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Rabie AA, Elhazmi A, Azzam MH, Abdelbary A, Labib A, Combes A, Zakhary B, MacLaren G, Barbaro RP, Peek GJ, Antonini MV, Shekar K, Al-Fares A, Oza P, Mehta Y, Alfoudri H, Ramanathan K, Ogino M, Raman L, Paden M, Brodie D, Bartlett R. Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study. Ann Intensive Care 2023; 13:36. [PMID: 37129771 PMCID: PMC10152433 DOI: 10.1186/s13613-023-01126-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/05/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus. OBJECTIVES To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS. METHODS The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel's questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively. RESULTS In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics. CONCLUSION Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations.
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Affiliation(s)
- Ahmed A Rabie
- Critical Care Department-ECMO care Unit (ECU), Riyadh Region Cluster1, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Alyaa Elhazmi
- Internal Medicine Department, King Faisal University, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Adult Critical Care Department, Dr. Sulaiman Alhabib Medical Group, Jeddah, Saudi Arabia
| | | | - Ahmed Labib
- Hamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, 75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | | | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, Singapore, Singapore
| | - Ryan P Barbaro
- Division of Pediatric Critical Care and Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | | | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Ministry of Health, Kuwait City, Kuwait
- Al-Amiri Hospital Center for Respiratory and Cardiac Failure, Kuwait Extracorporeal Life Support Program, Ministry of Health, Kuwait City, Kuwait
| | - Pranay Oza
- Riddhi Vinayak Multispecialty Hospital, Mumbai, India
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, 122001, Haryana, India
| | - Huda Alfoudri
- Department of Anaesthesia, Critical Care, and Pain Management, Al-Adan Hospital Ministry of Health, Hadiya, Kuwait
| | | | - Mark Ogino
- Chief Partnership Officer, Nemours Children's Health, Delaware Valley, USA
| | - Lakshmi Raman
- Division of Paediatric Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Paden
- Division of Paediatric Critical Care, Emory University, Atlanta, GA, USA
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian/Columbia University Medical Center, New York, USA
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Elhazmi A, Rabie AA, Al-Omari A, Mufti HN, Sallam H, Alshahrani MS, Mady A, Alghamdi A, Altalaq A, Azzam MH, Sindi A, Kharaba A, Al-Aseri ZA, Almekhlafi GA, Tashkandi W, Alajmi SA, Faqihi F, Alharthy A, Al-Tawfiq JA, Melibari RG, Arabi YM. Tocilizumab Outcomes in Critically Ill COVID-19 Patients Admitted to the ICU and the Role of Non-Tocilizumab COVID-19-Specific Medical Therapeutics. J Clin Med 2023; 12:jcm12062301. [PMID: 36983304 PMCID: PMC10053430 DOI: 10.3390/jcm12062301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/15/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Background: Tocilizumab is a monoclonal antibody proposed to manage cytokine release syndrome (CRS) associated with severe COVID-19. Previously published reports have shown that tocilizumab may improve the clinical outcomes of critically ill patients admitted to the ICU. However, no precise data about the role of other medical therapeutics concurrently used for COVID-19 on this outcome have been published. Objectives: We aimed to compare the overall outcome of critically ill COVID-19 patients admitted to the ICU who received tocilizumab with the outcome of matched patients who did not receive tocilizumab while controlling for other confounders, including medical therapeutics for critically ill patients admitted to ICUs. Methods: A prospective, observational, multicenter cohort study was conducted among critically ill COVID-19 patients admitted to the ICU of 14 hospitals in Saudi Arabia between 1 March 2020, and October 31, 2020. Propensity-score matching was utilized to compare patients who received tocilizumab to patients who did not. In addition, the log-rank test was used to compare the 28 day hospital survival of patients who received tocilizumab with those who did not. Then, a multivariate logistic regression analysis of the matched groups was performed to evaluate the impact of the remaining concurrent medical therapeutics that could not be excluded via matching 28 day hospital survival rates. The primary outcome measure was patients’ overall 28 day hospital survival, and the secondary outcomes were ICU length of stay and ICU survival to hospital discharge. Results: A total of 1470 unmatched patients were included, of whom 426 received tocilizumab. The total number of propensity-matched patients was 1278. Overall, 28 day hospital survival revealed a significant difference between the unmatched non-tocilizumab group (586; 56.1%) and the tocilizumab group (269; 63.1%) (p-value = 0.016), and this difference increased even more in the propensity-matched analysis between the non-tocilizumab group (466.7; 54.6%) and the tocilizumab group (269; 63.1%) (p-value = 0.005). The matching model successfully matched the two groups’ common medical therapeutics used to treat COVID-19. Two medical therapeutics remained significantly different, favoring the tocilizumab group. A multivariate logistic regression was performed for the 28 day hospital survival in the propensity-matched patients. It showed that neither steroids (OR: 1.07 (95% CI: 0.75–1.53)) (p = 0.697) nor favipiravir (OR: 1.08 (95% CI: 0.61–1.9)) (p = 0.799) remained as a predictor for an increase in 28 day survival. Conclusion: The tocilizumab treatment in critically ill COVID-19 patients admitted to the ICU improved the overall 28 day hospital survival, which might not be influenced by the concurrent use of other COVID-19 medical therapeutics, although further research is needed to confirm this.
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Affiliation(s)
- Alyaa Elhazmi
- Department of Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh 11643, Saudi Arabia
- Correspondence: or (A.E.); or (A.A.R.)
| | - Ahmed A. Rabie
- Critical Care Department, King Saud Medical City, Riyadh 11196, Saudi Arabia
- Correspondence: or (A.E.); or (A.A.R.)
| | - Awad Al-Omari
- Research Center, Dr. Sulaiman Alhabib Medical Group, Riyadh 11643, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Hani N. Mufti
- Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA-WR, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah 11481, Saudi Arabia
| | - Hend Sallam
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Jeddah 23431, Saudi Arabia
| | - Mohammed S. Alshahrani
- Department of Emergency and Critical Care, King Fahad Hospital of the University, Dammam University, Al Khobar 31952, Saudi Arabia
| | - Ahmed Mady
- Critical Care Department, King Saud Medical City, Riyadh 11196, Saudi Arabia
- Department of Anesthesiology and Intensive Care, Tanta University Hospital, Tanta 31527, Egypt
| | - Adnan Alghamdi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Ali Altalaq
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Mohamed H. Azzam
- Intensive Care Department, King Abdullah Medical Complex, Jeddah 23816, Saudi Arabia
| | - Anees Sindi
- Department of Medicine, Intensive Care, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ayman Kharaba
- Department of Critical Care, King Fahad Hospital, Al Medina Al Munawara 41477, Saudi Arabia
| | - Zohair A. Al-Aseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
- College of Medicine, Dar Al Uloom University, Riyadh 13314, Saudi Arabia
| | - Ghaleb A. Almekhlafi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Wail Tashkandi
- Department of Adult Critical Care, Fakeeh Care Group, Jeddah 23323, Saudi Arabia
- Department of Surgery, Intensive Care, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Saud A. Alajmi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defense, Riyadh 12233, Saudi Arabia
| | - Fahad Faqihi
- Department of Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh 11643, Saudi Arabia
| | | | - Jaffar A. Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran 34464, Saudi Arabia
- Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Rami Ghazi Melibari
- Department of Critical Care, King Abdullah Medical City, Makah 24246, Saudi Arabia
| | - Yaseen M. Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
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Elhazmi A, Al-Omari A, Sallam H, Mufti HN, Rabie AA, Alshahrani M, Mady A, Alghamdi A, Altalaq A, Azzam MH, Sindi A, Kharaba A, Al-Aseri ZA, Almekhlafi GA, Tashkandi W, Alajmi SA, Faqihi F, Alharthy A, Al-Tawfiq JA, Melibari RG, Al-Hazzani W, Arabi YM. Machine learning decision tree algorithm role for predicting mortality in critically ill adult COVID-19 patients admitted to the ICU. J Infect Public Health 2022; 15:826-834. [PMID: 35759808 PMCID: PMC9212964 DOI: 10.1016/j.jiph.2022.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/02/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Coronavirus disease-19 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is currently a major cause of intensive care unit (ICU) admissions globally. The role of machine learning in the ICU is evolving but currently limited to diagnostic and prognostic values. A decision tree (DT) algorithm is a simple and intuitive machine learning method that provides sequential nonlinear analysis of variables. It is simple and might be a valuable tool for bedside physicians during COVID-19 to predict ICU outcomes and help in critical decision-making like end-of-life decisions and bed allocation in the event of limited ICU bed capacities. Herein, we utilized a machine learning DT algorithm to describe the association of a predefined set of variables and 28-day ICU outcome in adult COVID-19 patients admitted to the ICU. We highlight the value of utilizing a machine learning DT algorithm in the ICU at the time of a COVID-19 pandemic. Methods This was a prospective and multicenter cohort study involving 14 hospitals in Saudi Arabia. We included critically ill COVID-19 patients admitted to the ICU between March 1, 2020, and October 31, 2020. The predictors of 28-day ICU mortality were identified using two predictive models: conventional logistic regression and DT analyses. Results There were 1468 critically ill COVID-19 patients included in the study. The 28-day ICU mortality was 540 (36.8 %), and the 90-day mortality was 600 (40.9 %). The DT algorithm identified five variables that were integrated into the algorithm to predict 28-day ICU outcomes: need for intubation, need for vasopressors, age, gender, and PaO2/FiO2 ratio. Conclusion DT is a simple tool that might be utilized in the ICU to identify critically ill COVID-19 patients who are at high risk of 28-day ICU mortality. However, further studies and external validation are still required.
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Affiliation(s)
- Alyaa Elhazmi
- Department of Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Awad Al-Omari
- Research Center, Dr. Sulaiman Alhabib Medical Group, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Hend Sallam
- Department of Adult Critical Care Medicine, King Faisal Specialist Hospital & Research Centre, Saudi Arabia
| | - Hani N Mufti
- Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA-WR, Jeddah, Saudi Arabia; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia. King Abdullah International Medical Research Center, Jeddah, Saudi Arabia Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Rabie
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Mohammed Alshahrani
- Emergency and Critical Care Department, King Fahad Hospital of The University, Imam Abdul Rahman ben Faisal University, Dammam, Saudi Arabia
| | - Ahmed Mady
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt
| | - Adnan Alghamdi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Ali Altalaq
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Intensive Care Department, King Abdullah Medical Complex, Jeddah, Saudi Arabia
| | - Anees Sindi
- Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ayman Kharaba
- Department of Critical Care, King Fahad Hospital, Al Medina Al Monawarah, Saudi Arabia
| | - Zohair A Al-Aseri
- Departments Of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia; College Of Medicine, Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Ghaleb A Almekhlafi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Wail Tashkandi
- Department of Critical Care, Fakeeh Care Group, Jeddah, Saudi Arabia; Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Saud A Alajmi
- Prince Sultan Military Medical City, Military Medical Services, Ministry of Defence, Riyadh, Saudi Arabia
| | - Fahad Faqihi
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Jaffar A Al-Tawfiq
- Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia. Infectious Disease Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rami Ghazi Melibari
- Department of Critical Care, King Abdullah Medical City, Makah, Saudi Arabia
| | - Waleed Al-Hazzani
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Yaseen M Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Rabie AA, Azzam MH, Al-Fares AA, Abdelbary A, Mufti HN, Hassan IF, Chakraborty A, Oza P, Elhazmi A, Alfoudri H, Pooboni SK, Alharthy A, Brodie D, Zakhary B, Shekar K, Antonini MV, Barrett NA, Peek G, Combes A, Arabi YM. Implementation of new ECMO centers during the COVID-19 pandemic: experience and results from the Middle East and India. Intensive Care Med 2021; 47:887-895. [PMID: 34156477 PMCID: PMC8217786 DOI: 10.1007/s00134-021-06451-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/02/2021] [Indexed: 01/15/2023]
Abstract
Purpose Extracorporeal membrane oxygenation (ECMO) use for severe coronavirus disease 2019 (COVID-19) patients has increased during the course of the pandemic. As uncertainty existed regarding patient’s outcomes, early guidelines recommended against establishing new ECMO centers. We aimed to explore the epidemiology and outcomes of ECMO for COVID-19 related cardiopulmonary failure in five countries in the Middle East and India and to evaluate the results of ECMO in 5 new centers. Methods This is a retrospective, multicenter international, observational study conducted in 19 ECMO centers in five countries in the Middle East and India from March 1, 2020, to September 30, 2020. We included patients with COVID-19 who received ECMO for refractory hypoxemia and severe respiratory acidosis with or without circulatory failure. Data collection included demographic data, ECMO-related specific data, pre-ECMO patient condition, 24 h post-ECMO initiation data, and outcome. The primary outcome was survival to home discharge. Secondary outcomes included mortality during ECMO, survival to decannulation, and outcomes stratified by center type. Results Three hundred and seven COVID-19 patients received ECMO support during the study period, of whom 78 (25%) were treated in the new ECMO centers. The median age was 45 years (interquartile range IQR 37–52), and 81% were men. New center patients were younger, were less frequently male, had received higher PEEP, more frequently inotropes and prone positioning before ECMO and were less frequently retrieved from a peripheral center on ECMO. Survival to home discharge was 45%. In patients treated in new and established centers, survival was 55 and 41% (p = 0.03), respectively. Multivariable analysis retained only a SOFA score < 12 at ECMO initiation as associated with survival (odds ratio, OR 1.93 (95% CI 1.05–3.58), p = 0.034), but not treatment in a new center (OR 1.65 (95% CI 0.75–3.67)). Conclusions During pandemics, ECMO may provide favorable outcomes in highly selected patients as resources allow. Newly formed ECMO centers with appropriate supervision of regional experts may have satisfactory results. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06451-w.
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Affiliation(s)
- Ahmed A Rabie
- Critical Care Department, King Saud Medical City, 12746 Ulaishah discreet, Riyadh, Saudi Arabia.
| | - Mohamed H Azzam
- Critical Care Department, King Abdullah Medical Complex, Ministry of Health, Jeddah, Saudi Arabia
| | - Abdulrahman A Al-Fares
- Department of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital Center for Respiratory and Cardiac Failure, Kuwait Extracorporeal Life Support Program, Jaber Al-Ahmed Hospital Critical Care Unit, Ministry of Health, Kuwait City, Kuwait
| | | | - Hani N Mufti
- Section of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, MNGHA, Jeddah, Saudi Arabia.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ibrahim F Hassan
- Medical Critical Care Division, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Arpan Chakraborty
- Cardiac Anesthesia, Critical Care and ECMO Services, Medica Superspecialty Hospital, Kolkata, India
| | - Pranay Oza
- Riddhi Vinayak Multispecialty Hospital, Mumbai, India
| | - Alyaa Elhazmi
- Adult Critical Care Department, Dr. Sulaiman Alhabib Medical Group, Riyadh, Saudi Arabia
| | - Huda Alfoudri
- Department of Anaesthesia, Critical Care, and Pain Management, Al-Adan Hospital Ministry of Health, Hadiya, Kuwait
| | - Suneel Kumar Pooboni
- Department of Pediatric Critical Care, Mediclinic Airport Road Hospital, Abu Dhabi, United Arab Emirates
| | - Abdulrahman Alharthy
- Critical Care Department, King Saud Medical City, 12746 Ulaishah discreet, Riyadh, Saudi Arabia
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | | | - Nicholas A Barrett
- Faculty of Life Sciences and Medicine, Department of Critical Care, Centre of Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Giles Peek
- Department of Cardiothoracic Surgery, Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Alain Combes
- Institute of Cardio-Metabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 75013, Paris, France.,Service de Médecine Intensive-Réanimation, Institute de Cardiologie, APHP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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Mufti HN, Rabie AA, Elhazmi AM, Bahaudden HA, Rajab MA, Al Enezi IS, Assiri AY, Maghrabi KA, Al Bshabshe AA, Abudayah AM, Tash AA, Al-Omari AA, Azzam MH. The Saudi Critical Care Society extracorporeal life support chapter guidance on utilization of veno-venous extracorporeal membrane oxygenation in adults with acute respiratory distress syndrome and special considerations in the era of coronavirus disease 2019. Saudi Med J 2021; 42:589-611. [PMID: 34078721 PMCID: PMC9149722 DOI: 10.15537/smj.2021.42.6.20200520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/09/2021] [Indexed: 11/16/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is considered as a supportive treatment that provides circulatory and ventilatory support and can be thought off as a bridge to organ recovery. Since 2009, it has been applied as a rescue treatment for patients with severe adult respiratory distress syndrome (ARDS) mainly due to viral causes. In December 2019, several patients presented with a constellation of symptoms of viral pneumonia in China. A new strain of the corona virus family, called COVID-19, has been discovered to be the cause of this severe mysterious illness that was named severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2). This new virus continued to spread across the globe leading to the World Health Organization announcing it as a pandemic in the early 2020. By the end of March 2021, the number of COVID-19 cases worldwide exceeded 126 million cases. In Saudi Arabia, the first confirmed case of COVID-19 was reported in the 2nd March 2020. By the end of March 2021, the total number of confirmed COVID-19 cases in Saudi Arabia is just above 360,000. In anticipation of the need of ECMO for the treatment of patients with SARS‑CoV‑2 based on the previous Middle East respiratory syndrome coronavirus pandemic experience, the Saudi Extra-Corporeal Life Support (ECLS) chapter that is under the umbrella of the Saudi Critical Care Society (SCCS) convened a working group of ECMO experts. The mission of this group was to formulate a guidance for the use of ECMO as a last resort for patients with severe ARDS, especially with COVID-19 based on available evidence. The ECLS-SCCS chapter wanted to generate a document that can be used to simple guide, with a focus on safety, to provide ECMO service for patients with severe ARDS with a special focus on SARS‑CoV‑2.
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Affiliation(s)
- Hani N. Mufti
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
- Address correspondence and reprint request to: Dr. Hani Mufti, Division of Cardiac Surgery, Department of Cardiac Sciences, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Kingdom of Saudi Arabia. E-mail: ORCID ID: https://orcid.org/0000-0002-0471-5738
| | - Ahmed A. Rabie
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Alyaa M. Elhazmi
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Husam A. Bahaudden
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Mostafa A. Rajab
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Ismael S. Al Enezi
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Ayed Y. Assiri
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Khalid A. Maghrabi
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Ali A. Al Bshabshe
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Abdullah M. Abudayah
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Adel A. Tash
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Awad A. Al-Omari
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
| | - Mohamed H. Azzam
- From the Department of Cardiac Sciences (Mufti), from the Department of Intensive Care (Bahaudden), King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs; from the College of Medicine (Mufti, Bahaudden), King Saud bin Abdulaziz University for Health Sciences; from Department of Medical Research (Mufti, Bahaudden), King Abdullah International Medical Research Center; from the Department of Cardiac Sciences (Tash) and from the Department of Intensive Care (Azzam), King Abdullah Medical Complex, Ministry of Health, Jeddah; from the College of Medicine (Bshabshe), King Khalid University, Abha; from the Critical Care Department (Rabie), King Saud Medical City; from the Department of Critical Care (Elhazmi, Al-Omari), from the Research Center (Elhazmi, Al-Omari), Dr. Sulaiman Al Habib Medical Group; from the Critical Care Department (Rajab, Enezi, Assiri), Prince Mohammad bin Abdulaziz Hospital; from the Intensive Care Department (Maghrabi), King Faisal Specialist Hospital and Research Center; from the Department of Intensive Care Services (Abudayah), Prince Sultan Military Medical City; and from the School of Medicine (Al-Omari), Alfaisal University, Riyadh, Kingdom of Saudi Arabia.
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Rabie AA, Asiri A, Rajab M, Mufti HN, Alsherbiny M, Azzam MH, Abdelbary A, Zakhary B, Arabi Y, Alharthy A, Futaih M, Sobhy M, Alenazi I, Bafaqeeh F. Beyond Frontiers: Feasibility and Outcomes of Prolonged Veno-Venous Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome. ASAIO J 2021; 67:339-344. [PMID: 33627610 DOI: 10.1097/mat.0000000000001367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) use in acute respiratory failure is increasing. We aim to compare characteristics and outcomes of patients with prolonged (≥21 days) veno-venous (VV) ECMO runs (pECMO), to patients with short (<21 days) VV ECMO runs (sECMO). The observational retrospective single-center study compared patients who received VV ECMO from January 2018 to June 2019 at Prince Mohamed Bin Abdulaziz Center in Riyadh, Saudi Arabia. Forty-three patients were supported with VV ECMO during the study period, of whom 37 are included as six patients were still receiving ECMO at time of data collection: 24 sECMO and 13 pECMO patients. Baseline characteristics and comorbidities were similar except pECMO patients were older and had a lower P/F ratio (61 [58-68] vs. 71[58-85.5], p = 0.05). Survival to hospital discharge (69% vs. 83%, p = 0.32; pECMO vs. sECMO) and 90 day survival (62% vs. 75%, p = 0.413; pECMO vs. sECMO) were similar among groups. At 1 year follow-up, all patients were still alive and independently functioning except for one patient in the pECMO group who required a walking aid related to trauma. In this single-center study, patients requiring pECMO had similar short- and long-term survival to those requiring sECMO duration.
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Affiliation(s)
- Ahmed A Rabie
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ayed Asiri
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Mostafa Rajab
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Hani N Mufti
- Cardiac Surgery Department, King Faisal Cardiac Center, King Saud Bin Abdulaziz University for Health Sciences, MNGHA Jeddah, Saudi Arabia
| | - Medhat Alsherbiny
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Mohamed H Azzam
- Critical Care Department, King Abdullah Medical Complex, Ministry of Health, Jeddah, Saudi Arabia
| | | | - Bishoy Zakhary
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Yaseen Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Mohamed Futaih
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Mohamed Sobhy
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Ismael Alenazi
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
| | - Fahad Bafaqeeh
- From the Critical Care Department, Prince Mohamed Bin Abdelaziz Hospital, Riyadh, Saudi Arabia
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