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

Urinary Neutrophil Gelatinase-Associated Lipocalin as a Predictor of Acute Kidney Injury, Severe Kidney Injury, and the Need for Renal Replacement Therapy in the Intensive Care Unit

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

Urinary neutrophil gelatinase-associated lipocalin is an excellent predictor of mortality in intensive care unit patients

Objectives: 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. Methods: 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. Results: 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). Conclusions: Day one uNGAL is a highly accurate predictor of ICU, but less so for in-hospital mortality

A case of severe hypercalcemia with arterial and venous thrombosis

We present a case of severe hypercalcemia with extensive venous and arterial thrombosis that led to the patient’s demise in the setting of possible multiple endocrine neoplasia (MEN) type 2a. A 35-year-old female presented to the emergency with nausea and vomiting for one week. Physical examination revealed dry mucous membranes, a thyroid nodule on left side and epigastric tenderness. Initial investigations revealed evidence of renal impairment and hypercalcemia. Parathyroid hormone (PTH) level was very high. Ultrasound of the thyroid showed a solitary left thyroid nodule with mixed cystic and solid isoechoic echogenicity. The patient developed progressive dyspnea and hypoxemia, which mandated mechanical ventilation. Dialysis was initiated via the right femoral catheter and stopped due to extensive venous thrombosis of the right lower limb. Pulmonary emboli were excluded and pulmonary edema was confirmed by computed tomography. The patient was subsequently intubated for persistent respiratory distress. The same condition occurred in the right upper limb. Fine needle biopsy of the left thyroid nodule revealed medullary thyroid cancer. The consulting team preferred to manage her conservatively as she was rapidly-deteriorating. She developed progressive shock and multi-organ failureed.&#x0D; Citation: Algethamy HM, Shikdar YA, Alansari TA. A case of severe hypercalcemia with arterial and venous thrombosis. Anaesth pain intensive care 2020;24(1):__&#x0D; DOI: https://doi.org/10.35975/apic.v24i1.&#x0D; Received – 1 December 2019,&#x0D; Reviewed – 11 December 2019, 2 January 2020,&#x0D; Accepted – 10 January 2020;</jats:p

Does the time between ordering and administering the first dose of antibiotic influences outcome in septic shock patients?

Background &amp; Objectives: It is generally believed that significant delay in administering antibiotics in severely septic patients and those with septic shock increases mortality. However, most studies were retrospective and/or of questionable design. Moreover, the starting times from which delays were measured varied and often seemed somewhat amorphous. We assessed the duration of time between antibiotics being ordered and first administered among patients with newly diagnosed septic shock in a Saudi intensive care unit (ICU), and its effects on 30-day mortality and the rate of major complications. We also sought to identify any time threshold at which the mortality rate clearly increased.&#x0D; Methodology: Data were prospectively collected on 96 patients ≥14-years-old (male/ female = 49%; mean age 62.1 y) admitted to our ICU and followed for ≥30 days, or until hospital discharge or death. The time between ordering and administering the first dose of antibiotics after diagnosis of septic shock was recorded and its impact upon survival and major complications analyzed.&#x0D; Results: Fifty of 96 patients died within the ICU. Unexpectedly, mortality rate declined steadily between &lt; one min (60%) and 5 h delay (44%), but rose sharply beyond five hours (p &lt; 0.001). Time delay did not significantly influence the rate of any major complication other than death.&#x0D; Conclusions: Our results call into question recent conclusions that delays administering antibiotics beyond one to two hours result in significantly increased mortality. Further prospective, large scale studies are necessary to clarify this issue.&#x0D; Citation: Algethamy HM, Arab AA, Morish A, Meriky LH, Numan MS, Alotaibi AF. Does the time between ordering and administering the first dose of antibiotic influence outcomes in septic shock patients? Anaesth pain &amp; intensive care 2019;23(3):--</jats:p

Comparing critically-ill ARDS patients with versus without COVID-19: Prospective analysis of 690 patients

Abstract BACKGROUND: Few studies have directly and prospectively compared ICU patients with acute respiratory distress syndrome (1) caused by COVID-19 versus other causes, almost all previously-published studies retrospective and employing historical non-COVID cases. This study aimed to identify patient characteristics and predictors of mortality associated with COVID-related ARDS.METHODS: We performed a Prospective cohort study. Consecutive ARDS patients with versus without confirmed COVID-19 admitted to a single ICU of a major tertiary-care hospital from March-December 2020 were included. Data were collected and both bivariate and multivariable analysis performed on COVID-19 status, demographics; morphometrics; comorbidities; presenting symptoms; admission general health status (APACHE-II); respiratory and laboratory tests at admission, within 24 hours of admission, and pre-intubation; treatments administered; and outcomes. Data capture was almost 100%.RESULTS: Numerous clinical differences were detected between n=160 patients with versus n=530 patients without COVID-19. Most notably, COVID-19 patients were generally older and heavier, much more frequently presented with fevers/chills, dyspnoea, cough, anosmia/ageusia, and sore throat — and had worse outcomes, including over a two-fold rate of mortality and five-fold rate of survivors requiring prolonged supplemental oxygen. The presenting symptom dyad of fevers and/or chills and dyspnoea was 93.0% sensitive and 63.4% specific for COVID-related ARDS. A baseline APACHE-II Score ≥17 and requiring mechanical ventilation was 94.4% sensitive and 70.5% specific for mortality. All 37 COVID patients with an APACHE-II score &gt;30 died, versus survival among non-COVID patients with APACHE-II scores up to 40.CONCLUSION: In one of the first large studies to directly compare contemporary populations of COVID-19 and non-COVID ICU patients with ARDS, employing multi-variable analysis, numerous differences in patient characteristics, presentation, and outcomes were detected.</jats:p

Comparing critically-ill ARDS patients with versus without COVID-19: Prospective analysis of 690 patients

Abstract BACKGROUND Few studies have directly and prospectively compared ICU patients with acute respiratory distress syndrome (1) caused by COVID-19 versus other causes, almost all previously-published studies retrospective and employing historical non-COVID cases. This study aimed to identify patient characteristics and predictors of mortality associated with COVID-related ARDS. METHODS We performed a Prospective cohort study. Consecutive ARDS patients with versus without confirmed COVID-19 admitted to a single ICU of a major tertiary-care hospital from March-December 2020 were included. Data were collected and both bivariate and multivariable analysis performed on COVID-19 status, demographics; morphometrics; comorbidities; presenting symptoms; admission general health status (APACHE-II); respiratory and laboratory tests at admission, within 24 hours of admission, and pre-intubation; treatments administered; and outcomes. Data capture was almost 100%. RESULTS Numerous clinical differences were detected between n = 160 patients with versus n = 530 patients without COVID-19. Most notably, COVID-19 patients were generally older and heavier, much more frequently presented with fevers/chills, dyspnoea, cough, anosmia/ageusia, and sore throat — and had worse outcomes, including over a two-fold rate of mortality and five-fold rate of survivors requiring prolonged supplemental oxygen. The presenting symptom dyad of fevers and/or chills and dyspnoea was 93.0% sensitive and 63.4% specific for COVID-related ARDS. A baseline APACHE-II Score ≥ 17 and requiring mechanical ventilation was 94.4% sensitive and 70.5% specific for mortality. All 37 COVID patients with an APACHE-II score &gt; 30 died, versus survival among non-COVID patients with APACHE-II scores up to 40. CONCLUSION In one of the first large studies to directly compare contemporary populations of COVID-19 and non-COVID ICU patients with ARDS, employing multi-variable analysis, numerous differences in patient characteristics, presentation, and outcomes were detected.</jats:p