Critical Care

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 Saudi Critical Care Journal 2019 3(1):1-2

1999–2019: Twenty years of watershed moments for patient safety M Sofia Macedo, Yasser Mandourah, Anita Moore, Abdulelah AlHawsawi Saudi Critical Care Journal 2019 3(1):3-11 The case for patient safety is obvious; no one would argue in favor of harming patients. Since the launch of the paper To Err is Human, patient safety has been on the forefront of public health policymakers' priorities. Yet, 20 years later, while progress has been made, harm to patients is still a reality, daily, in health systems over the world. As countries reform their health systems, the national health programs must ensure not only the integration of universal health coverage (UHC) but also that the health coverage provided is safe. To this point, new models of care must be designed and implemented, and organizations should aim to achieve high-reliability care, similar to other industries that keep a solid safety record. This can be achieved by aiming for high-reliability organization principles, ensuring empowerment of patients as codesigners of health care, workforce safety to ensure safety of patients, and UHC without harm and proper regulation of digital health to avoid unintended adverse consequences. Since the past 20 years, the knowledge gap on patient safety has been shortened and therefore the health-care community holds a firm foundation for starting to implement evidence-based strategies that ensure safe care. The Jeddah Declaration on Patient Safety, 2019, is an actionable document that provides guidance to policy- and decision-makers globally that aim to achieve UHC free of harm. Nevertheless, given the high-level of complexity of health-care systems and its vulnerability to error, the question is what is the way forward toward a safer provision of care? How can the year 2019 be the watershed moment for the health-care industry?

Management of carbon monoxide poisoning-induced cardiac failure and multiorgan dysfunction with combined respiratory and circulatory extracorporeal membrane oxygenation AA Rabie, A Asiri, M Alsherbiny, W Alqassem, M Rajab, S Mohamed, W Hazem I Alenazi, L Ariplackal Saudi Critical Care Journal 2019 3(1):12-14 Carbon monoxide (CO) is an odorless, colorless, and nonirritant gas; it is the most common cause of poisoning and poisoning-related death. The main mechanism of CO toxicity is ischemic hypoxia secondary to hypoxemia. The heart is the major target organ of acute CO poisoning. Cardiac failure is the most common cardiac presentation; however, other cardiovascular manifestations include arrhythmia, pulmonary edema, and myocardial infarction. Recovery time from CO-induced cardiomyopathy varies from 4 days to 6 weeks. To our knowledge, there are a limited number of reported cases that demonstrated successful extracorporeal membrane oxygenation (ECMO) in adult and pediatric patients with CO poisoning and multiple organ failure. We present our experience with a case we think that it is the first case to be published for a patient with acute CO poisoning received both circulatory and respiratory support (hybrid venoarterial-venous ECMO).

Fluid administration strategies in traumatic brain injury Abdulrahman Alharthy, Waleed Tharwat Aletreby, Ibrahim Soliman, Fahad AlFaqihi, Waseem Alzayer, Nassir Nasim Mahmoud, Lawrence Marshall Gillman, Dimitrios Karakitsos Saudi Critical Care Journal 2019 3(1):15-18 Fluid restriction strategies may reduce morbidity and mortality in critical care patients and are currently trending as preliminary data showed encouraging results. A positive fluid balance was related to increase morbidity and mortality in a variety of disorders (i.e., sepsis, acute respiratory distress syndrome, and postsurgical cases) as well as resulted in an increased rate of complications observed in the intensive care unit setting. Traumatic brain injury (TBI) has been managed thus far in terms of fluid resuscitation under the concept of general trauma resuscitation recommendations that favored euvolemia above all fluid balance states. Notwithstanding, scarce data exist to clarify details about fluid management strategies in TBI such as the desirable fluid balance per se and/or its impact on patients' outcomes. We, therefore, reviewed previously published data and concluded in an observational manner (by creating a visual display model) that a highly positive and/or a negative fluid balance may have a detrimental impact on the prognosis of TBI patients. Accordingly, well-designed randomized controlled trials are clearly required to investigate further and in detail the most efficacious fluid administration strategies in TBI contributing thus in the rapidly expanding field of neurocritical care.

King Saud Medical City Intensive Care Unit: A critical and cost-focused appraisal Abdulrahman Alharthy, Dimitrios Karakitsos Saudi Critical Care Journal 2019 3(1):19-23 Intensive care unit (ICU) cost analysis has not been extensively addressed in the Kingdom of Saudi Arabia. We have implemented cost analysis (2015–2016) at the largest polyvalent ICU of the Kingdom (King Saud Medical City). Our block model analysis assimilated both modified Therapeutic Intervention Scoring System (TISS) and Omega scoring points to evaluate the overall cost; while, specific utilization elements were included in such as medication, procedural, laboratory, radiology, physiotherapy, nursing/physician, and overhead/other costs. The overall cost (Saudi Riyals [SAR]/ICU patient/day) averaged for TISS/Omega scores and adjusted for 2015–2016 inflation rates was approximately 23.269 (TISS: 167 points; Omega: 173 points generating predictive costs scores which were approximating the aforementioned score [R2 validated 0.91 and 0.90, respectively, all P < 0.005). Thereafter, we have applied effective antibiotic stewardship program and control of procedural supplies, novel administration policies, diversification of the ergonomy and clinical orientation, early mobilization of patients, increase of by-the-bed critical care ultrasound applications and decrease in the length of stay. The cost was reduced to 19.800 SAR (15%) in 2017–2018 that is comparable to international standards. Preliminary follow-up cost analysis (2019) is confirming projections of stabilizing the ICU cost <18.000 SAR (4790 USD)/patient/day. Our budget-cut policy has provided the department with a vital investment space to integrate new therapeutic technologies.

Prevention of pressure injury in the intensive care unit Hasan M Al-Dorzi Saudi Critical Care Journal 2019 3(1):24-28 Pressure injury (PI) is common in critically ill patients and is largely preventable. Prevention of PI in the intensive care unit (ICU) depends on routine risk assessment and implementation of preventive measures, such as adequate nutritional support, proper positioning and repositioning, mobilization, proper skin care, use of appropriate pressure-redistributing surfaces, and application of skin protective dressings. The available evidence suggests that a multifaceted approach is usually required. In addition, there is a need for high-quality studies to guide PI prevention in ICU patients.

Machine learning applications in critical care Mohammed Al Dhoayan, Huda Alghamdi, Yaseen M Arabi Saudi Critical Care Journal 2019 3(1):29-32 The use of machine learning (ML) applications in the intensive care units (ICUs) has surged over the last two decades. This is the result of the digital transformation that many health-care organizations have implemented. Data that are generated in the process of intensive care have more volume, velocity, and value than data generated in any other general hospital's department. This characteristic of ICUs makes them attractive environments for developing models that require rich dataset. ML has been used to develop clinical decision support system (CDSS) that could make informative decisions without requiring prior in-depth knowledge about the roots of the disease or common characteristics of the patients. The adoption of ML-based CDSS in ICUs is continuously increasing as ML algorithms achieve high levels of accuracy in descriptive, diagnostic, predictive, and prescriptive decisions. This article reviews some of the applications of ML in ICUs. This article will show examples of how ML was used for outcome predictions, such as predicting mortality and readmission. Examples in this article also include using ML for diagnostic and image recognition purposes. This review will discuss the use of ML for monitoring ICU patients, whether monitoring their physical safety with artificial intelligence vision detection algorithms, monitoring their continuous bedside measurements, or monitoring the administration and dosage of their medications. All these examples show that ML-based CDSS are on the path for a journey full of innovative and creative solutions that will increase the quality, efficiency, and effectiveness of critical care.

Neuromuscular-blocking agent use in critically ill patients Shmeylan A Al Harbi, Hind S Almodaimegh, Yaseen M Arabi Saudi Critical Care Journal 2019 3(1):33-37 Neuromuscular-blocking agents (NMBAs) are a cornerstone in the management of critically ill patients. There is evidence supporting short course (<48 h) of paralysis for patients with moderate-to-severe acute respiratory distress syndrome with PaO2/FiO2 ratio <150. Proper knowledge of these agents and their evidence-based use is fundamental. Health-care providers can play an important role in the regulation and the use of NMBAs in critically ill patients.

Management of heavy smokers in the intensive care unit Jawaher Grmaish Saudi Critical Care Journal 2019 3(1):38-42 Quitting smoking abruptly can precipitate the nicotine withdrawal syndrome, characterized by psychological and physical components. Data from critically ill patients have shown that active smokers are more likely to suffer from psychomotor agitation, self-removal of tubes and catheters, need for physical restraint, and therefore usually require higher doses of sedatives, neuroleptics, and analgesic agents. Furthermore, smokers admitted to the intensive care unit (ICU) experience delirium or agitation, which increases the length of hospital stay and the cost of medical care. Nicotine replacement therapy (NRT) has been shown to be safe and effective in the outpatient setting in smokers who intended to quit. However, the management of nicotine withdrawal symptoms in critically ill patients is controversial. Several studies have identified that treating nicotine withdrawal symptoms with NRT can be beneficial while others suggest that it can potentially increase mortality in critically ill patients. In the absence of high-quality data, NRT cannot currently be recommended for routine use to prevent delirium or to reduce hospital or ICU mortality in critically ill smokers. From the currently available data, it seems that the use of NRT in critically ill patients should be limited to selected patients where the potential benefit clearly outweighs the risk. To establish definitive conclusions regarding the use of NRT in smokers admitted to the ICU, it is necessary to carry out well-designed prospective studies with a sample of adequate size to limit the confounding factors and biases present in the current retrospective observational studies.

Central line-associated bloodstream infections in the Kingdom of Saudi Arabia Raymond M Khan, Jawad Subhani, Yaseen M Arabi Saudi Critical Care Journal 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.

Alexandros Sfakianakis
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