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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.

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.

Acinetobacter is a strictly aerobic Gram-negative coccobacillus that is commonly present in hospital environment. It is considered a major healthcare problem worldwide. It can lead to different forms of severe infections, especially in critically ill patients. The prevalence of Acinetobacter infections is increasing in Saudi Arabia ,also the pattern of its antimicrobial susceptibility is changing as. Multidrug resistance and even pandrug resistance is increasing in almost all regions. Infections due to Acinetobacter are associated with high mortality reaching up to 58% in severe bloodstream infection. Additional research on Acinetobacter infections in critically ill patients in Saudi Arabia is needed.

Acute critical illness is associated with proteolysis which leads to immunosuppression, poor wound healing, intensive care unit (ICU)-acquired weakness, increased mortality, and delayed recovery. It has been suggested that exogenous protein should be supplemented in sufficient amounts to mitigate this protein loss. However, there is a continuing controversy regarding the optimal amount of protein that should be administered to critically ill patients and its impact on the outcomes. The current clinical practice guidelines recommend protein intake in the range of 1.2–2.5 g/kg per day. These guidelines are mostly based on observational studies and a few randomized controlled trials. In addition, small studies showed improvement in muscle mass or handgrip strength but with no effect on ICU mortality or length of stay due to small sample size and presence of confounders such as energy intake or due to heterogeneous population. On the other hand, there is some evidence suggesting that higher protein intake provided in the 1st week of illness may actually cause harm due to inhibition of autophagy or increased ureagenesis. Therefore, there is a need for a well-designed randomized multicenter clinical trial to evaluate the optimal protein requirement in different phases of critical illness, in different subgroups, and in nutritionally high-risk patients.

Background: Middle East Respiratory Syndrome (MERS) is a disease of the lower respiratory tract and is characterized by high mortality. It is caused by a beta coronavirus (CoV) referred to as MERS-CoV. Majority of MERS-CoV cases have been reported from Saudi Arabia. Aim: We investigated the human leukocyte antigen (HLA) Class II alleles in patients with severe MERS who were admitted in our Intensive Care Unit. Methods: A total of 23 Saudi patients with severe MERS-CoV infection were typed for HLA class II, results were compared with those of 161 healthy controls. Results: Two HLA class II alleles were associated with the disease; HLA-DRB1*11:01 and DQB1*02:02, but not with the disease outcome. Conclusions: Our results suggest that the HLA-DRB1*11:01 and DQB1*02:02 may be associated with susceptibility to MERS.

Critical care research is growing around the world including Saudi Arabia. The objective of this review is to discuss the building capacity in critical care research coordination in Saudi Arabia as a part of the research strategy of the Saudi Critical Care Trials Group (SCCTG). The SCCTG was developed to promote high impact critical care research in Saudi Arabia and to facilitate collaboration in national and international clinical research. Well-organized coordination between all parties is necessary by the presence of qualified clinical research coordinator (CRC). Critical care has unique features that make clinical research conduct more complex and demanding. It is a high-risk area with increased potentiality of error or adverse events occurrence. Critical care providers such as critical care nurses, critical care pharmacists, respiratory therapists, critical care physiotherapists, or intensive care unit physicians with added skills may be appropriate candidates to handle CRC roles in critical care setting. These skills include but not limited to data collection, obtaining consent, patient assessment, patient screening for the study eligibility, data entry, ethics submissions, providing teaching regarding the study protocol and research topics to clinical staff, attending to regulatory requirements, and designing data collection tools. The SCCTG shall focus on training the clinical research coordination skills through providing specialized courses and workshops that enable different hospitals to conduct and participate in clinical research. It will also help developing network group to connect critical care CRCs in Saudi Arabia and worldwide.

Rationale: Empirical antimicrobial therapy (EAT) for Acinetobacter infections may not be appropriate as it tends to be multidrug-resistant. This study evaluated the relationship between appropriate EAT and the outcomes of Intensive Care Unit (ICU) patients with Acinetobacter bacteremia. Methods: This is a retrospective study of patients admitted to a medical-surgical ICU (2005-2010) and developed Acinetobacter bacteremia during the stay. Patients were categorized according to EAT appropriateness, defined as administration of at least one antimicrobial agent to which the Acinetobacter was susceptible before susceptibility results were known. The relation between EAT appropriateness and outcomes was evaluated. Results: Sixty patients developed Acinetobacter bacteremia in the 6-year period (age = 50 ± 19 years; 62% males; Acute Physiology and Chronic Health Evaluation II score = 28 ± 9; 98.3% with central lines; 67% in shock and 59% mechanically ventilated) on average on day 23 of ICU and day 38 of hospital stay. All isolates were resistant to at least three of the tested antimicrobials. Appropriate EAT was administered to 60% of patients, mostly as intravenous colistin. Appropriate EAT was associated with lower ICU mortality risk (odds ratio: 0.15; 95% confidence interval: 0.03-0.96) on multivariate analysis. Conclusions: In this 6-year cohort, Acinetobacter bacteremia was related to multidrug-resistant strains. Appropriate EAT was associated with decreased ICU mortality risk.

Traumatic brain injury (TBI) was referred to as silent epidemic, neglected epidemic, and public health crisis by the World Health Organization due to its growing incidence and global public health, social, and economic burden. Despite the massive technological progress, no definitive treatment was found to cure TBI medically.The available evidence-based protocols are primarily directed toward stabilizing the patient and preventing secondary brain injuries, and their effectiveness has been validated in in high-income countries, but they may not be applicable to low and middle-income countries due to the lack of the appropriate infrastructure and limited human resources. Therefore, discrepancies are predicted between centers in high, low and middle-income countries and further studies are needed to asses the global managment of TBI.

Healthcare organizations around the globe are increasingly turning to multicenter quality improvement collaboratives (QICs) to improve patient care and outcomes. Despite the increase in demand and popularity of establishing multi-organizational QICs, there is limited evidence of these collaboratives in Saudi Arabia and in the Middle Eastern region. This article highlights the main components of successful QICs, recommendations to ensure successful QICs, and implications for establishing future collaboratives in Saudi Arabia.

RATIONALE: Acute respiratory failure (ARF) may complicate the course of hematologic malignancies (HMs). Our objective was to study the characteristics, outcomes and predictors of mortality of patients with HMs who required intubation for ARF. METHODS: This retrospective cohort study evaluated all patients with HMs who were admitted to the Intensive Care Unit (ICU) of King Abdul-Aziz Medical City-Riyadh between 2008 and 2013 and required invasive mechanical ventilation. We noted their baseline characteristics, treatments and different outcomes. Multivariable logistic regression analysis was performed to evaluate predictors of hospital mortality. RESULTS: During the 6-year period, 190 patients with HMs were admitted to the ICU and 122 (64.2%) required intubation for ARF. These patients had mean age of 57.2 ± 19.3 years and Acute Physiology and Chronic Health Evaluation II score of 28.0 ± 7.8 and were predominantly males (63.4%). Lymphoma (44.3%) and acute leukemia (38.5%) were the most common hematologic malignancy. Noninvasive ventilation (NIV) was tried in 22 patients (18.0%) but failed. The code status was changed to “Do-Not-Resuscitate” for 39 patients (32.0%) during ICU stay. Hospital mortality was 70.5% and most deaths (81.4%) occurred in the ICU. The mortality of patients with “Do-Not-Resuscitate” status was 97.4%. On multivariable logistic regression analysis, male gender (odds ratio (OR), 6.74; 95% confidence interval (CI), 2.24–20.30), septic shock (OR, 6.61; 95% CI, 1.93–22.66) were independent mortality predictors. Remission status, non-NIV failure and chemotherapy during ICU stay were not associated with mortality. CONCLUSIONS: Patients with HMs requiring intubation had high mortality (70.5%). Male gender and presence of septic shock were independent predictors of mortality.

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.

Predicting successful liberation of patients from mechanical ventilation has been a focus of interest to clinicians practicing in intensive care. Various weaning indices have been investigated to identify an optimal weaning window. Among them, the rapid shallow breathing index (RSBI) has gained wide use due to its simple technique and avoidance of calculation of complex pulmonary mechanics. Since its first description, several modifications have been suggested, such as the serial measurements and the rate of change of RSBI, to further improve its predictive value. The objective of this paper is to review the utility of RSBI in predicting weaning success. In addition, the use of RSBI in specific patient populations and the reported modifications of RSBI technique that attempt to improve the utility of RSBI are also reviewed.

RATIONALE: Sepsis is a leading cause of intensive care unit (ICU) admissions worldwide and a major cause of morbidity and mortality. Limited data exist regarding the outcomes and functional status among survivors of severe sepsis and septic shock. OBJECTIVES: This study aimed to determine the functional status among survivors of severe sepsis and septic shock a year after hospital discharge. METHODS: Adult patients admitted between April 2007 and March 2010 to the medical-surgical ICU of a tertiary hospital in Saudi Arabia, were included in this study. The ICU database was investigated for patients with a diagnosis of severe sepsis or septic shock. Survival status was determined based on hospital discharge. Patients who required re-admission, stayed in ICU for less than 24 hours, had incomplete data were all excluded. Survivors were interviewed through phone calls to determine their functional status one-year post-hospital discharge using Karnofsky performance status scale. RESULTS: A total of 209 patients met the eligibility criteria. We found that 38 (18.1%) patients had severe disability before admission, whereas 109 (52.2%) patients were with severe disability or died one-year post-hospital discharge. Only one-third of the survivors had good functional status one-year post-discharge (no/mild disability). After adjustment of baseline variables, age [adjusted odds ratio (aOR) = 1.03, 95% confidence interval (CI) = 1.01-1.04] and pre-sepsis functional status of severe disability (aOR = 50.9, 95% CI = 6.82-379.3) were found to be independent predictors of functional status of severe disability one-year post-hospital discharge among survivors. CONCLUSIONS: We found that only one-third of the survivors of severe sepsis and septic shock had good functional status one-year post-discharge (no/mild disability). Age and pre-sepsis severe disability were the factors that highly predicted the level of functional status one-year post-hospital discharge.

Background: Traumatic brain injury (TBI) is a growing epidemic throughout the world and may present as major global burden in 2020. Some intensive care units throughout the world still have no access to specialized monitoring methods, equipments and other technologies related to intensive care management of these patients; therefore, this review is meant for providing generalized supportive measurement to this subgroup of patients so that evidence based management could minimize or prevent the secondary brain injury. Methods: Therefore, we have included the PubMed search for the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Results: General supportive measures are equally important to prevent and minimize the effects of secondary brain injury and therefore, have a substantial impact on the outcome in patients with TBI. The important considerations for general supportive intensive care unit care remain the prompt reorganization and treatment of hypoxemia, hypotension and hypercarbia. Evidences are found to be either against or weak regarding the use of routine hyperventilation therapy, tight control blood sugar regime, use of colloids and late as well as parenteral nutrition therapy in patients with severe TBI. Conclusion: There is also a need to develop some evidence based protocols for the health-care sectors, in which there is still lack of specific management related to monitoring methods, equipments and other technical resources. Optimization of physiological parameters, understanding of basic neurocritical care knowledge as well as incorporation of newer guidelines would certainly improve the outcome of the TBI patients.

Traumatic brain injury (TBI) is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation (BTF) 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews (from 1 January 2007 to 31 March 2013), which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.

This paper summarizes the roundtable discussion in September 25, 2013, Riyadh, Saudi Arabia as part of the World Sepsis Day held in King Abdulaziz Medical City, Riyadh. The objectives of the roundtable discussion were to (1) review the chasm between the current management of sepsis and best practice, (2) discuss system redesign and role of the microsystem in sepsis management, (3) emphasize the multidisciplinary nature of the care of sepsis and that improvement of the care of sepsis is the responsibility of all, (4) discuss the bundle concept in sepsis management, and (5) reflect on the individual responsibility of the health care team toward sepsis with a focus on accountability and the moral agent.

Background: There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia (VAP). The contribution of multi-drug resistant (MDR) pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. Materials and Methods: We conducted a retrospective susceptibility study in the adult intensive care unit (ICU) of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. Results: A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly (60-89%) resistant to all tested antimicrobials, including carbapenems (three- and four-class MDR prevalence were 86% and 69%, respectively). Pseudomonas aeruginosa was moderately (13-31%) resistant to all tested antimicrobials, including antipseudomonal penicillins (three- and four-class MDR prevalence were 13% and 10%, respectively). With an exception of ampicillin (fully resistant), Klebsiella spp. had low (0-13%) resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. however not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients′ outcomes. Conclusion: Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.

Rationale: Near-fatal asthma (NFA) has not been well studied in Saudi Arabia. We evaluated NFA risk factors in asthmatics admitted to a tertiary-care hospital and described NFA management and outcomes. Materials and Methods: This was a retrospective study of NFA patients admitted to an ICU in Riyadh (2006-2010). NFA was defined as a severe asthma attack requiring intubation. To evaluate NFA risk factors, randomly selected patients admitted to the ward for asthma exacerbation were used as controls. Collected data included demographics, information on prior asthma control and various NFA treatments and outcomes. Results: Thirty NFA cases were admitted to the ICU in the five-year period. Compared to controls (N = 120), NFA patients were younger (37.5 ± 19.9 vs. 50.3 ± 23.1 years, P = 0.004) and predominantly males (70.0% vs. 41.7%, P = 0.005) and used less inhaled steroids/long-acting ß2-agonists combination (13.6% vs. 38.7% P = 0.024. Most (73.3%) NFA cases presented in the cool months (October-March). On multivariate analysis, age (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.92-0.99, P = 0.015) and the number of ED visits in the preceding year (OR, 1.25; 95% CI, 1.00-1.55) were associated with NFA. Rescue NFA management included ketamine (50%) and theophylline (19%) infusions. NFA outcomes included: neuromyopathy (23%), mechanical ventilation duration = 6.4 ± 4.7 days, tracheostomy (13%) and mortality (0%). Neuromuscular blockade duration was associated with neuromyopathy (OR, 3.16 per one day increment; 95% CI, 1.27-7.83). Conclusions: In our study, NFA risk factors were younger age and higher number of ED visits. NFA had significant morbidity. Reducing neuromuscular blockade duration during ventilator management may decrease neuromyopathy risk.