Extracorporeal membrane oxygenation in obstetric patients: An Israeli nationwide study.

BACKGROUND: The leading causes of maternal mortality include respiratory failure, cardiovascular events, infections, and hemorrhages. The use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in the peripartum period for cardiopulmonary failure is expanding in critical care medicine. METHODS: This retrospective observational study was conducted on a nationwide cohort in Israel. During the 3-year period, between September 1, 2019, and August 31, 2022, all women in the peripartum period who had been supported by ECMO for respiratory or circulatory failure at 10 large Israeli hospitals were identified. Indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and complications were collected. RESULTS: During the 3-year study period, in Israel, there were 540 234 live births, and 28 obstetric patients were supported by ECMO, with an incidence of 5.2 cases per 100 000 or 1 case per 19 000 births (when excluding patients with COVID-19, the incidence will be 2.5 cases per 100 000 births). Of these, 25 were during the postpartum period, of which 16 (64%) were connected in the PPD1, and 3 were during pregnancy. Eighteen patients (64.3%) were supported by V-V ECMO, 9 (32.1%) by V-A ECMO, and one (3.6%) by a VV-A configuration. Hypoxic respiratory failure (ARDS) was the most common indication for ECMO, observed in 21 patients (75%). COVID-19 was the cause of ARDS in 15 (53.7%) patients. The indications for the V-A configuration were cardiomyopathy (3 patients), amniotic fluid embolism (2 patients), sepsis, and pulmonary hypertension. The maternal and fetal survival rates were 89.3% (n = 25) and 100% (n = 28). The average ECMO duration was 17.6 ± 18.6 days and the ICU stay was 29.8 ± 23.8 days. Major bleeding complications requiring surgical intervention were observed in one patient. CONCLUSIONS: The incidence of using ECMO in the peripartum period is low. The maternal and neonatal survival rates in patients treated with ECMO are high. These results show that ECMO remains an important treatment option for obstetric patients with respiratory and/or cardiopulmonary failure.

Accurate positioning of extracorporeal membrane oxygenation cannulas using real-time trans-thoracic echocardiography.

In this retrospective observational case series, we aimed to evaluate the use of real-time trans-thoracic echocardiography in accurate positioning of extracorporeal membrane oxygenation cannulas. Patients admitted to the intensive care unit with severe adult respiratory distress syndrome in need for extracorporeal membrane oxygenation were screened. Twenty-one extracorporeal membrane oxygenation cannulas were inserted in 10 patients, and 95% of the cannulas were located exactly at the vena cava-right atria junction as planned. Real-time point-of-care trans-thoracic echocardiography for the exact positioning of extracorporeal membrane oxygenation cannula is feasible, simple, time saving, and accurate.

Single-Operator Ultrasound-Guided Central Venous Catheter Insertion Verifies Proper Tip Placement.

OBJECTIVES: To evaluate whether a single-operator ultrasound-guided, right-sided, central venous catheter insertion verifies proper placement and shortens time to catheter utilization. DESIGN: Prospective observational study with historical controls. SETTING: Adult ICUs. PATIENTS: Sixty-four consecutive patients undergoing ultrasound-assisted right-sided central venous catheterization compared with 92 serial historic controls who had unassisted central catheter insertion at the same sites. INTERVENTIONS: Subcostal transthoracic echocardiography during catheter insertion. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the correct placement of the catheter tip determined by postprocedural chest radiography. The subclavian site was used in 41 patients (64%) (inserted without ultrasound guidance) in the ultrasound-assisted group and 62 (67%) in the control group, whereas the jugular vein was used in the remaining patients. The tip was accurately positioned in 59 of 68 patients (86.7%) in the ultrasound-assisted group compared with 51 of 94 (54.8%) in the control group (p < 0.001). The median time from end of the procedure to catheter utilization after chest radiography approval was 2.4 hours. CONCLUSIONS: A single-operator ultrasound-guided central venous catheter insertion is effective in verifying proper tip placement and shortens time to catheter utilization.

High-frequency QRS analysis in the evaluation of chest pain in the emergency department.

OBJECTIVES: High frequency QRS (HFQRS) analysis has been shown to be an accurate marker for myocardial ischemia. Our objective was to test the use of HFQRS in diagnosing ACS in the emergency department. METHODS: 324 patients presenting to the ED with chest pain were enrolled. Resting ECG was recorded and later analyzed by an HFQRS algorithm. Results were compared to the conventional ECG diagnosis by 3 independent interpretations: treating physician, expert cardiologist and an automated computer program. RESULTS: The HFQRS analysis demonstrated improved sensitivity (67.5%) for the NSTE-ACS group compared to the human interpreters (59.7% and 53.2% for the treating physician and cardiologist respectively) with similar specificity. The automatic program had significantly lower sensitivity (31%) with a higher specificity (77%). CONCLUSIONS: HFQRS which has shown great promise in diagnosing stable CAD may also be helpful in the ED for diagnosing ACS.

The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum.

BACKGROUND: Teaching cardiac ultrasound to medical students in a brief course is a challenge. We aimed to evaluate the feasibility of teaching large groups of medical students the acquisition and interpretation of cardiac ultrasound images using a pocket ultrasound device (PUD) in a short, specially designed course. METHODS: Thirty-one medical students in their first clinical year participated in the study. All were novices in the use of cardiac ultrasound. The training consisted of 4 hours of frontal lectures and 4 hours of hands-on training. Students were encouraged to use PUD for individual practice. Finally, the students' proficiency in the acquisition of ultrasound images and their ability to recognize normal and pathological states were evaluated. RESULTS: Sixteen of 27 (59%) students were able to demonstrate all main ultrasound views (parasternal, apical, and subcostal views) in a six-minute test. The most obtainable view was the parasternal long-axis view (89%) and the least obtainable was the subcostal view (58%). Ninety-seven percent of students correctly differentiated normal from severely reduced left ventricular function, 100% correctly differentiated a normal right ventricle from a severely hypokinetic one, 100% correctly differentiated a normal mitral valve from a rheumatic one, and 88% correctly differentiated a normal aortic valve from a calcified one, while 95% of them correctly identified the presence of pericardial effusion. CONCLUSIONS: Training of medical students in cardiac ultrasound during the first clinical year using a short, focused course is feasible and enables students with modest ability to acquire the main transthoracic ultrasound views and gain proficiency in the diagnosis of a limited number of cardiac pathologies.

Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge.

INTRODUCTION: Sepsis and septic shock continue to be syndromes that carry a high mortality rate worldwide. Early aggressive fluid and vasopressor support have resulted in significant improvement in patient outcomes. The prognostic clinical significance of a positive fluid balance in septic intensive care unit (ICU) patients remains undetermined. METHODS: We collected data from 297 septic patients hospitalized in our general and medical ICUs at Soroka Medical Center between January 2005 and June 2011 and divided the 4 study groups into the following 4 fluid balances: group 1, patients with fluid balance at discharge from ICU (FBD) less than 10 L; group 2, patients with an FBD of 10 to 20 L; group 3, patients with an FBD of 20 to 30 L; and group 4, patients with FBD in excess of 30 L. RESULTS: The ICU and in-hospital mortality rate was also significantly higher in groups 2 to 4 as compared with group 1 (P < .001 for both ICU and in-hospital mortality). The positive cumulative FBD was found to be an independent predictor of ICU mortality (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .001; Table 3) and in-hospital mortality (OR, 1.06; 95% CI, 1.03-1.08; P < .001; Table 5) and also to constitute a risk factor for new organ system dysfunction at hospital discharge (OR, 1.01; 95% CI, 1.01-1.013; P < .001; Table 6) in critically ill patients with severe sepsis/septic shock. CONCLUSIONS: Although it is a monocentric retrospective study, we suggest that positive cumulative fluid balance is one of the major factors that can predict the clinical outcome of critically ill patients during their ICU stay and after their discharge from the ICU.

Self-learning of cardiac ultrasound by medical students: can augmented online training improve and maintain manual POCUS skills over time?

BACKGROUND: The use of cardiac point of care ultra-sound is rapidly growing and so is the demand for quality POCUS teaching. POCUS teaching is usually conducted in small groups requiring much space and equipment. This study attempts to test whether providing access to an E-learning module as an adjunct to a cardiac POCUS course can increase students' image acquisition skills. This will show POCUS teaching can improve significantly without having to invest a significant amount of resources. METHODS: Medical students (N = 125) were divided into two groups and had undergone a hands-on Cardiac POCUS course before their internal clerkship. During the clerkship, members of both groups got to practice their POCUS skills in the internal wards. One group was provided with accounts to a cardiac POCUS teaching E-learning platform (eMedical Academy©). After limited time for self- practice, both groups underwent a pre-validated ultrasound examination. The two groups' test results were then compared for each POCUS view and for the total exam score. RESULTS: The E-learning group performed significantly better than the course-only group in the 6-min exam total score, and at acquiring the following views: parasternal long axis view, apical four-chamber view, and the inferior vena cava view. CONCLUSION: E-learning platforms can be an efficient tool for improving cardiac POCUS teaching and maintaining POCUS skills. Using it as a supplement to a hands-on course provides better POCUS skills without the need of extra hands-on teaching.

Lung ultrasound is associated with distinct clinical phenotypes in COVID-19 ARDS: A retrospective observational study.

BACKGROUND: ARDS is a heterogeneous syndrome with distinct clinical phenotypes. Here we investigate whether the presence or absence of large pulmonary ultrasonographic consolidations can categorize COVID-19 ARDS patients requiring mechanical ventilation into distinct clinical phenotypes. METHODS: This is a retrospective study performed in a tertiary-level intensive care unit in Israel between April and September 2020. Data collected included lung ultrasound (LUS) findings, respiratory parameters, and treatment interventions. The primary outcome was a composite of three ARDS interventions: prone positioning, high PEEP, or a high dose of inhaled nitric oxide. RESULTS: A total of 128 LUS scans were conducted among 23 patients. The mean age was 65 and about two-thirds were males. 81 scans identified large consolidation and were classified as "C-type", and 47 scans showed multiple B-lines with no or small consolidation and were classified as "B-type". The presence of a "C-type" study had 2.5 times increased chance of receiving the composite primary outcome of advanced ARDS interventions despite similar SOFA scores, Pao2/FiO2 ratio, and markers of disease severity (OR = 2.49, %95CI 1.40-4.44). CONCLUSION: The presence of a "C-type" profile with LUS consolidation potentially represents a distinct COVID-19 ARDS subphenotype that is more likely to require aggressive ARDS interventions. Further studies are required to validate this phenotype in a larger cohort and determine causality, diagnostic, and treatment responses.

High-frequency QRS analysis in patients with acute myocardial infarction: a preliminary study.

BACKGROUND: The 12-lead electrocardiogram (ECG) is a primary tool in the evaluation and risk stratification of patients with suspected acute myocardial infarction (AMI), even though the initial ECG of these patients is often normal or nondiagnostic. Myocardial ischemia induces depolarization changes that can be quantified by analysis of high-frequency QRS (HFQRS) components. We aimed to demonstrate the potential usefulness of HFQRS analysis in diagnosing myocardial ischemia by characterizing the morphological patterns of the HFQRS signals in patients with AMI before and following reperfusion. METHODS: Five-minute high-resolution ECG was acquired from 30 patients with AMI (age 55 ± 11 years, 26 men) upon their admission to the intensive coronary care unit (ICCU). Serial ECGs were acquired following coronary revascularization and after additional 24 hours (24h). High-frequency morphology index (HFMI), quantifying the extent of ischemic patterns was computed by a custom software, and its values were compared between the serial ECG measurements. RESULTS: HFMI values were significantly higher on the admission ECG as compared to the post intervention ECG (4.6 ± 2.9% vs 3.4 ± 2.3%, P < 0.05) and to the 24h ECG (4.6 ± 2.9% vs 2.8 ± 2.1%, P < 0.01). In 79% of the patients who were successfully revascularized HFMI value decreased from admission ECG to 24h ECG. CONCLUSIONS: Analysis of HFQRS morphology in patients with AMI provides information about the existence and severity of myocardial ischemia. HFQRS analysis may aid in risk stratification of patients with suspected myocardial ischemia, complementarily to conventional ECG.

A case report of rapid diagnosis of atrial-oesophageal fistula by transthoracic echocardiogram with agitated saline injection.

Background: Catheter ablation is a common treatment for atrial fibrillation (AF). Atrial-oesophageal fistula (AOF) is a rare yet fatal complication of catheter ablation. Chest computed tomography (CT) is the diagnostic modality of choice but may be undiagnostic in up to 24% of cases. Case summary: We present the case of a 61-year-old male who presented with pleuritic chest pain, hypotension, fever, and coffee-ground emesis 20 days after cryoablation for AF. His chest CT was undiagnostic. Atrial-oesophageal fistula was diagnosed by injecting agitated saline into the nasogastric tube during a transthoracic echocardiogram (TTE) that showed bubbles in the left atrium and ventricle. Discussion: In the case presented, as often happens, the diagnosis of AOF was delayed for several days, during which the patient presented with septic shock and concomitant multiorgan failure. The high mortality rate associated with AOF is partially attributable to delayed diagnosis. As prompt surgical intervention offers the best chance of survival, a high level of suspicion is of the utmost importance. We suggest contrast-enhanced TTE as a potential diagnostic tool when a rapid and definitive diagnosis is crucial and CT is inconclusive. Since this procedure is not without risk, proper risk consideration and management are necessary.

Severity of a Vipera palaestinae envenomation objective findings associated with a complicated hospitalization course following a Vipera palaestinae bite.

The most common snake in Israel, responsible for most snakebites is Vipera palaestinae (VP). Envenomation signs and symptoms vary from local manifestations to systemic reactions that may end with death. Antivenom treatment, given to high-risk patients, reduces complications and mortality but carries risks. As of now, there is no standardized protocol for adults bitten by VP based on objective clinical and laboratory findings. We conducted A retrospective analysis of 159 patients admitted to two large tertiary care institutions in the center (Hadassah University Medical Center) and south (Soroka University Medical Center) of Israel with Vipera palaestinae bites during 1990-2017. Epidemiological and clinical data were extracted, and the patients were divided into two groups based on hospitalization time (over or under 48 h). 159 patients were included in this study. The average hospitalization time was 66.1 h, with 49.7% of patients admitted over 48 h. The main factors that statistically correlated with a longer hospitalization time were: Male gender, lower extremity bite, platelets lower than 150 K at presentation, leukocyte count of over 10 K at presentation and elevated D-Dimer levels. This study provides factors which are associated with a severe VP envenomation. These clinical or laboratory findings (along with accompanying clinical symptoms) are associated with a higher risk of a prolonged hospitalization with more complications and may require a more intensive treatment and monitoring.

Extracorporal Membrane Oxygenation in Nonintubated Patients (Awake ECMO) With COVID-19 Adult Respiratory Distress Syndrome: The Israeli Experience.

In this retrospective multicenter observational study, we describe the Israeli experience with veno-venous extracorporeal membrane oxygenation (VV ECMO) for the treatment of COVID-19-induced severe adult respiratory distress syndrome (ARDS), in which ECMO cannulation was done while the patients were awake and spontaneously breathing without endotracheal tube, namely "awake ECMO." We enrolled all adult patients with severe ARDS due to COVID-19, treated with VV ECMO between March 1, 2020, and November 30, 2021, in which cannulation was done while the patient was awake and spontaneously breathing. During the study period, 365 COVID-19 ARDS patients were treated with VV ECMO. Of these, 25 (6.8%) were treated as awake ECMO. The patient's mean age was 52 years, and 80% were male. Nine of the 25 patients (36%) remained awake throughout their intensive care unit stay and were not sedated and mechanically ventilated at all. Sixteen (64%) were eventually intubated while being on ECMO. Six months survival was 76%. Median mechanical ventilation-free days on ECMO was 8 (interquartile range 5-12) days. This hypothesis-generating study suggests that treating COVID-19 ARDS patients with VV ECMO without sedation and mechanical ventilation is feasible, yet, additional research will be required in order to determine if this modality offers a survival benefit and to identify who are the patients most likely to benefit from it.

Outcomes of Extracorporeal Membrane Oxygenation (ECMO) for COVID-19 Patients: A Multi-Institutional Analysis.

BACKGROUND: In March 2020, COVID-19 was announced as a global pandemic. The first COVID-19 patient was connected to an ECMO device in Israel during that time. Since then, over 200 patients have required ECMO support due to COVID-19 infection. The present study is a multi-institutional analysis of all COVID-19 patients requiring veno-venous (VV) ECMO in Israel. The aim was to characterize and compare the survivors and deceased patients as well as establish risk factors for mortality. METHODS: This retrospective multi-institutional study was conducted from March 2020 to March 2021 in eleven of twelve ECMO centers operating in Israel. All COVID-19 patients on VV ECMO support were included in the cohort. The patients were analyzed based on their comorbidities, procedural data, adverse event on ECMO, and outcomes. Univariate and multivariate analyses were used to compare the deceased and the surviving patients. RESULTS: The study included 197 patients, of which 150 (76%) were males, and the mean age was 50.7 ± 12 years. Overall mortality was 106 (54%). Compared with the deceased subjects, survivors were significantly younger (48 ± 11 vs. 53 ± 12 years), suffered less from ischemic heart disease (IHD) (3% vs. 12%), and were ventilated for a significantly shorter period (≤4 days) prior to cannulation (77% vs. 63%). Patients in the deceased group experienced more kidney failure and sepsis. Rates of other complications were comparable between groups. CONCLUSIONS: Based on this study, we conclude that early cannulation (≤4 days) of younger patients (≤55 years) may improve overall survival and that a history of IHD might indicate a reduced prognosis.

Outcome predictors and patient progress following delivery in pregnant and postpartum patients with severe COVID-19 pneumonitis in intensive care units in Israel (OB-COVICU): a nationwide cohort study.

BACKGROUND: A key unresolved controversy in severe COVID-19 pneumonitis in pregnancy is the optimum timing of delivery and whether delivery improves or worsens maternal outcomes. We aimed to assess clinical data on every intensive care unit (ICU) day for pregnant and postpartum women admitted to the ICU with COVID-19, with a particular focus on the days preceding and following delivery. METHODS: In this multicentre, nationwide, prospective and retrospective cohort study, we evaluated all pregnant women who were admitted to an ICU in Israel with severe COVID-19 pneumonitis from the 13th week of gestation to the 1st week postpartum. We excluded pregnant patients in which the ICU admission was unrelated to severe COVID-19 pneumonitis. We assessed maternal and neonatal outcomes and longitudinal clinical and laboratory ICU data. The primary overall outcome was maternal outcome (worst of the following: no invasive positive pressure ventilation [IPPV], use of IPPV, use of extracorporeal membrane oxygenation [ECMO], or death). The primary longitudinal outcome was Sequential Organ Failure Assessment (SOFA) score, and the secondary longitudinal outcome was the novel PORCH (positive end-expiratory pressure [PEEP], oxygenation, respiratory support, chest x-ray, haemodynamic support) score. Patients were classified into four groups: no-delivery (pregnant at admission and no delivery during the ICU stay), postpartum (ICU admission ≥1 day after delivery), delivery-critical (pregnant at admission and receiving or at high risk of requiring IPPV at the time of delivery), or delivery-non-critical (pregnant at admission and not critically ill at the time of delivery). FINDINGS: From Feb 1, 2020, to Jan 31, 2022, 84 patients were analysed: 34 patients in the no-delivery group, four in postpartum, 32 in delivery-critical, and 14 in delivery-non-critical. The delivery-critical and postpartum groups had worse outcomes than the other groups: 26 (81%) of 32 patients in the delivery-critical group and four (100%) of four patients in the postpartum group required IPPV; 12 (38%) and three (75%) patients required ECMO, and one (3%) and two (50%) patients died, respectively. The delivery-non-critical and no-delivery groups had far better outcomes than other groups: six (18%) of 34 patients and two (14%) of 14 patients required IPPV, respectively; no patients required ECMO or died. Oxygen saturation (SpO2), SpO2 to fraction of inspired oxygen (FiO2) ratio (S/F ratio), partial pressure of arterial oxygen to FiO2 ratio (P/F ratio), ROX index (S/F ratio divided by respiratory rate), and SOFA and PORCH scores were all highly predictive for adverse maternal outcome (p<0·0001). The delivery-critical group deteriorated on the day of delivery, continued to deteriorate throughout the ICU stay, and took longer to recover (ICU duration, Mantel-Cox p<0·0001), whereas the delivery-non-critical group improved rapidly following delivery. The day of delivery was a significant covariate for PORCH (p<0·0001) but not SOFA (p=0·09) scores. INTERPRETATION: In patients who underwent delivery during their ICU stay, maternal outcome deteriorated following delivery among those defined as critical compared with non-critical patients, who improved following delivery. Interventional delivery should be considered for maternal indications before patients deteriorate and require mechanical ventilation. FUNDING: None.

[Brain natriuretic peptide (BNP) level predicts long term ventricular arrhythmias in patients with moderate to severe left ventricular dysfunction].

BACKGROUND: Brain natriuretic peptide (BNP) is a powerful predictor of mortality in patients with left ventricular dysfunction. Since malignant ventricular arrhythmias such as sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) are a major cause of death among those patients, we postulated that BNP levels can predict their long-term occurrence. OBJECTIVES: To study the association between malignant ventricular arrhythmias and BNP level over a long term follow-up. METHODS: We prospectively followed 94 patients with ischemic heart disease and left ventricular dysfunction, all implanted with an implantable cardioverter defibrillator (ICD). BNP level was measured at baseline and ICD interrogation and clinical status were recorded at 6 months intervals for a median of 3.5 years. RESULTS: Patients with BNP levels in the highest quartile experienced significantly more arrhythmic events than those at the lower three quartiles (OR 2.2, 95% C.I 1.2-4.2). In a multivariate analysis only BNP level predicted arrhythmic events. Among patients implanted for primary prevention of sudden cardiac death, BNP at the lowest quartile significantly predicted low event rate. CONCLUSION: While high BNP level is predictive of malignant ventricular arrhythmias, low levels among patients implanted for primary prevention can identify a low risk subgroup for which the ICD might be of borderline therapeutic benefit.

Unusual presentation of aggressive high-grade B-cell lymphoma of colonic origin: A case report and review of the literature.

Colonic lymphoma is a rare disease. The presented case is unique, being manifested with abrupt onset, including circulatory shock and lactic acidosis as the initial presentation.

Real time wire localization by ultrasound during central line insertion improves accurate positioning in all upper torso sites.

PURPOSE: To investigate whether point of care ultrasound can improve central venous catheter tip positioning. MATERIAL AND METHODS: A single center retrospective case control study. We compared the precision of central venous catheter tip positioning between two intensive care units while in only one of the units, we used point of care ultrasound for guidewire identification. RESULTS: 207 cases in which central venous catheter was inserted using point of care ultrasound guided method, compared to 192 controls. The primary outcome of correct placement of the central venous catheter tip was significantly higher in the point of care ultrasound guided group (97.6% vs 88.0% p = 0.001). Central venous catheter tip was located too low among 12% of patients in the control group while in only 2.4% of patients in the point of care ultrasound group (p = 0.001). Logistics regression analysis revealed that the correct placement of central venous catheter tip in the point of care ultrasound group versus the control group had an odds ratio of 4.9 (CI 1.6-14.5 P = 0.004). CONCLUSION: Point of care ultrasound for guidewire identification and localization, while inserting central venous catheter from all upper torso sites, improves precision positioning.