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BackgroundThe 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).MethodsThe 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.ResultsThe 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. ConclusionThe 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.

Abdulrahman I Alshaya,1– 3 Khalid Bin Saleh,1– 3 Mohammed Aldhaeefi,1– 3 Hisham A Baderldin,1– 3 Farris O Alamody,1 Qusai A Alhamdan,1 Mohammed A Almusallam,1 Omar Alshaya,1– 3 Khalid Al Sulaiman,1– 3 Shaima Alshareef,3 Shuroug A Alowais,1– 3 Shmeylan A Al Harbi,1– 3 Ghassan Alghamdi2,4 1College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 2King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; 3Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia; 4College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaCorrespondence: Abdulrahman I Alshaya, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, Email alshayaab@gmail.comPurpose: Intravenous (IV) colistin is commonly used to treat multidrug-resistant gram-negative infections. It is primarily eliminated renally and may induce acute kidney injury (AKI) at a rate of up to 53%. Consequently, septic patients who require colistin administration have an additional risk of developing AKI. The aim of this study is to investigate clinical failure and AKI predictors for septic patients treated with IV colistin.Methods: This retrospective cohort study was conducted at a tertiary teaching hospital in Saudi Arabia. Adult septic patients with suspected or confirmed gram-negative infections who received colistin admitted to the hospital between May 2016 and December 2020 were screened after obtaining IRB approval. AKI was defined based on the AKI Network criteria. We investigated the incidence of clinical failure based on colistin dosing and AKI risk factors, such as the development of septic shock, severity of illness, and medication co-administration using a multiple logistic regression model.Results: After screening 163 patients, 103 patients were included in the analysis. No difference was observed between the colistin dosing strategies for clinical failure. Of the included predictors, development of septic shock (OR: 3.75; 95% CI 1.18– 13.15), carbapenem co-administration (OR, 3.96; 95% CI, 1.134– 15.57) were associated with an increased risk of AKI. The other factors were not significant predictors.Conclusion: Clinical failure was not affected by colistin dosing strategies in our cohort of patients with sepsis. Moreover, the co-administration of carbapenems and the development of septic shock may increase the risk of inducing AKI in adult septic patients treated with IV colistin. Further studies are required to confirm these findings.Keywords: sepsis, infection, colistin, loading dose, gram-negative, renal failure

Background Type 2 diabetes mellitus (DM) is prevalent in developing countries and is associated with many comorbidities, including diabetic peripheral neuropathy (DPN) and cardiovascular disease (CVD). In this study, we assessed and evaluated the association between DPN and CVD. Methods The study is a cross-sectional study that included DM patients who are attending DM primary care clinics. We evaluated each patient and collected epidemiological data, the physical examination findings, including cardiovascular status, and the presence of DPN. DPN was assessed with the neuropathic disability score (NDS), and it was considered present if the score was 5 or higher. The age and the levels of blood glucose, HbA1C, and plasma total cholesterol were recorded. Results The study included 116 DM, the mean age was 64.5±15 years (19 to 84 years) and the majority (61.2%) of the sample were male. The sample was divided into two groups: patients with DM only and patients with DM and CVD. The CVD group had a higher NDS score compared to the non-CVD group (P=0.006). The result indicated that for the CVD group, the prevalence of DPN was higher (50.8%) as compared to the non-CVD group (30.2%) (P=0.041). DPN was also associated with the acute coronary syndrome (ACS) (P = 0.013) but not heart failure (HF) (P=0.427). In addition, the HbA1C was significantly higher in patients with DPN (P=0.0345). Conclusion Our findings indicate that DPN was more prevalent in the CVD group and, in particular, in the group with ACS. The evidence provides support for the association between DPN and CVD.

Given that colon cancer is one of the most prevalent cancers worldwide, it is essential to employ strategies to try to reduce its incidence and recurrence rate. Though colon cancer is a sporadic disease in the vast majority of cases, multiple risk factors are linked to this disease, namely, obesity and cigarette smoking. Additionally, not many studies have been done in Saudi Arabia studying the recurrence rate of colon cancer. Therefore, we conducted a retrospective cohort study at King Khalid Hospital, King Abdulaziz Medical City, National Guard Health Affairs (NGHA), Jeddah, Saudi Arabia to investigate the recurrence rate of colon cancer in patients treated with complete colon resection followed by chemotherapy versus patients treated with colon resection alone via electronic and paper medical records. A total of 120 patients were included in this study; 61 were males (50.8%) and 59 were females (49.2%). According to our findings, the recurrence rate in patients who underwent surgical resection with adjuvant chemotherapy was 15.6% (n = 10), while the recurrence rate in patients with surgery alone was 21.4% (n = 12). Cancer recurrence is associated with significant morbidity and mortality. Therefore, further studies should be done to investigate the recurrence rate in patients with risk factors to identify and deal with the causes of recurrence.

Farmer Frog is a teaching farm organization focused on agriculture innovations, including aquaponics. Working with local student engineering teams, they prototyped an aquaponics system which monitors water characteristics, then controls energy use for pumps and aerators. The power system runs from mains AC and photovoltaic panels, backed by batteries. Future engineering plans include wind turbines for power and a mobile application for managing the system. Farm Frog may also build, test and distribute these systems.

Context: Time pressure has been implicated in the suboptimal diagnostic performance of doctors and in increases in diagnostic errors. However, the reasons underlying these effects are not clear. The aim of this study was to investigate the influence of time pressure on physicians' diagnostic accuracy and to explore the mediating effects of perceived stress (emotional pathway) and number of plausible diagnostic hypotheses (cognitive pathway) on the proposed relationship. Methods: We conducted a randomised controlled experiment. A total of 75 senior internal medicine residents completed eight written clinical cases under conditions with (n = 40) or without (n = 35) time pressure. They were then asked to: (i) rate the overall stress experienced, and (ii) write down any alternative hypotheses they had thought of when diagnosing the cases. In a post hoc analysis, a mediation path analysis was performed to test the causal relationships between time pressure, perceived stress and number of alternative diagnoses. Results: Participants who were under time pressure spent less time diagnosing the cases (85.54 seconds versus 181.81 seconds; p< 0.001) and had a lower mean diagnostic accuracy score (0.44 versus 0.53; p = 0.01). In addition, they reported more stress (5.80 versus 4.69; p = 0.01) and generated fewer plausible tentative hypotheses (0.37 versus 0.51; p = 0.01). Two path coefficients were found to be statistically significant; the first path coefficient referred to the relationship between time pressure and perceived stress (standardised β = 0.25, p = 0.029), and the second negative path coefficient referred to the relationship between time pressure and number of plausible alternative hypotheses (standardised β = −0.32, p< 0.01). Conclusions: Time pressure adversely influences physicians’ diagnostic accuracy by increasing their stress response and reducing the number of plausible hypotheses as mediators. Published version

Background: Although recent international guidelines have been published on the management of critically ill patients with the novel coronavirus disease 2019 (COVID-19), there is a vital need to develop clinical practice guidelines tailored to the context of Saudi Arabia. Methods: The Saudi Critical Care Society (SCCS) is the sponsor for this guideline. The expert panel consisted of 19 members. All members completed the World Health Organization Conflict of Interest Form. The expert panel formulated questions on the management of critically ill patients in the intensive care unit with COVID-19. Panel members identified relevant studies. The panel used the categories of Grading Recommendations, Assessment, Development, and Evaluation (GRADE) to assess the confidence in the evidence. Results: The SCCS expert panel issued 53 statements; of which 7 were strong recommendations, 9 were best practice statements, 32 were weak recommendations, and we were not able to issue recommendations in 5 instances. The statements covered different aspects of the critical illness in COVID-19 patients, including: infection control; therapeutic interventions; supportive care; and crisis management. Conclusion: The SCCS guidelines on the management of critically ill COVID-19 patients have been based on the best available evidence and tailored to the context of Saudi Arabia. These guidelines will be updated periodically to incorporate new evidence.

Rationale The relationship between kidney function and venous thromboembolism (VTE) in critically ill patients is not well studied. The main objective of this study was to evaluate this relationship in patients admitted to a medical-surgical intensive care unit (ICU). Methods This was a retrospective study of 798 patients admitted to a tertiary-care ICU and prospectively followed for the development of clinically suspected and radiologically diagnosed deep venous thrombosis or pulmonary embolism. Patients were divided based on admission creatinine and dialysis history into five groups: normal kidney function, RIFLE classes R, I and F (combined = acute kidney injury [AKI]) and endstage renal disease (ESRD). We compared VTE prophylaxis practices and VTE incidence in these groups and evaluated renal failure as a VTE risk factor using multivariate Cox regression analysis. Results Of the 798 patients, 27.2% had AKI and 10.1% had ESRD. Unfractionated heparin use was similar in the five groups but enoxaparin use was less frequent in AKI (13.4%) and ESRD (3.8%) patients compared with patients with normal kidney function (39.0%). VTE occurred in 7.6% of patients with normal renal function, 7.8% AKI patients and 2.5% ESRD patients (p = 0.22). The adjusted hazard ratios for VTE compared to patients with normal kidney function were 0.35 (95% confidence interval [CI], 0.08-1.47) for RIFLE class R, 1.19 (95% CI, 0.83-1.70) for RIFLE class I, 0.82 (95% CI, 0.59-1.14) for RIFLE class F and 0.71 (95% CI, 0.49-1.02, p = 0.06) for ESRD. Conclusions Neither AKI nor ESRD was an independent risk factors for critically ill patients.

Background Middle East Respiratory Syndrome Coronavirus (MERS-CoV) leads to healthcare-associated transmission to patients and healthcare workers with potentially fatal outcomes. Aim We aimed to describe the clinical course and functional outcomes of critically ill healthcare workers (HCWs) with MERS. Methods Data on HCWs was extracted from a multi-center retrospective cohort study on 330 critically ill patients with MERS admitted between (9/2012–9/2015). Baseline demographics, interventions and outcomes were recorded and compared between survivors and non-survivors. Survivors were approached with questionnaires to elucidate their functional outcomes using Karnofsky Performance Status Scale. Findings Thirty-Two HCWs met the inclusion criteria. Comorbidities were recorded in 34% (11/32) HCW. Death resulted in 8/32 (25%) HCWs including all 5 HCWs with chronic renal impairment at baseline. Non-surviving HCW had lower PaO2/FiO2 ratios 63.5 (57, 116.2) vs 148 (84, 194.3), p = 0.043, and received more ECMO therapy compared to survivors, 9/32 (28%) vs 4/24 (16.7%) respectively (p = 0.02).Thirteen of the surviving (13/24) HCWs responded to the questionnaire. Two HCWs confirmed functional limitations. Median number of days from hospital discharge until the questionnaires were filled was 580 (95% CI 568, 723.5) days. Conclusion Approximately 10% of critically ill patients with MERS were HCWs. Hospital mortality rate was substantial (25%). Patients with chronic renal impairment represented a particularly high-risk group that should receive extra caution during suspected or confirmed MERS cases clinical care assignment and during outbreaks. Long-term repercussions of critical illness due to MERS on HCWs in particular, and patients in general, remain unknown and should be investigated in larger studies.

Introduction The clinical significance of elevation of lactate levels within the reference range is not well studied. The objective of this study was to determine the best cutoff threshold for serum lactate within the reference range (0.01 to 2.00 mM) that best discriminated between survivors and nonsurvivors of critical illness and to examine the association between relative hyperlactatemia (lactate above the identified threshold) and mortality. Methods This was a retrospective cohort study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care academic center. Youden index was calculated to identify the best lactate cutoff threshold that discriminated between survivors and nonsurvivors. Patients with lactate above the identified threshold were defined as having relative hyperlactatemia. Multivariate logistic regression, adjusting for baseline variables, was performed to determine the relationship between the above two ranges of lactate levels and mortality. In addition, a test of interaction was performed to assess the effect of selected subgroups on the association between relative hyperlactatemia and hospital mortality. Results During the study period, 2,157 patients were included in the study with mean lactate of 1.3 ± 0.4 mM, age of 55.1 ± 20.3 years, and acute physiology and chronic health evaluation (APACHE) II score of 22.1 ± 8.2. Vasopressors were required in 42.4%. Lactate of 1.35 mM was found to be the best cutoff threshold for the whole cohort. Relative hyperlactatemia was associated with increased hospital mortality (adjusted odds ratio (aOR), 1.60, 95% confidence interval (CI) 1.29 to 1.98), and ICU mortality (aOR, 1.66; 95% CI, 1.26 to 2.17) compared with a lactate level of 0.01 to 1.35 mM. This association was consistent among all examined subgroups. Conclusions Relative hyperlactatemia (lactate of 1.36 to 2.00 mM) within the first 24 hours of ICU admission is an independent predictor of hospital and ICU mortality in critically ill patients.