Yasser Mandourah

Clinical and temporal patterns of severe pneumonia causing critical illness during Hajj

BackgroundPneumonia is a leading cause of hospitalization during Hajj and susceptibility and transmission may be exacerbated by extreme spatial and temporal crowding. We describe the number and temporal onset, co–morbidities, and outcomes of severe pneumonia causing critical illness among pilgrims.MethodA cohort study of all critically ill Hajj patients, of over 40 nationalities, admitted to 15 hospitals in 2 cities in 2009 and 2010. Demographic, clinical, and laboratory data, and variables necessary for calculation of the Acute Physiology and Chronic Health Evaluation IV scores were collected.ResultsThere were 452 patients (64.6% male) who developed critical illness. Pneumonia was the primary cause of critical illness in 123 (27.2%) of all intensive care unit (ICU) admissions during Hajj. Pneumonia was community (Hajj)–acquired in 66.7%, aspiration–related in 25.2%, nosocomial in 3.3%, and tuberculous in 4.9%. Pneumonia occurred most commonly in the second week of Hajj, 95 (77.2%) occurred between days 5–15 of Hajj, corresponding to the period of most extreme pilgrim density. Mechanical ventilation was performed in 69.1%. Median duration of ICU stay was 4 (interquartile range [IQR] 1–8) days and duration of ventilation 4 (IQR 3–6) days. Commonest preexisting co–morbidities included smoking (22.8%), diabetes (32.5%), and COPD (17.1%). Short–term mortality (during the 3–week period of Hajj) was 19.5%.ConclusionPneumonia is a major cause of critical illness during Hajj and occurs amidst substantial crowding and pilgrim density. Increased efforts at prevention for at risk pilgrim prior to Hajj and further attention to spatial and physical crowding during Hajj may attenuate this risk.

Clinical experience with severe 2009 H1N1 influenza in the intensive care unit at King Saud Medical City, Saudi Arabia.

PURPOSE The objective of this study was to describe the epidemiological characteristics, clinical features, treatment, and outcome of 2009 H1N1-infected patients who were admitted to the intensive care unit (ICU) at King Saud Medical City (KSMC) in Riyadh, Kingdom of Saudi Arabia. METHODS Retrospectively, we collected demographic data as well as data on the clinical presentation and risk factors for 86 patients who were admitted to the ICU with H1N1 influenza A. The APACHE IV System was used to assess the severity of the illness. The overall hospital mortality was calculated and correlated with the use of steroids and the time of oseltamivir administration. RESULTS The mean age of the patients was 40.8 years. Mortality increased steadily with increasing APACHE IV score. Patients who received steroids had a mortality rate of 47% compared with 23% for patients who were not treated with steroids; this difference was significant, with a P value of <0.01. The late administration of oseltamivir was associated with a mortality rate of 82% compared with 28% in the context of early oseltamivir administration; this difference was significant, with a P value of <0.01. CONCLUSIONS Patients who were admitted to the ICU with severe 2009 H1N1 infection were young and had a relatively high severity-of-illness score. The late administration of oseltamivir was associated with a 12-fold increase in mortality. Steroid use was associated with a 3-fold increase in mortality.

The epidemiology of Hajj-related critical illness: Lessons for deployment of temporary critical care services*

Rational:The annual Hajj experience has direct relevance for other jurisdictions planning rapid deployment strategies for intensive care for large groups during expected or emergent events. Objective:Approximately 2–3 million Muslims from over 160 countries travel to Saudi Arabia each year for Hajj. These pilgrims are typically older adults with a spectrum of comorbid conditions and of various ethnicities. This, coupled with a 2-wk period of physical migration in close contact with others, can lead to acute and critical illness from a variety of infectious and noninfectious causes and a requirement for full-scale but temporary intensive care to a large population. We describe patient characteristics, patterns of disease, and critical illness, including episodes of Influenza A 2009 (H1N1), therapies delivered, and clinical outcomes. Methods:Prospective cohort study of 110 critically ill patients in four hospitals during the 2009 (“1431”: November 18 to December 4) Hajj in Saudi Arabia. Measurements and Main Results:Median (interquartile range) age was 60.5 (51.3–70) yrs, 69 (62.7%) were male, and Acute Physiology and Chronic Health Evaluation IV score was 60.5 (47–78.3). Forty-one patients (37.3%) were critically ill due to cardiovascular diseases (23.6% with myocardial infarction); 51 (46.4%) had severe infections (21.8% with H1N1); electrolyte disturbance (21.8%); or pulmonary illness (15.5%). Sixty patients (54.6%) required ventilation. Median predicted mortality by Acute Physiology and Chronic Health Evaluation IV was 14% while actual short-term mortality was 6.4% (p = .009). Longer-term mortality may be higher. Conclusion:Both event-specific conditions and patient-specific comorbid conditions are common causes of critical illness during large gatherings. With the ability to provide temporary but full-service intensive care, morbidity and mortality due to critical illness can be low, even among an older patient population and difficult care conditions.

Introducing the Comprehensive Unit-based Safety Program for mechanically ventilated patients in Saudi Arabian Intensive Care Units

Over the past decade, there have been major improvements to the care of mechanically ventilated patients (MVPs). Earlier initiatives used the concept of ventilator care bundles (sets of interventions), with a primary focus on reducing ventilator-associated pneumonia. However, recent evidence has led to a more comprehensive approach: The ABCDE bundle (Awakening and Breathing trial Coordination, Delirium management and Early mobilization). The approach of the Comprehensive Unit-based Safety Program (CUSP) was developed by patient safety researchers at the Johns Hopkins Hospital and is supported by the Agency for Healthcare Research and Quality to improve local safety cultures and to learn from defects by utilizing a validated structured framework. In August 2015, 17 Intensive Care Units (ICUs) (a total of 271 beds) in eight hospitals in the Kingdom of Saudi Arabia joined the CUSP for MVPs (CUSP 4 MVP) that was conducted in 235 ICUs in 169 US hospitals and led by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. The CUSP 4 MVP project will set the stage for cooperation between multiple hospitals and thus strives to create a countrywide plan for the management of all MVPs in Saudi Arabia.

Statistical analysis plan for the Pneumatic CompREssion for PreVENting Venous Thromboembolism (PREVENT) trial: a study protocol for a randomized controlled trial

BackgroundThe Pneumatic CompREssion for Preventing VENous Thromboembolism (PREVENT) trial evaluates the effect of adjunctive intermittent pneumatic compression (IPC) with pharmacologic thromboprophylaxis compared to pharmacologic thromboprophylaxis alone on venous thromboembolism (VTE) in critically ill adults.Methods/designIn this multicenter randomized trial, critically ill patients receiving pharmacologic thromboprophylaxis will be randomized to an IPC or a no IPC (control) group. The primary outcome is “incident” proximal lower-extremity deep vein thrombosis (DVT) within 28 days after randomization. Radiologists interpreting the lower-extremity ultrasonography will be blinded to intervention allocation, whereas the patients and treating team will be unblinded. The trial has 80% power to detect a 3% absolute risk reduction in the rate of proximal DVT from 7% to 4%.DiscussionConsistent with international guidelines, we have developed a detailed plan to guide the analysis of the PREVENT trial. This plan specifies the statistical methods for the evaluation of primary and secondary outcomes, and defines covariates for adjusted analyses a priori. Application of this statistical analysis plan to the PREVENT trial will facilitate unbiased analyses of clinical data.Trial registrationClinicalTrials.gov, ID: NCT02040103. Registered on 3 November 2013;Current controlled trials, ID: ISRCTN44653506. Registered on 30 October 2013.