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2022| April-June | Volume 6 | Issue 2
September 30, 2022
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Modafinil for wakefulness and disorders of consciousness in the critical care units: An updated narrative review and case series
Marwa Amer, Mouhamad Ghyath Jamil, Eiad Kseibi
April-June 2022, 6(2):23-35
Cognitive improvement after critical illness is complex. Neurostimulants are used to speed up physical and mental processes. Modafinil for wakefulness in the intensive care unit (ICU) holds the potential to facilitate recovery from cognitive impairment. We aim to provide an updated narrative review of the current evidence on modafinil use for wakefulness and disorders of consciousness (DoC) and describe modafinil effect for wakefulness in eight adults admitted to our ICUs at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
For the narrative review, we searched MEDLINE for modafinil studies as neurostimulant for wakefulness and DoC published from inception through May 30, 2022, with no language or study design restriction, focused on adults, and neurocritical care population (traumatic brain injury [TBI], poststroke). The case series included adult patients (age ≥18 years), admitted between January 2017 and June 2020 to coronavirus disease 2019 (COVID-19) and non-COVID ICUs with an ICU stay of at least 48 h, started on modafinil during ICU stay for at least 48 h and required ventilatory support.
For the narrative review, we identified five studies in TBI (
= 285; two RCTs and three retrospective cohort studies), one systematic review poststroke (
= 120), two studies on ICU population, and one case report describing modafinil use in post-COVID encephalopathy. We also identified additional three recent studies that were published after systematic review for modafinil use poststroke. A total of eight patients out of approximately 10,000–13,000 ICU admissions used modafinil over the 4 years' period and described in our case series; 3 admitted to COVID-19 ICU, 4 surgical ICU, and 1 transplant ICU. Modafinil 100–200 mg daily was started for median duration of 4 days and median initiation time in relation to ICU admission was 11 (IQR 9–17) days. Glasgow Coma Score improvement was noted in 5 (62.5%) patients. No significant adverse effects were documented.
In this case series, modafinil as neurostimulant was infrequently prescribed in ICU over the 4 years and was associated with a low incidence of adverse effects. Based on our observations, modafinil might have a potential role when administered to certain patients. Our findings can be biased by confounders that influence cognitive function and recovery. Larger studies are warranted to evaluate its role in this indication fully.
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Evaluation of standard dosing for selected broad-spectrum Hydrophilic antibiotics in critically ill patients with Augmented renal clearance: An Observational Study
Majed Almutairi, Khalid Al Sulaiman, Sultan Al Enazi, Ramesh Vishwakarma, Ohoud Aljuhani
April-June 2022, 6(2):43-49
Inappropriate antibiotic dosing in critically ill patients with augmented renal clearance (ARC) may be associated with pathogens' resistance and worse outcomes. Unfortunately, studies regarding the relationship between ARC and clinical outcomes in patients treated with antibiotics are scarce. This study aims to evaluate selected broad-spectrum hydrophilic antibiotics' effectiveness and clinical outcomes in ARC critically ill patients with confirmed infections.
A retrospective a retrospective cohort study in adult critically ill patients who were admitted to intensive care units at King Abdulaziz Medical City, Riyadh, and received standard dosing of selected broad-spectrum hydrophilic antibiotics (meropenem, imipenem, or piperacillin/tazobactam) with confirmed infection. All the patients who met our eligibility criteria during the study period (January 1, 2018, to December 31, 2019) were included. According to the calculated creatinine clearance using the Cockcroft-Gault equation, eligible patients had been classified into two groups: ARC versus non-ARC. The primary outcome was to assess pathogen eradication at 10–14 days; other outcomes were considered secondary. Multivariate logistic and generalized linear regression analyses were used. We considered
< 0.05 statistically significant.
A total of 133 patients were included in the study; 66 patients had ARC. The distribution of infections and types of pathogens between the groups were similar. The pathogen eradication at 10–14 days was similar between the two groups (odds ratio [OR] 1.08; 95% confidence interval [CI], 0.41–2.78;
= 0.88). Moreover, the odds of resistance development and persistence after three days were not significantly different between the two groups ([OR 0.78; 95% CI, 0.25–2.40;
= 0.66] and [OR 0.88; 95% CI, 0.35–2.18;
= 0.78], respectively).
In terms of pathogen eradication, resistance, and persistence, ARC patients and non-ARC patients responded similarly to conventional doses of hydrophilic broad-spectrum antibiotics. To confirm our findings, further randomized controlled clinical trials are needed.
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0.9% sodium chloride versus dextrose 5% in water safety as medication's diluents in critically ill patients: Meta-analysis of observational studies
Samiah Alsohimi, Alaa Ghazi Almagthali, Khalid Eljaaly, Ghazwa B Korayem, Khalid Al Sulaiman, Ohoud Aljuhani
April-June 2022, 6(2):36-42
Adverse drug effects such as electrolyte abnormalities and acid-base disturbances are commonly associated with intravenous (IV) fluids administered in the intensive care units (ICUs). Although several studies have addressed the risk associated with resuscitative fluids in ICU patients, limited data evaluating the safety of IV medications diluents and their association with clinical outcomes in critical care settings. We conducted a systematic review and meta-analysis to compare the safety of 0.9% sodium chloride (0.9% NaCl) and dextrose 5% in water (D5W) as drug diluents in ICU settings. We searched PubMed, MEDLINE, Cochrane Library bibliographic databases, and conference abstracts for studies comparing medication diluents in adult critically ill patients. Our primary outcome was the risk of hypernatremia. The secondary outcomes included hyperchloremia, acute kidney injury (AKI) rate, ICU length of stay (LOS), ICU mortality, and hospital mortality. Three observational studies were included (1549 patients), all received 0.9% NaCl as standard diluents and D5W was the comparison. Our results shows that hypernatremia and hyperchloremia were significantly higher in 0.9% NaCl group (risk ratio [RR], 1.84; 95% confidence interval [CI], 1.38–2.47;
= 0%), (RR, 1.78; 95% CI, 1.38–2.31;
= 0%), respectively. There was no significant difference in AKI risk, hyperglycemia, and hospital mortality between the groups. However, the 0.9% NaCl group has a longer ICU LOS (mean difference 0·407, 0·062–0·752;
= 0.021). The utilization of D5W as medication diluent in critical care settings was associated with a lower incidence of hypernatremia and hyperchloremia, In addition, may be associated with shorter ICU LOS.
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Advanced medical directives or written living wills among saudi intensive care units, current practice and need to optimization: Opinion of trainees
Eyad Fareed Alsayed, Baraa O Tayeb, Abdulaziz Boker
April-June 2022, 6(2):50-57
Ethical dilemmas are mostly developed in critically ill patients near the end of life. The point where the treating physician decides to withhold the intensive medical support represents a daily challenge on the current intensive care medicine. Considering patients' wishes in near-death events and their vision, through writing an advance medical directive (also known as Living Will), was introduced early in the developed western countries. On the other hand, it is not easy to talk about near-death events in many other regions of the world, mainly because of cultural and religious differences.
The study aimed to explore the current practice regarding near-death events in one of the Middle Eastern countries, particularly in Saudi Arabia. The main objectives of this study were measuring the involvement of patient's wishes in near-death medical decisions and analyzing the need and usefulness of encouraging the practice of writing advance medical directives in this demographic area.
The data were obtained from a group of Saudi intensivists, who are dealing the most among other groups of physicians with near-death events, almost daily. They were affiliated with ten hospitals or intensive care units in Saudi Arabia. Data were collected during the period from March 2018 to July 2018. It was done based on participants' knowledge. Due to the low response rate, data were analyzed using descriptive statistics only.
A total of 51 physicians working in different intensive medical care units had responded to our survey. About 88% of them were male, 47% aged between 31 and 40 years of age; with different levels of experience (45% were residents, 35% worked as a senior registrars and 20% were consultants' intensivists). Although in Saudi Arabia, a (living will) be not considered legal writing, 31.35% of the respondents had seen many cases where patients openly discussed their near-death wishes with the family members. From the respondents, 84.31% believed that a living will tend to help in their decision-making, and 92.16% considered living wills helpful in making the final call regarding withholding/withdrawing the treatment. According to 72.55% of them, the presence of living wills would help in decreasing the near-death anxiety and depression among family members of a deceased patient and tend to help ease out the situation as they consider it as a final wish of the patient.
It is concluded that the patient's wishes are essential in making an end-of-life decision; they should be represented by the patient and should also be respected by the clinical staff. However, more studies needed to explore the willingness of the general population in this culture to express their wishes and the best method to elicit these wishes should be sought, with respect to the cultural and religious beliefs and differences.
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Thoracoscopy and fluoroscopy assisted broviac central line insertion utilizing bedside echocardiogram to prevent cardiac tamponade
Muhammed Nishil Aboo, Mohammed Al-Hasani, Jihad Zahraa, Abdulwahab Al-Jubab
April-June 2022, 6(2):58-60
Prolonged and multiple requirements of central venous catheters in some patients gradually make access to the central vein problematic due to possible formation of obstructive thrombi. Here, we describe a case of chronic intestinal failure and difficult access of central vein, where cardiac tamponade (CT) developed even after thoracoscopy and fluoroscopy-guided insertion of a Broviac catheter. This report points out the importance of a postprocedural echocardiogram after central venous line placement in difficult cases to detect fatal complications such as CT.
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