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Pro/Con debate: Should 24/7 in-house intensivist coverage be implemented?
Yaseen Arabi
Critical Care , 2008, DOI: 10.1186/cc6905
Abstract: Intensivist coverage traditionally has followed the 'business hours' model used in other professions, with reduced availability during weekends, weeknights, and holidays. This type of staffing would be appropriate if the need for the service were limited to business hours or if delaying the service (for example, from the night to the next morning) did not have any negative consequences. Clearly, this is not the case in critical care. First, critical illness does not recognize the boundaries of business hours, and therefore qualified intensivists need to be available around the clock. Studies have demonstrated that 66% to 69% of intensive care unit (ICU) admissions are admitted during off-hours [1,2]. Second, in no area more than in the ICU is the outcome of patients affected by providing the right treatment at the right time; delays in such treatment have been demonstrated to have negative consequences [3-5].Several studies have demonstrated increased mortality of acutely ill patients admitted during weekends, weeknights, and holidays, a phenomenon that has been attributed, at least in part, to lower staffing levels. A large Canadian study showed a significantly increased risk of death for patients admitted during weekends with several acute diagnoses, including ruptured abdominal aortic aneurysm, acute epi-glotitis, and pulmonary embolism [6]. A study from California showed higher adjusted mortality for patients admitted from the emergency department on weekends compared with those admitted on weekdays [7]. Of note, a larger 'weekend effect' was observed in major teaching hospitals [7]. Similarly, a Finnish study showed that weekend and weeknight ICU admissions were associated with increased mortality even after adjustment for severity of illness [8]. In a multi-center pediatric ICU study, emergency admissions during evening hours had a higher mortality, especially for patients admitted with shock, congenital heart disease, or after cardiac arrest [9]. Investigator
Scientific misconduct and medical publishing
Arabi Yaseen
Annals of Thoracic Medicine , 2007,
Bench-to-bedside review: Early tracheostomy in critically ill trauma patients
Nehad Shirawi, Yaseen Arabi
Critical Care , 2005, DOI: 10.1186/cc3828
Abstract: Trauma is currently one of the most important causes of morbidity and mortality in the age group between 15 to 35 years [1]. About 500,000 people are hospitalized yearly in the United States as a result of motor vehicular accident-related injuries [1]. In addition, motor vehicle-related deaths and injuries cost the United States more than $150 billion each year [1]. According to World Health Organization statistics for the year 2000, over 50% of global mortality due to road traffic accidents occurs among young adults and the mortality rates per 100,000 is in the range of 18.7 to 34.1 in the Eastern Mediterranean region and between 11.2 and 16.1 in Europe [2]. Many trauma patients require intubation and mechanical ventilation for several reasons, including relief of upper airway obstruction secondary to severe facial or laryngeal trauma, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation [3]. The percentage of trauma patients who require tracheostomy varies considerably and ranges from 14% to 48% [4-6].Traditionally, tracheostomy has been provided for trauma patients who required endotracheal intubation for a prolonged period of time. In 1989, the American College of Chest Physicians' Consensus Conference on Artificial Airways in Patients Receiving Mechanical Ventilation recommended that tracheostomy should be considered in patients anticipated to require endotracheal intubation for more than 21 days [7]. It also recommended, however, that if tracheostomy is indicated, it should be done early to minimize the duration of translaryngeal intubation and lower the incidence of associated complications. Recently, there has been an increasing trend towards converting endotracheal intubation to tracheostomy at an earlier stage as more evidence supports the benefits of early tracheostomy [5,8-10]. Whited [11] conducted a prospective study involving
A review of large animal vehicle accidents with special focus on Arabian camels
Abdullah Al Shimemeri,Yaseen Arabi
Journal of Emergency Medicine, Trauma and Acute Care , 2012, DOI: 10.5339/jemtac.2012.21
Abstract: Traffic accidents resulting from the collision of motor vehicles with wildlife occur worldwide. In the United States, Canada, Europe, the Middle East and Australia these collisions usually involve deer, moose, camels and kangaroos. Because these are large animals, the collisions are frequently associated with high morbidity and mortality rates. Camel-vehicle collisions in the Middle East—especially Saudi Arabia—have risen to such disturbing proportions that definitive action is necessary for mitigating the trend. Arabian camels, weighing up to 726 kg, form a crucial part of the socio-cultural experience in Saudi Arabia, where about half a million of them are found. Saudi Arabia presents a case of habitat fragmentation, especially in rural communities, where good road systems coexist with domesticated camels. This environment has made camel-vehicle collisions inevitable, and in 2004 alone two hundred such cases were reported. Injuries are directly related to the size of the camel, the speed of the vehicle, passengers' use or avoidance of seat belts, and the protective reflex movements taken to avoid collision. Cervical and dorsal spinal injuries, especially fractured discs, head and chest injuries, are the most commonly reported injuries, and the fatality rate is four times higher than for other causes of traffic accidents. Various mitigation measures are considered in the present work, including measures to improve driver's visibility; the construction of highway fencing; under- and over-passes allowing free movement of camels; the use of reflective warning signs, and awareness programs.
Critical care management of severe traumatic brain injury in adults
Samir H Haddad, Yaseen M Arabi
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2012, DOI: 10.1186/1757-7241-20-12
Abstract: Severe traumatic brain injury (TBI), defined as head trauma associated with a Glasgow Coma Scale (GCS) score of 3 to 8 [1], is a major and challenging problem in critical care medicine. Over the past twenty years, much has been learned with a remarkable progress in the critical care management of severe TBI. In 1996, the Brain Trauma Foundation (BTF) published the first guidelines on the management of severe TBI [2] that was accepted by the American Association of Neurological Surgeons and endorsed by the World Health Organization Committee in Neurotraumatology. The second revised edition was published in 2000 [3] with an update in 2003, and the 3rd edition was published in 2007 [4]. Several studies have reported the impact of implementation of guidelines-based management protocols for severe TBI on patient's treatment and outcome [5,6]. These studies have clearly demonstrated that the implementation of protocols for the management of severe TBI, incorporating recommendations from the guidelines, is associated with substantially better outcomes such as mortality rate, functional outcome scores, length of hospital stay, and costs [7,8]. However, there is still considerable and wide institutional variation in the care of patients with severe TBI.In general, TBI is divided into two discrete periods: primary and secondary brain injury. The primary brain injury is the physical damage to parenchyma (tissue, vessels) that occurs during traumatic event, resulting in shearing and compression of the surrounding brain tissue. The secondary brain injury is the result of a complex process, following and complicating the primary brain injury in the ensuing hours and days. Numerous secondary brain insults, both intracranial and extracranial or systemic, may complicate the primarily injured brain and result in secondary brain injury. Secondary, intracranial brain insults include cerebral edema, hematomas, hydrocephalus, intracranial hypertension, vasospasm, metabolic derangement, e
Top ten articles in venous thromboembolism
Arabi Yaseen,Dawood Abdulaziz,Dabbagh Ousama
Annals of Thoracic Medicine , 2006,
Abstract: Emerging literature about venous thromboembolism (VTE) increased our understanding of the risk factors, diagnosis, therapy and prophylaxis of this serious medical condition. In this review, we examine new studies on the incidence and the risk factors for VTE in the critically ill patients, diagnostic approaches to VTE, the relation between VTE and cardiovascular risk and duration of therapy. Also, we will review the new evidence on the use of electronic reminders to improve the adherence to VTE prophylaxis and the risk of heparin-induced thrombocytopenia in patients receiving pharmacologic prophylaxis for VTE.
Association between statin therapy and outcomes in critically ill patients: a nested cohort study
Shmeylan A Al Harbi, Hani M Tamim, Yaseen M Arabi
BMC Pharmacology and Toxicology , 2011, DOI: 10.1186/1472-6904-11-12
Abstract: This was a nested cohort study within two randomised controlled trials conducted in a tertiary care ICU. All 763 patients who participated in the two trials were included in this study. Of these, 107 patients (14%) received statins during their ICU stay. The primary endpoint was all-cause ICU and hospital mortality. Secondary endpoints included the development of sepsis and severe sepsis during the ICU stay, the ICU length of stay, the hospital length of stay, and the duration of mechanical ventilation. Multivariate logistic regression was used to adjust for clinically and statistically relevant variables.Statin therapy was associated with a reduction in hospital mortality (adjusted odds ratio [aOR] = 0.60, 95% confidence interval [CI] 0.36-0.99). Statin therapy was associated with lower hospital mortality in the following groups: patients >58 years of age (aOR = 0.58, 95% CI 0.35-0.97), those with an acute physiology and chronic health evaluation (APACHE II) score >22 (aOR = 0.54, 95% CI 0.31-0.96), diabetic patients (aOR = 0.52, 95% CI 0.30-0.90), patients on vasopressor therapy (aOR = 0.53, 95% CI 0.29-0.97), those admitted with severe sepsis (aOR = 0.22, 95% CI 0.07-0.66), patients with creatinine ≤100 μmol/L (aOR = 0.14, 95% CI 0.04-0.51), and patients with GCS ≤9 (aOR = 0.34, 95% CI 0.17-0.71). When stratified by statin dose, the mortality reduction was mainly observed with statin equipotent doses ≥40 mg of simvastatin (aOR = 0.53, 95% CI 0.28-1.00). Mortality reduction was observed with simvastatin (aOR = 0.37, 95% CI 0.17-0.81) but not with atorvastatin (aOR = 0.80, 95% CI 0.84-1.46). Statin therapy was not associated with a difference in any of the secondary outcomes.Statin therapy during ICU stay was associated with a reduction in all-cause hospital mortality. This association was especially noted in high-risk subgroups. This potential benefit needs to be validated in a randomised, controlled trial.Statins, also known as 3-hydroxy-3-methylglutaryl coenzyme
Pro/con debate: Octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin?
Yaseen Arabi, Bandar Al Knawy, Alan N Barkun, Marc Bardou
Critical Care , 2006, DOI: 10.1186/cc4958
Abstract: A 59 year old male has been admitted to the intensive care unit with febrile neutropenia and septic shock. The patient has been diagnosed with acute myelogenous leukemia and following induction is pancytopenic. He is mechanically ventilated and receiving H2 antagonists. You are called because the patient is having large amounts of melena and a modest amount of blood returning from his nasogastric tube. He is hemodynamically unstable. You transfuse blood, platelets and plasma as appropriate, and start an intravenous proton pump inhibitor. Endoscopy cannot be performed until the following day. You have to decide whether to treat the patient empirically with intravenous octreotide. You know it has a role in certain types of gastrointestinal (GI) bleeding but you are uncertain if you should be using it when the cause of bleeding is unclear. Your administrator tells you the drug is relatively expensive.Yaseen Arabi and Bandar Al KnawyThere is evidence to support the use of octreotide in variceal and non-variceal upper GI bleeding (UGB). As a somatostatin analogue, octreotide binds with endothelial cell somatostatin receptors, inducing strong, rapid and prolonged vaso-constriction [1]. Octreotide reduces portal and variceal pressures as well as splanchnic and portal-systemic collateral blood flows [2]. It also prevents postprandial splanchnic hyperemia in patients with portal hypertension [3] and lowers gastric mucosal blood flow in normal and portal hypertensive stomachs [4]. Octreotide inhibits both acid and pepsin secretion. As a result, it prevents the dissolution of freshly formed clots at the site of bleeding [5].The use of octreotide as a first, single therapy versus emergency sclerotherapy in bleeding esophageal varices was examined in a Cochrane systematic review of 12 randomized controlled trials (RCTs), including 6 trials of octreotide [6]. Emergency sclerotherapy was not significantly superior to any of the pharmacological treatments with regard to the assesse
Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review
Yaseen Arabi, Samir Haddad, Nehad Shirawi, Abdullah Al Shimemeri
Critical Care , 2004, DOI: 10.1186/cc2924
Abstract: The 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.Of 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).Early 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 m
Status epilepticus and cardiopulmonary arrest in a patient with carbon monoxide poisoning with full recovery after using a neuroprotective strategy: a case report
Abdulaziz Salman,Dabbagh Ousama,Arabi Yaseen,Kojan Suleiman
Journal of Medical Case Reports , 2012, DOI: 10.1186/1752-1947-6-421
Abstract: Introduction Carbon monoxide poisoning can be associated with life-threatening complications, including significant and disabling cardiovascular and neurological sequelae. Case presentation We report a case of carbon monoxide poisoning in a 25-year-old Saudi woman who presented to our facility with status epilepticus and cardiopulmonary arrest. Her carboxyhemoglobin level was 21.4 percent. She made a full recovery after we utilized a neuroprotective strategy and normobaric oxygen therapy, with no delayed neurological sequelae. Conclusions Brain protective modalities are very important for the treatment of complicated cases of carbon monoxide poisoning when they present with neurological toxicities or cardiac arrest. They can be adjunctive to normobaric oxygen therapy when the use of hyperbaric oxygen is not feasible.
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