Yaseen Arabi

Health risks at the Hajj

Summary Annually, millions of Muslims embark on a religious pilgrimage called the “Hajj” to Mecca in Saudi Arabia. The mass migration during the Hajj is unparalleled in scale, and pilgrims face numerous health hazards. The extreme congestion of people and vehicles during this time amplifies health risks, such as those from infectious diseases, that vary each year. Since the Hajj is dictated by the lunar calendar, which is shorter than the Gregorian calendar, it presents public-health policy planners with a moving target, demanding constant preparedness. We review the communicable and non-communicable hazards that pilgrims face. With the rise in global travel, preventing disease transmission has become paramount to avoid the spread of infectious diseases, including SARS (severe acute respiratory syndrome), avian influenza, and haemorrhagic fever. We examine the response of clinicians, the Saudi Ministry of Health, and Hajj authorities to these unique problems, and list health recommendations for prospective pilgrims.

Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review.

IntroductionDespite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients.MethodsThe following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay.ResultsOf 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean ± standard error: 9.6 ± 1.2 days versus 18.7 ± 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 ± 1.2 days versus 21.0 ± 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 ± 1.2 days versus 4.9 ± 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days).ConclusionEarly tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization.

Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study

See related commentary by Dickerson, http://ccforum.com/content/17/3/154IntroductionData are sparse as to whether obesity influences the risk of death in critically ill patients with septic shock. We sought to examine the possible impact of obesity, as assessed by body mass index (BMI), on hospital mortality in septic shock patients.MethodsWe performed a nested cohort study within a retrospective database of patients with septic shock conducted in 28 medical centers in Canada, United States and Saudi Arabia between 1996 and 2008. Patients were classified according to the World Health Organization criteria for BMI. Multivariate logistic regression analysis was performed to evaluate the association between obesity and hospital mortality.ResultsOf the 8,670 patients with septic shock, 2,882 (33.2%) had height and weight data recorded at ICU admission and constituted the study group. Obese patients were more likely to have skin and soft tissue infections and less likely to have pneumonia with predominantly Gram-positive microorganisms. Crystalloid and colloid resuscitation fluids in the first six hours were given at significantly lower volumes per kg in the obese and very obese patients compared to underweight and normal weight patients (for crystalloids: 55.0 ± 40.1 ml/kg for underweight, 43.2 ± 33.4 for normal BMI, 37.1 ± 30.8 for obese and 27.7 ± 22.0 for very obese). Antimicrobial doses per kg were also different among BMI groups. Crude analysis showed that obese and very obese patients had lower hospital mortality compared to normal weight patients (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.66 to 0.97 for obese and OR 0.61, 95% CI 0.44 to 0.85 for very obese patients). After adjusting for baseline characteristics and sepsis interventions, the association became non-significant (OR 0.80, 95% CI 0.62 to 1.02 for obese and OR 0.69, 95% CI 0.45 to 1.04 for very obese).ConclusionsThe obesity paradox (lower mortality in the obese) documented in other populations is also observed in septic shock. This may be related in part to differences in patient characteristics. However, the true paradox may lie in the variations in the sepsis interventions, such as the administration of resuscitation fluids and antimicrobial therapy. Considering the obesity epidemic and its impact on critical care, further studies are warranted to examine whether a weight-based approach to common therapeutic interventions in septic shock influences outcome.

Ventilator-associated pneumonia in adults in developing countries: a systematic review

BACKGROUND Ventilator-associated pneumonia (VAP) is a leading cause of death in hospitalized patients, but there has been no systematic analysis of the incidence, microbiology, and outcome of VAP in developing countries or of the interventions most applicable in that setting. METHODS We reviewed MEDLINE (January 1966-April 2007) and bibliographies of the retrieved articles for all observational or interventional studies that examined the incidence, microbiology, outcome, and prevention of VAP in ventilated adults in developing countries. We evaluated the rates of VAP using the National Healthcare Safety Network (NHSN) definitions and the impact of VAP on the intensive care unit (ICU) length of stay (LOS) and mortality, and the impact of interventions used to reduce VAP rates. RESULTS The rates of VAP varied from 10 to 41.7 per 1000 ventilator-days and were generally higher than NHSN benchmark rates. Gram-negative bacilli were the most common pathogens (41-92%), followed by Gram-positive cocci (6-58%). VAP was associated with a crude mortality that ranged from 16% to 94% and with increased ICU LOS. Only a small number of VAP intervention studies were performed; these found that staff education programs, implementation of hand hygiene, and VAP prevention practice guidelines, and/or implementation of sedation protocol were associated with a significant reduction in VAP rates. Only one interventional study was a randomized controlled trial comparing two technologies, the rest were sequential observational. This study compared a heat and moisture exchanger (HME) to a heated humidifying system (HHS) and found no difference in VAP rates. CONCLUSIONS Based on the existing literature, the rate of VAP in developing countries is higher than NHSN benchmark rates and is associated with a significant impact on patient outcome. Only a few studies reported successful interventions to reduce VAP. There is a clear need for additional epidemiologic studies to better understand the scope of the problem. Additionally, more work needs to be done on strategies to prevent VAP, probably with emphasis on practical, low-cost, low technology, easily implemented measures.

The incidence of venous thromboembolism and practice of deep venous thrombosis prophylaxis in hospitalized cirrhotic patients

BackgroundCirrhotic patients are characterized by a decreased synthesis of coagulation and anticoagulation factors. The coagulopathy of cirrhotic patients is considered to be auto-anticoagulation. Our aim was to determine the incidence and predictors of venous thromboembolism (VTE) and examine the practice of deep venous thrombosis (DVT) prophylaxis among hospitalized cirrhotic patients.MethodsA retrospective cohort study was performed in a tertiary teaching hospital. We included all adult patients admitted to the hospital with a diagnosis of liver cirrhosis from January 1, 2009 to December 31, 2009. We grouped our cohort patients in two groups, cirrhotic patients without VTE and cirrhotic with VTE.ResultsOver one year, we included 226 cirrhotic patients, and the characteristics of both groups were similar regarding their clinical and laboratory parameters and their outcomes. Six patients (2.7%) developed VTE, and all of the VTEs were DVT. Hepatitis C was the most common (51%) underlying cause of liver cirrhosis, followed by hepatitis B (22%); 76% of the cirrhotic patients received neither pharmacological nor mechanical DVT prophylaxis.ConclusionCirrhotic patients are at risk for developing VTE. The utilization of DVT prophylaxis was suboptimal.

Management and outcome of mechanically ventilated neurologic patients.

Objective: To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients. Design: Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation. Setting: Three hundred forty-nine intensive care units from 23 countries. Patients: We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons. Interventions: None. Measurements and Main Results: We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit. Conclusions: In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality rate than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction.

Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis

It is unclear whether practice‐related aspects of antimicrobial therapy contribute to the high mortality from septic shock among patients with cirrhosis. We examined the relationship between aspects of initial empiric antimicrobial therapy and mortality in patients with cirrhosis and septic shock. This was a nested cohort study within a large retrospective database of septic shock from 28 medical centers in Canada, the United States, and Saudi Arabia by the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group between 1996 and 2008. We examined the impact of initial empiric antimicrobial therapeutic variables on the hospital mortality of patients with cirrhosis and septic shock. Among 635 patients with cirrhosis and septic shock, the hospital mortality was 75.6%. Inappropriate initial empiric antimicrobial therapy was administered in 155 (24.4%) patients. The median time to appropriate antimicrobial administration was 7.3 hours (interquartile range, 3.2‐18.3 hours). The use of inappropriate initial antimicrobials was associated with increased mortality (adjusted odds ratio [aOR], 9.5; 95% confidence interval [CI], 4.3‐20.7], as was the delay in appropriate antimicrobials (aOR for each 1 hour increase, 1.1; 95% CI, 1.1‐1.2). Among patients with eligible bacterial septic shock, a single rather than two or more appropriate antimicrobials was used in 226 (72.9%) patients and was also associated with higher mortality (aOR, 1.8; 95% CI, 1.0‐3.3). These findings were consistent across various clinically relevant subgroups. Conclusion: In patients with cirrhosis and septic shock, inappropriate and delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality. Monotherapy of bacterial septic shock is also associated with increased mortality. The process of selection and implementation of empiric antimicrobial therapy in this high‐risk group should be restructured. (HEPATOLOGY 2012;56:2305–2315)

Airway pressure release ventilation versus assist-control ventilation: a comparative propensity score and international cohort study

PurposeTo compare characteristics and clinical outcomes of patients receiving airway pressure release ventilation (APRV) or biphasic positive airway pressure (BIPAP) to assist-control ventilation (A/C) as their primary mode of ventilatory support. The objective was to estimate if patients ventilated with APRV/BIPAP have a lower mortality.MethodsSecondary analysis of an observational study in 349 intensive care units from 23 countries. A total of 234 patients were included who were ventilated only with APRV/BIPAP and 1,228 patients who were ventilated only with A/C. A case-matched analysis according to a propensity score was used to make comparisons between groups.ResultsIn logistic regression analysis, the most important factor associated with the use of APRV/BIPAP was the country (196 of 234 patients were from German units). Patients with coma or congestive heart failure as the reason to start mechanical ventilation, pH <7.15 prior to mechanical ventilation, and patients who developed respiratory failure (SOFA score >2) after intubation with or without criteria of acute respiratory distress syndrome were less likely to be ventilated with APRV/BIPAP. In the case-matched analysis there were no differences in outcomes, including mortality in the intensive care unit, days of mechanical ventilation or weaning, rate of reintubation, length of stay in the intensive care unit or hospital, and mortality in the hospital.ConclusionsIn this study, the APRV/BIPAP ventilation mode is being used widely across many causes of respiratory failure, but only in selected geographic areas. In our patient population we could not demonstrate any improvement in outcomes with APRV/BIPAP compared with assist-control ventilation.

Recombinant Activated Factor VII Treatment of Retroperitoneal Hematoma in a Patient with Renal Failure Receiving Enoxaparin and Clopidogrel

Enoxaparin is a low‐molecular‐weight heparin that has pharmacokinetic and therapeutic advantages over unfractionated heparin in certain clinical conditions. However, its administration is not without risk. We describe the case of a 70‐year‐old woman with numerous medical problems who developed severe retroperitoneal bleeding after receiving several therapeutic doses of subcutaneous enoxaparin that inadvertently were not adjusted for her renal function until day 14 of therapy. She had severe bleeding with hemodynamic instability and required massive transfusions of blood products. Her bleeding could be controlled only by administration of four doses of recombinant activated factor VII (factor VIIa) in addition to embolization of the bleeding sites through angiographic microcoiling. The patients hemodynamic status improved, and her hemoglobin level stabilized. This case report provides evidence of the clinical effectiveness of factor VIIa use as part of the management of refractory enoxaparin‐induced retroperitoneal bleeding. However, further studies are needed to validate the dose‐response relationship and further support the clinical utility of factor VIIa in this life‐threatening situation.

Microbiology of community-acquired pneumonia in the Gulf Corporation Council states.

Summary In spite of advances in microbiological and serological investigations over the last two decades, etiological attribution remains difficult in community-acquired pneumonia (CAP). Even after exhaustive investigation, the etiology of CAP remains unknown in up to 50% of patients. Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. In addition, several investigators document the importance of atypical pathogens including Mycoplasma pneumoniae, Chlamydophila pneumoniae and Legionella pneumophila in the etiology of CAP in the GCC region. Increasingly, other etiologies, particularly influenza viruses, varicella zoster virus and Mycobacterium tuberculosis, have been recognized as causative pathogens of CAP within the region. Rates of antimicrobial resistance of S. pneumoniae and other pathogens are rising in the Gulf Corporation Council (GCC) region and susceptibility profiles of antibiotics against intracellular pathogens such as Chlamydophila pneumoniae and Mycoplasma pneumoniae are not routinely performed. Injudicious prescribing and over-use of antibiotics drive much resistance. The GCC CAPWG calls for urgent governmental regulations to limit and monitor antibiotic prescription in the GCC region.