The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section

BACKGROUND: 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). METHODS: 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. RESULTS: 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. CONCLUSION: 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

Prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy: A systematic review and meta-analysis

Background: Patients with upper gastrointestinal bleeding (UGIB) often require urgent or emergent esophagogastroduodenoscopy (EGD) and are at risk of complications such as aspiration of gastric content or blood. The role of prophylactic endotracheal intubation (PEI) in the absence of usual respiratory status-related indications is not well established. Methods: We searched Medline, EMBASE, Cochrane Library's Central Register of Controlled Trials (CENTRAL) and SCOPUS from inception through July 2017 without date or language of publication restriction. We included studies that compared PEI with usual care (UC) in patients with acute UGIB, and reported any of the following outcomes: aspiration, pneumonia, mortality and length of stay. We excluded studies in which majority of included patients required intubation due to respiratory failure or decreased level of consciousness. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence for each outcome. Results: We did not identify any randomized trials on this topic. We included 10 observational studies (n = 6068). We were not able to perform any adjusted analyses. PEI was associated with a significant increase in aspiration (OR 3.85, 95% CI, 1.46, 10.25; P = 0.01; I2 = 56%; low-quality evidence), pneumonia (OR 4.17, 95% CI, 1.82, 9.57; P = 0.0007; I2 =52%; low-quality evidence) and hospital length of stay (mean difference 0.86 days, 95% CI 0.13, 1.59; P = 0.02; I2 = 0; low-quality evidence), without clear effect on mortality (OR 1.92, 95% CI, 0.71, 5.23; P = 0.2; I2 = 95%; very low-quality evidence). Conclusions: Low- to very low-quality evidence from observational studies suggests that PEI in the setting of UGIB may be associated with higher rates of respiratory complications and, less likely, with increased mortality. Although the results are alarming, the lack of higher quality evidence calls for randomized trials to inform practice

Intra-aortic balloon pump in patients with cardiogenic shock complicating myocardial infarction: a systematic review and meta-analysis of randomized trials (protocol)

Abstract Background Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction. Despite significant advancements in health technology and research, hospital mortality approaches 50%. The intra-aortic balloon pump is a mechanical hemodynamic assist device that has been used for over 40 years in the management of patients with cardiogenic shock. A recent randomized trial suggests that the use of intra-aortic balloon pumps does not reduce mortality in patients with ischemic cardiogenic shock. Methods We plan to search MEDLINE, EMBASE, and the Cochrane Trial Registry for potentially eligible randomized trials that compare the use of intra-aortic balloon pump with no mechanical device support in patients with cardiogenic shock. No date, language or journal limitations will be applied. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria. Data abstraction will be done independently and in duplicate. We plan to use RevMan software to generate pooled estimates across included studies, using the previously published method of DerSimonian and Laird. We will report pooled estimates as risk ratios with 95% confidence intervals for binary outcomes, and as mean differences with 95% confidence intervals for continuous outcomes. We will assess the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Discussion The aim of this systematic review and meta-analysis is to summarize the available evidence on the efficacy of the intra-aortic balloon pump in cardiogenic shock. Systematic review registration: PROSPERO CRD42014007056

Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials

PURPOSE: Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver support (ECLS) devices have been used as a bridge to liver transplant; however, the efficacy and safety of ECLS are unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the efficacy and safety of ECLS in liver failure. METHODS: We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from inception through March 13, 2019. RCTs comparing ECLS to usual care in ALF or ACLF were included. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. RESULTS: We identified 25 RCTs (1796 patients). ECLS use was associated with reduction in mortality (RR 0.84; 95% CI 0.74, 0.96, moderate certainty) and improvement in hepatic encephalopathy (HE) (RR 0.71; 95% CI 0.60, 0.84, low certainty) in patients with ALF or ACLF. The effect of ECLS on hypotension (RR 1.46; 95% CI 0.98, 2.2, low certainty), bleeding (RR 1.21; 95% CI 0.88, 1.66, moderate certainty), thrombocytopenia (RR 1.62; 95% CI 1.0, 2.64, very low certainty) and line infection (RR 1.92; 95% CI 0.11, 33.44, low certainty) was uncertain. CONCLUSIONS: ECLS may reduce mortality and improve HE in patients with ALF and ACLF. The effect on other outcomes is uncertain. However, the evidence is limited by risk of bias and imprecision, and larger trials are needed to better determine the effect of ECLS on patient-important outcomes

The cuff leak test in critically ill patients: An international survey of intensivists

International audienceBackground: The cuff leak test (CLT) is used to assess laryngeal edema prior to extubation. There is limited evidence for its diagnostic accuracy and conflicting guidelines surrounding its use in critically ill patients who do not have risk factors for laryngeal edema. The primary study aim was to describe intensivists' beliefs, attitudes, and practice regarding the use of the CLT. Methods: A 13-item survey was developed, pilot-tested, and subjected to clinical sensibility testing. The survey was distributed electronically through MetaClinician®. Descriptive statistics and multivariable regression analysis were performed to examine associations between participant demographics and survey responses. Results: 1184 practicing intensivists from 17 countries in North and South America, Europe, Oceania, and Asia participated. The majority (59%) of respondents reported rarely or never perform the CLT prior to extubating patients not at high risk of laryngeal edema, which correlated with 54% of respondents reporting they believed a failed CLT did not predict reintubation. Intensivists from the Middle East were 2.4 times more likely to request a CLT compared to those from North America. Intensivists with base training in medicine or emergency medicine were more likely to request a CLT prior to extubation compared to those with base training in anesthesiology. Conclusion: Use of the CLT prior to extubating patients not at high risk of laryngeal edema in the intensive care unit is highly variable. Practice appears to be influenced by country of practice and base specialty training