among those 21 developed AKI, 18 severe AKI, and 17 required RRT. Bivariate analysis revealed intergroup differences for almost all clinical variables (e.g., patients with AKI vs. patients without AKI); while multivariate analysis identified mean arterial pressure as the only predictor for AKI (p < 0.001) and the SOFA score (p = 0.04) as the only predictor for severe AKI. For RRT, day 1 maximum uNGAL was the stronger predictor (p < 0.001) when compared to admission diagnosis (p = 0.014). Day 1 and day 2 maximum uNGAL levels were good and excellent predictors for future RRT, but only fair to good predictors for AKI and severe AKI. Conclusions: Maximum urine levels of uNGAL measured over the first and second 24 h of an ICU admission were highly accurate predictors of the future need for RRT, however less accurate at detecting early and severe AKI.
Intensive care unit (ICU) patients with neurological impairments often require neuroimaging. However, the relative sensitivity of various imaging modalities of the brain has not yet been explored in ...this population.
In this study, we compare the findings of CT and MRI scans in ICU patients to (1) identify the number and rate of clinically relevant lesion detected by MRI while missed by CT and vice versa and (2) determine specific lesion types for which CT versus MRI discrepancies exist. A review of medical records included CT and MRI reports of patients who underwent these procedures while they were patients in our ICUs between July 2004 and July 2009. MRI and CT were compared regarding their ability to detect clinically relevant abnormalities. Odds ratios with 95% confidence limits were calculated to compare diagnostic categories regarding the rate of discrepant MRI versus CT findings, followed by power analyses to estimate sample sizes necessary to allow for further testing in a larger trial.
MRI revealed clinically relevant additional abnormalities over CT in 129 of 136 patients (95%) that included the detection of additional finding for 15/27 hemorrhagic lesions (55.6%), 33/36 (92%) ischemic strokes, 19/27 (70%) traumatic lesions, 8/14 (57%) infections, 15/24 (62.5%) metabolic abnormalities, and all seven neoplasms. Odds ratio analysis revealed the added sensitivity of MRI to be greater for ischemic and neoplastic lesions than for trauma, metabolic-related abnormalities, infection, or hemorrhage.
MRI is more sensitive than CT in identifying clinically meaningful lesions in at least a subset of ICU patients, regardless of pathology.
Delaying broad-spectrum antibiotics beyond 1-2 hours once the septic shock is diagnosed increases patients' risk of death. However, what is the impact of already being on antibiotics when a septic ...shock is diagnosed?
We compared demographics, clinical characteristics and outcomes in septic shock patients on antibiotics initiated prior to versus after septic shock was diagnosed; whose initial antibiotics were considered appropriate for the offending organism(s); and who died in versus were discharged from the ICU.
Data were prospectively collected on 161 patients ≥ 14-years-old (female: male=1:1; mean age 61.1yrs) admitted to the ICU for septic shock, and followed for ≥30 days, or until hospital discharge or death.
Few inter-group differences were identified. Those treated early were more likely to have a nosocomial infection (p=0.03), skin or soft tissue source of their infection (p=0.01), or a diabetes-related limb amputation (p=0.02); but received fewer antibiotics (p=0.01). Those on appropriate antibiotics were more likely to be female (p=0.048), but less likely to have a skin or soft tissue source of infection (p=0.03). Neither starting antibiotics early, nor being on appropriate antibiotics impacted any outcome measure, including survival. Predictors of mortality were ≥1 co-morbid condition (p=0.03), more versus fewer co-morbid conditions (p=0.009), cardiovascular disease at baseline (p=03), requiring dialysis at baseline (p=0.008), and a higher day#1 SOFA score (p<0.001).
Our data fail to demonstrate any benefit to being on antibiotics prior to the diagnosis, irrespective of whether the ultimately-identified offending organism is sensitive or resistant.
To assess urine neutrophil gelatinase-associated lipocalin (uNGAL) level as a potential predictor of acute kidney injury (AKI), and both intensive care unit (ICU) and in-hospital mortality.
Patients ...presenting to our ICU with a systolic blood pressure (SBP) less than 90 mmHg or mean arterial pressure (MAP) less than 65 mmHg, and no prior kidney disease were followed prospectively. Baseline data were collected on patient demographics, admission diagnosis, APACHE II and SOFA scores, SBP, MAP, serum creatinine and cystatin C, and uNGAL. Patients were monitored throughout hospitalization, including daily uNGAL, serum creatinine and cystatin C, and continuous MAP. Bivariate analysis compared those dying in the ICU and in-hospital versus survivors; with hierarchical binary logistic regression used to identify predictors of mortality. Areas under receiver-operating-characteristic curves (AUC) were used to measure sensitivity and specificity at different uNGAL thresholds.
Among 75 patients followed, 16 died in the ICU, and another 24 prior to hospital discharge. Mortality rates were greatest in trauma and sepsis patients. The ICU survivors differed from non-survivors in almost all clinical variables; but only 2 predicted ICU mortality on multivariate analysis: day one uNGAL (p=0.01) and 24-hour APACHE II score (p=0.07). Only the APACHE II score significantly predicted in-hospital mortality (p=0.003). The AUC for day one uNGAL was greater for ICU (AUC=0.85) than in-hospital mortality (AUC=0.74).
Day one uNGAL is a highly accurate predictor of ICU, but less so for in-hospital mortality.
Background
To develop evidence-based clinical practice guidelines on venous thromboembolism (VTE) prevention in adults with trauma in inpatient settings.
Methods
The Saudi Critical Care Society ...(SCCS) sponsored guidelines development and included 22 multidisciplinary panel members who completed conflict-of-interest forms. The panel developed and answered structured guidelines questions. For each question, the literature was searched for relevant studies. To summarize treatment effects, meta-analyses were conducted or updated. Quality of evidence was assessed using the Grading Recommendations, Assessment, Development, and Evaluation (GRADE) approach, then the evidence-to-decision (EtD) framework was used to generate recommendations. Recommendations covered the following prioritized domains: timing of pharmacologic VTE prophylaxis initiation in non-operative blunt solid organ injuries; isolated blunt traumatic brain injury (TBI); isolated blunt spine trauma or fracture and/or spinal cord injury (SCI); type and dose of pharmacologic VTE prophylaxis; mechanical VTE prophylaxis; routine duplex ultrasonography (US) surveillance; and inferior vena cava filters (IVCFs).
Results
The panel issued 12 clinical practice recommendations—one, a strong recommendation, 10 weak, and one with no recommendation due to insufficient evidence. The panel suggests starting early pharmacologic VTE prophylaxis for non-operative blunt solid organ injuries, isolated blunt TBIs, and SCIs. The panel suggests using low molecular weight heparin (LMWH) over unfractionated heparin (UFH) and suggests either intermediate–high dose LMWH or conventional dosing LMWH. For adults with trauma who are not pharmacologic candidates, the panel strongly recommends using mechanical VTE prophylaxis with intermittent pneumatic compression (IPC). The panel suggests using either combined VTE prophylaxis with mechanical and pharmacologic methods or pharmacologic VTE prophylaxis alone. Additionally, the panel suggests routine bilateral lower extremity US in adults with trauma with elevated risk of VTE who are ineligible for pharmacologic VTE prophylaxis and suggests against the routine placement of prophylactic IVCFs. Because of insufficient evidence, the panel did not issue any recommendation on the use of early pharmacologic VTE prophylaxis in adults with isolated blunt TBI requiring neurosurgical intervention.
Conclusion
The SCCS guidelines for VTE prevention in adults with trauma were based on the best available evidence and identified areas for further research. The framework may facilitate adaptation of recommendations by national/international guideline policymakers.
Antibiotic-resistant Acinetobacter baumannii is a continuously-emerging worldwide health crisis, with mortality rates approaching 50% in intensive care unit (ICU) patients. The objective of this ...study was to evaluate regional, patient-related, and organism-related predictors of survival among critically-ill patients with confirmed Acinetobacter infection.
This prospective cohort study was conducted within ten ICUs across six geographically- and climatologically-distinct cities across Saudi Arabia over 13 months.
Of 169 patients with confirmed Acinetobacter infection enrolled in the study, 80 (47.6%) died. Survivors were statistically younger, predominantly male, more likely to be admitted for trauma, less likely to have hypertension, diabetes, or have undergone hemodialysis, and more likely to have been treated with antibiotics prior to having a positive culture for Acinetobacter, but less likely to have received an aminoglycoside. Survivors also had lower baseline APACHE II and SOFA scores and were infected with stains of Acinetobacter that had less meropenem- or colistin-resistance. Multivariate analysis identified the following independent predictors of survival: younger age, lower ICU-day#1 APACHE-II and ICU-day#3 SOFA scores, being admitted for trauma, and having no history of hemodialysis.
Patient-related factors outweigh regional and hospital-related factors as predictors of survival among critically-ill patients with Acinetobacter infection.
IntroductionNon-invasive ventilation (NIV) delivered by helmet has been used for respiratory support of patients with acute hypoxaemic respiratory failure due to COVID-19 pneumonia. The aim of this ...study was to compare helmet NIV with usual care versus usual care alone to reduce mortality.Methods and analysisThis is a multicentre, pragmatic, parallel randomised controlled trial that compares helmet NIV with usual care to usual care alone in a 1:1 ratio. A total of 320 patients will be enrolled in this study. The primary outcome is 28-day all-cause mortality. The primary outcome will be compared between the two study groups in the intention-to-treat and per-protocol cohorts. An interim analysis will be conducted for both safety and effectiveness.Ethics and disseminationApprovals are obtained from the institutional review boards of each participating institution. Our findings will be published in peer-reviewed journals and presented at relevant conferences and meetings.Trial registration numberNCT04477668.
The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel ...of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU).
The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations.
The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations.
The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.
Severe traumatic brain injury (sTBI) is a common cause of death and disability worldwide, with long-term squeal among survivors that include cognitive deficits, psychosocial and neuropsychiatric ...dysfunction, failure to return to pre-injury levels of work, school and inter-personal relationships, and overall reduced quality of and satisfaction with life.
The aim of this work is to review the current literature on baseline predictors of outcomes in adults post sTBI.
Most of available literature on baseline predictors of outcomes in adults post sTBI were reviewed and summarized in this work.
Currently, a sizeable number of composite predictors of mortality and overall function exists; however, these instruments tend to over-estimate poor outcomes and fail to address issues like cognition, psychosocial/ neuropsychiatric dysfunction, and return to work or school.
This article reviews currently-identified predictors of all these outcomes.
Abstract Background: Uncertainty remains regarding potential benefits of induced hypothermia (IHT) after out-of-hospital cardiac arrest (OHCA). Spanning 12 meta-analyses of randomized clinical trials ...(RCTs) published since 2020, conclusions have ranged from IHT improving both survival and neurological outcomes, to improving neither, to increasing patient risk. In this meta-analysis, we compare IHT to 31-33°C against both no IHT and IHT to 34-36°C while trying to overcome some of the shortfalls of prior meta-analyses. Methods: After an extensive search of four scientific databases, steps were taken to select RCTs at low risk of bias, using the Cochrane Collaboration risk of bias tool, and otherwise appropriate for the question at hand after examining issues of concern with prior meta-analyses. Meta-analysis was performed of patients with shockable and non-shockable cardiac arrest rhythms both together and, as feasible, separately, generating odds ratios (OR) for each RCT separately and compiled for both mortality and neurological outcomes. Result: Ten RCTs encompassing 2129 IHT 31-33 patients and 2123 rhythm-matched controls were analyzed. Overall, no benefit for either mortality or neurological outcome was identified. However, three of six RCTs comparing IHT 31-33 against no IHT unveiled statistically-significant improvements in neurological outcomes, and compiling data from these six studies just failed to identify a significant benefit (OR=1.16, 0.98-1.36; p=0.077). Among 496 patients in whom rhythm-specific outcomes were reported, survival and good outcomes were achieved in 57.0% and 54.9% versus just 20.1% and 8.6% among those with shockable versus non-shockable rhythms, respectively. Conclusion: RCTs evaluating moderate IHT use after shockable OHCA remain necessary.
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