The clinical relevance of oliguria in the critically ill patient : Analysis of a large observational database

Funding Information: Marc Leone reports receiving consulting fees from Amomed and Aguettant; lecture fees from MSD, Pfizer, Octapharma, 3 M, Aspen, Orion; travel support from LFB; and grant support from PHRC IR and his institution. JLV is the Editor-in-Chief of Critical Care. The other authors declare that they have no relevant financial interests. Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Urine output is widely used as one of the criteria for the diagnosis and staging of acute renal failure, but few studies have specifically assessed the role of oliguria as a marker of acute renal failure or outcomes in general intensive care unit (ICU) patients. Using a large multinational database, we therefore evaluated the occurrence of oliguria (defined as a urine output 16 years) patients in the ICON audit who had a urine output measurement on the day of admission were included. To investigate the association between oliguria and mortality, we used a multilevel analysis. Results: Of the 8292 patients included, 2050 (24.7%) were oliguric during the first 24 h of admission. Patients with oliguria on admission who had at least one additional 24-h urine output recorded during their ICU stay (n = 1349) were divided into three groups: transient - oliguria resolved within 48 h after the admission day (n = 390 [28.9%]), prolonged - oliguria resolved > 48 h after the admission day (n = 141 [10.5%]), and permanent - oliguria persisting for the whole ICU stay or again present at the end of the ICU stay (n = 818 [60.6%]). ICU and hospital mortality rates were higher in patients with oliguria than in those without, except for patients with transient oliguria who had significantly lower mortality rates than non-oliguric patients. In multilevel analysis, the need for RRT was associated with a significantly higher risk of death (OR = 1.51 [95% CI 1.19-1.91], p = 0.001), but the presence of oliguria on admission was not (OR = 1.14 [95% CI 0.97-1.34], p = 0.103). Conclusions: Oliguria is common in ICU patients and may have a relatively benign nature if only transient. The duration of oliguria and need for RRT are associated with worse outcome.publishersversionPeer reviewe

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

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

Distinct relative abundances in pathogens detected in mechanically ventilated patients with suspected pneumonia in the intensive care unit at King Abdulaziz University Hospital

Abstract In this study, we present for the first time the landscape of the lung microbiota in patients with ventilator-associated pneumonia in Intensive Care Units in Saudi Arabia. DNA from 83 deep endotracheal aspirate lung samples was subjected to PacBio sequencing to identify pathogens in comparison with conventional diagnostic techniques. Patients on ventilation with pneumonia presented with similar lung flora to those of patients on ventilation without pneumonia. Proteobacteria, Firmicutes, and Bacteroidetes were detected in the majority of the samples. Samples treated with different antibiotics exhibited similar abundances of phyla and families. In order, the ten most common species detected in 16 clusters were Klebsiella pneumoniae, Stenotrophomonas maltophilia, Haemophilus influenzae, Pseudomonas aeruginosa, Metamycoplasma salivarium, Elizabethkingia anophilis, Staphylococcus aureus, Acinetobacter baumannii, Prevotella oris and Klebsiella africana. Of 51 on ventilation with pneumonia, the pathogens identified through sequencing corresponded with the findings from culture-dependent tests in 26 patients (50.98%), whereas the results differed in 30 patients (58.82%). Of 32 patients on ventilation without pneumonia, the pathogens identified through sequencing matched the conventional diagnostics results in only two patients (6.25%) but differed in 25 patients (78.13%). In summary, patients on mechanical ventilation with pneumonia did not display notable phenotypic traits. K. pneumoniae and S. maltophilia were the most common taxa detected in the samples, although some variations in microbial composition were observed. We conclude that Intensive Care Units exhibit distinct patterns of microbial colonization