Papers by Waleed Aletreby
Early versus late DNR orders and its predictors in a Saudi Arabian ICU: A descriptive study
Saudi journal of medicine & medical sciences, 2022
Independent Risk Factors of Failed Extubation among Adult Critically Ill Patients: A Prospective Observational Study from Saudi Arabia
Saudi journal of medicine & medical sciences, Jun 20, 2024
Diagnostic accuracy of ePOS score in predicting DNR labeling after ICU admission: A prospective observational study (ePOS-DNR)
Journal of Intensive Medicine
Pakistan Journal of Medical and Health Sciences, Oct 30, 2021
Background: Over the past decade, excessive use of Colistin against multidrug-resistant, Gram-neg... more Background: Over the past decade, excessive use of Colistin against multidrug-resistant, Gram-negative bacteria have resulted in the evolution of resistance to Colistin. Objective: To evaluate efficacy of Colistin against multidrug-resistant organisms (MDRO), the emergence of Colistin resistance and its effects on clinical outcomes. Study Design: Retrospective study Place and Duration of Study: King Saud Medical City (KSMC) from 1 st October 2015 till 31 st January 2016. Methodology: Forty-three patients, resistant to Colistin on blood culture and sensitivity were enrolled. Results: Colistin was not effective at breaking the MDRO. The results revealed no significant impact of Colistin on site of infection such as chest, urinary tract or skin (p=0.612), types of organisms (p=0.629), length of hospital stay and the IV Colistin days (p=0.097 and p=0.166 respectively) in the past 12 months. The positive finding was that more than two third (76.7%) of the ICU patients were alive. Conclusion: Emergence of Multi drug resistance organism is matter of global concern that caused the ineffectiveness of many potent antibiotics and led to the drastic clinical outcomes. Collaboration between medical, paramedical, and administrative staff, with strict implementation of preventive protocol can slow down the velocity of microbial multidrug resistance.
Journal of Anesthesia & Critical Care: Open Access, Dec 30, 2020
Liver transplantation has gone through significant improvement since its start early last century... more Liver transplantation has gone through significant improvement since its start early last century. Which resulted in an increased demand unmatched by availability of donors, hence, several new approaches were devised to maintain an adequate supply of grafts, paralleled with tremendous efforts to minimize graft rejection in many aspects of the procedure, particularly, choice of patients to be transplanted, pre-operative preparation, intra-operative anesthetic as well as surgical management, the care of the transplanted patient in the intensive care unit, and finally long term follow up.The aim of this review was to update on the most recent approaches involves in different steps of the procedure. Several new modalities of management and interventions were recognized, pertaining to patient allocation, perioperative period, critical care management, and follow up.
Deferoxamine in the management of COVID-19 adult patients admitted to ICU: a prospective observational cohort study
PubMed, May 1, 2023
COVID-19 infection is associated with high mortality, and despite extensive studying the scientif... more COVID-19 infection is associated with high mortality, and despite extensive studying the scientific society is still working to find a definitive treatment. Some experts postulated a beneficial role of Deferoxamine. Aim: The aim of this study was to compare the outcomes of COVID-19 adult patients admitted to the ICU who received deferoxamine to those who received standard of care. Methods: Prospective observational cohort study, in the ICU of a tertiary referral hospital in Saudi Arabia to compare all-cause hospital mortality between COVID-19 patients who received deferoxamine and standard of care. Results: A total of 205 patients were enrolled, with an average age of 50.1±14.3, 150 patients received standard of care only, and 55 patients received deferoxamine additionally. Hospital mortality was lower in deferoxamine group (25.5 vs. 40.7%, 95% CI=1.3-29.2%; P=0.045). Clinical status score upon discharge was lower in deferoxamine group (3.6±4.3 vs. 6.2±4, 95% CI: 1.4-3.9; P<0.001), as was the difference between discharge score and admission score (indicating clinical improvement). More patients admitted with mechanical ventilation were successfully extubated in the deferoxamine group (61.5 vs. 14.3%, 95% CI: 15-73%; P=0.001), with a higher median ventilator-free days. There were no differences between groups in adverse events. Deferoxamine group was associated with hospital mortality [odds ratio=0.46 (95% CI: 0.22-0.95); P=0.04]. Conclusions: Deferoxamine may have mortality and clinical improvement benefits in COVID-19 adults admitted to ICU. Further powered and controlled studies are required.
Pakistan Journal of Medical and Health Sciences
Background: Colistin is an effective treatment option, recommended for carbapenem resistant gram-... more Background: Colistin is an effective treatment option, recommended for carbapenem resistant gram-negative bacilli (CR-GNB) in critically ill patients. Due to high nephrotoxicity, dose management of Colistin is a tough decision to make. At standard dosage the efficacy of Colistin is not well defined. Consequently, strategies involving higher dosages were suggested. Objective: To evaluate the high dose of Colistin as non-inferior to standard dose in the treatment of CR-GNB in critically ill patients. Study Design: Retrospective comparative study Place and Duration of Study: Intensive Care Unit, King Saud Medical City Riyadh, Saudi Arabia from 1st January 2015 to 31st December 2017. Methodology: One hundred and ninety two patients that met the inclusion criteria from all participants were further divided into two groups. Group H (High dose) given the high dose of Colistin (9 million units intravenously (IV) loading dose, and then 9 million units/day in 2 or three divided doses) whereas...
One of the most important quality measures is process, which includes access to care and timeline... more One of the most important quality measures is process, which includes access to care and timeliness as key dimensions. Reduction of the time taken to transfer admitted patients to ICU from ED helps enhance process greatly. In addition, early admission to ICU of critical patients, not only helps to solve the problem of ED overcrowding, it was also shown by studies to improve patients' outcome. Aims To measure the median time between the decision to admit a patient from ED, and actual arrival to ICU, at King Saud Medical City, Riyadh, KSA. Methods Median time (in minutes) between decision to admit a patient from ED and arrival to ICU, during April 2014 Results The median time between decision to admit and ICU arrival during April 2014 was 100 minutes, which is below our delay deadline of 240 minutes, however, 13 patients were delayed, out of which 7 delays were justified medically, but 6 cases were delayed due to non-medical reasons. Conclusions Despite having a median time betwee...
International Journal of Health Sciences and Research, 2020
COVID-19 outbreak is highly contagious, and healthcare workers are at higher risk of infection pa... more COVID-19 outbreak is highly contagious, and healthcare workers are at higher risk of infection particularly with aerosol generating procedures like intubation. Airway management guidelines of COVID-19 patients recommend swift and familiar procedures, while recent reports indicate a safety benefit of using Aerosol Box (AB) during intubation. Aim: Explore the impact of using AB on duration of intubation, and satisfaction of physicians using AB. Design: Crossover simulation study of intubation on a manikin with and without AB. Results: Duration of intubation without AB and with AB was 11.2±3.6 and 18±2.7 seconds respectively (p < 0.001). Most physicians were unsatisfied with using AB in intubation. Conclusion: The protective benefits of AB are not established and validated, while it prolongs time of intubation, and exposes the airway manager to unduly difficulties, which may negatively impact safety.
PLOS ONE
Background Rapid Response Teams were developed to provide interventions for deteriorating patient... more Background Rapid Response Teams were developed to provide interventions for deteriorating patients. Their activation depends on timely detection of deterioration. Automated calculation of warning scores may lead to early recognition, and improvement of RRT effectiveness. Method This was a “Before” and “After” study, in the “Before” period ward nurses activated RRT after manually recording vital signs and calculating warning scores. In the “After” period, vital signs and warning calculations were automatically relayed to RRT through a wireless monitoring network. Results When compared to the before group, the after group had significantly lower incidence and rate of cardiopulmonary resuscitation (CPR) (2.3 / 1000 inpatient days versus 3.8 / 1000 inpatient days respectively, p = 0.01), significantly shorter length of hospital stay and lower hospital mortality, but significantly higher number of RRT activations. In multivariable logistic regression model, being in the “After” group dec...
Heart & Lung
Background: SARS-CoV-2 infection demonstrates a wide range of severity, with more severe cases pr... more Background: SARS-CoV-2 infection demonstrates a wide range of severity, with more severe cases presenting with a cytokine storm with elevated serum interleukin-6; hence, the interleukin-6 receptor antibody tocilizumab was used for the management of severe cases. Objective: To explore the effect of tocilizumab on ventilator-free day composite outcomes among critically ill patients with SARS-CoV-2 infection. Methods: This retrospective propensity score-matching study compared mechanically ventilated patients who received tocilizumab to a control group. Results: Twenty-nine patients in the intervention group were compared to 29 controls. The matched groups were similar. The ventilator-free days composite outcome was higher in the intervention group (sub-distribution hazard ratio 2.7, 95% confidence interval [CI]: 1.2À6.3; p = 0.02), the mortality rate in the intensive care unit was not different (37.9% vs 62%, p = 0.1), and actual ventilator-free days were significantly longer in the tocilizumab group (mean difference 4.7 days; p = 0.02). Sensitivity analysis showed a significantly lower hazard ratio for death in the tocilizumab group (HR 0.49, 95% CI: 0.25À0.97; p = 0.04). Positive cultures were not significantly different among the groups (55.2% vs 34.5% in the tocilizumab and control groups, respectively; p = 0.1). Conclusions: Tocilizumab may improve the composite outcome of ventilator-free days at day 28 among mechanically ventilated patients with SARS-CoV-2 infection. It is associated with significantly longer actual ventilator-free days, insignificantly lower mortality, and higher superinfection.
Journal of Ayub Medical College Abbottabad
Background: Corona virus disease is caused by the enveloped, single stranded RNA virus known as s... more Background: Corona virus disease is caused by the enveloped, single stranded RNA virus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) becoming the deadliest disease of the century. Its global outbreak has led researchers to develop drugs or vaccines to prevent the spread of the disease. Favipiravir is an approved orally administered antiviral drug that selectively inhibits RNA-dependent RNA polymerase, used off-label to treat COVID-19. Objectives: The purpose of this study was to assess the efficacy and safety of this drug for severe COVID-19 infection. Methods: This was an observational retrospective study, carried out at the ICU of King Saud Medical City (KSMC) from June 2020 to August 2020. Including a total of one thousand six hundred and ninety-nine patients (n=1699). Categorized into a treatment group (193 patients) who received Favipiravir along with standard care, and non-treatment group (1506 patients) who received standard care only. Results: ICU all...
Retardo na transferência do pronto-socorro para a unidade de terapia intensiva: impacto nos desfechos do paciente. Um estudo retrospectivo
Revista Brasileira De Terapia Intensiva, 2021
Estudar o impacto do retardo na admissão à unidade de terapia intensiva em mais do que 4 horas no... more Estudar o impacto do retardo na admissão à unidade de terapia intensiva em mais do que 4 horas nos desfechos de pacientes críticos.
Dynamics of SARS-CoV-2 outbreak in the Kingdom of Saudi Arabia: A predictive model
Saudi Critical Care Journal, 2020
Background: COVID-19 is a worldwide pandemic that was first reported in China, and has spread to ... more Background: COVID-19 is a worldwide pandemic that was first reported in China, and has spread to almost all nations. Measures of containment and control practiced by governments and authorities may benefit from prediction of the extent and peaks of spread to properly prepare to face the pandemic. Aim: The aim of the study was to predict the peak numbers of mortality, intensive care unit (ICU) admission, hospitalization, and positive cases and the time of their occurrence. Settings and Design: The study design is of a mathematical prediction model of prediction of spread of infectious disease, based on data from Saudi Arabia. Materials and Methods: We utilized a SEIR predictive model that divides the population into compartments and utilizes mathematical equations to predict the dynamics of the infection and its peak. The model exploited data from reliable sources on the Internet, and is – by design – based on certain assumptions. Statistical Analysis: Predefined mathematical equations that incorporate different parameters and assumptions were used for statistical analysis. Results: We estimated an R 0 value for our model of 2.2, and the model predicted a peak incidence of the pandemic around July 26, 2020. The peak mortality was predicted at 99,749 persons, predicted peak ICU admission of 70,246 patients, and peak hospitalization of 11,997,936 patients; all these predicted values were out of a total of predicted 14,049,104.83 COVID-19-positive cases. Conclusion: The COVID-19 pandemic in Saudi Arabia is predicted to peak by the end of July 2020, and may pose a serious burden on health-care systems already in shortage. Proper crisis management and effective resource utilization is crucial to safely overcome the pandemic, in addition to continuing control measures at least till the predicted peak time is over.
General Medicine: Open Access, 2019
Background: Antibiotics are commonly administered therapies in ICU. There has been a concern over... more Background: Antibiotics are commonly administered therapies in ICU. There has been a concern over antibiotic misuse recently. ICU is both a victim and a contributor to the ongoing antibiotic misuse problem and a cause of emerging resistance among the pathogens commonly acquired in intensive care units. Because of high mortality associated with sepsis, it is a great challenge for intensive care physicians to select appropriate antibiotic sometimes without any culture and sensitivity. Similarly the time to deescalate also remains a tough call. Selection of appropriate antibiotics empirically has always been a topic of debate among Intensive Care and Infectious Disease practitioners. Objective: The aim of our pilot study was not only to assess the appropriateness of use of antibiotics in our ICU but to help us guide to design a bigger study and structure a stewardship program for ICU. Also to assess the differences among prescription of ICU and Infectious Disease Consultants. Methods: A prospective observational study in King Saud Medical City ICU following antibiotics started and stopped from 6th November 2014 to 23 rd November 2014. Study included 23 adult patients admitted with different etiologies. All 23 patients' records were shared with two alien referees (one was infectious diseases and other was ICU consultant) from other hospital. Prescribers were blinded to the fact that data was being collected for auditing and the referees were blinded to prescribers and to each other's. Results: Total 46 antibiotics were used. 40 among them were started on empirically, 6 were culture based. 31 antibiotics were stopped by ICU. 28 among these 31 antibiotics were empirical. Most of included patients responded to combination or monotherapy. Piperacillin-Tazobactam was the most commonly prescribed antibiotic. No major difference was noted among the choice of intensive care or infectious disease consultant. Conclusion: Empirical antibiotics are vital for patients admitted in ICU. We need to follow hospital's anti-biogram and stewardship programs with prompt de-escalation wherever appropriate.
The intensive care unit (ICU) of any hospital consumes a large portion of the hospital’s budget, ... more The intensive care unit (ICU) of any hospital consumes a large portion of the hospital’s budget, which mandates continuous evaluation of the performance of the unit to substantiate its expenditure. Measuring the quality of the performance in the ICU is difficult and complex, however, two identified performance indicators of ICU in terms of effectiveness are length of stay (LOS) of patients, and severity adjusted standardized mortality ratio utilizing a severity related prediction model. Aims: To evaluate the performance in an adult ICU in terms of effectiveness, using predefined targets for the length of stay and standardized mortality ratio, as well as comparison to predicted values. Methods: All discharged patients from our ICU during 2018 were included, the average LOS for all and acute patients, and the mortality rate were calculated, and compared to values predicted by APACHE 4 scoring system. Results: During 2018 we discharged 2769 patients, and 2484 patients met the inclusion...
Background Rapid Response Teams were developed to provide interventions for deteriorating patient... more Background Rapid Response Teams were developed to provide interventions for deteriorating patients. Their activation depends on timely detection of deterioration. Automated calculation of warning signs may lead to early recognition, and improvement of RRT effectiveness. Method This was a Before and After study, in the Before period ward nurses activated RRT after manually recording vital signs and calculating warning scores. In the After period, vital signs and warning calculations were automatically relayed to RRT through a wireless monitoring network. Results The After group had significantly lower incidence and rates of cardiopulmonary resuscitation compared to the Before group (2.3 / 1000 inpatient days versus 3.8 / 1000 inpatient days respectively, p = 0.01), the Before group had a significantly higher hospital length of stay, and significantly fewer visits by the RRT. In multivariable logistic regression model, being in the After group decreases odds of CPR by 30% (OR = 0.7 [9...
Optic Nerve Sheath Diameter Ultrasound for Raised Intracranial Pressure
Journal of Ultrasound in Medicine, 2021
Optic nerve sheath diameter (ONSD) ultrasound is becoming increasingly more popular for estimatin... more Optic nerve sheath diameter (ONSD) ultrasound is becoming increasingly more popular for estimating raised intracranial pressure (ICP). We performed a systematic review and analysis of the diagnostic accuracy of ONSD when compared to the standard invasive ICP measurement. METHOD We performed a systematic search of PUBMED and EMBASE for studies including adult patients with suspected elevated ICP and comparing sonographic ONSD measurement to a standard invasive method. Quality of studies was assessed using the QUADAS-2 tool by two independent authors. We used a bivariate model of random effects to summarize pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Heterogeneity was investigated by meta-regression and sub-group analyses. RESULTS We included 18 prospective studies (16 studies including 619 patients for primary outcome). Only one study was of low quality, and there was no apparent publication bias. Pooled sensitivity was 0.9 [95% confidence intervals (CI): 0.85-0.94], specificity was 0.85 (95% CI: 0.8-0.89), and DOR was 46.7 (95% CI: 26.2-83.2) with partial evidence of heterogeneity. The Area-Under-the-Curve of the summary Receiver-Operator-Curve was 0.93 (95% CI: 0.91-0.95, P < .05). No covariates were significant in the meta-regression. Subgroup analysis of severe traumatic brain injury and parenchymal ICP found no heterogeneity. ICP and ONSD had a correlation coefficient of 0.7 (95% CI: 0.63-0.76, P < .05). CONCLUSION ONSD is a useful adjunct in ICP evaluation but is currently not a replacement for invasive methods where they are feasible.
Supplementary File 1 Content
Renal Tubular Acidosis in Critically Ill Patients with Coronavirus Disease 2019 Acute Respiratory Distress Syndrome
Saudi Journal of Kidney Diseases and Transplantation, 2021
The coronavirus disease 2019 (COVID-19) infection associated with multisystemic involvement inclu... more The coronavirus disease 2019 (COVID-19) infection associated with multisystemic involvement including renal manifestations has been described in the literature. The recent data show a high mortality rate of 60%–90% once renal function begins to deteriorate. We report on three patients who were admitted to intensive care unit due to severe COVID-19 acute respiratory distress syndrome and developed distal renal tubular acidosis. The three COVID-19 patients had hyperchloremic acidosis which was investigated thoroughly through a biochemical analysis of arterial blood gases and urine test as well as serological tests for autoimmune diseases and chronic infections, in addition to renal ultrasound. Metabolic acidosis was managed through repeated doses of intravenous sodium bicarbonate therapy; however, continuous renal replacement therapy was initiated for two refractory cases. We found that severe COVID-19 infection may be accompanied by hyperchloremic acidosis due to the cytopathic damage of the distal renal tubules, making the buffering system nonefficient and if not managed adequately, it may lead to poor prognosis.
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Papers by Waleed Aletreby