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.

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.

Point of Care Lung Ultrasound Injury Score-A simple and reliable assessment tool in COVID-19 patients (PLIS I): A retrospective study.

BACKGROUND: In COVID-19 patients, lung ultrasound is superior to chest radiograph and has good agreement with computerized tomography to diagnose lung pathologies. Most lung ultrasound protocols published to date are complex and time-consuming. We describe a new illustrative Point-of-care ultrasound Lung Injury Score (PLIS) to help guide the care of patients with COVID-19 and assess if the PLIS would be able to predict COVID-19 patients' clinical course. METHODS: This retrospective study describing the novel PLIS was conducted in a large tertiary-level hospital. COVID-19 patients were included if they required any form of respiratory support and had at least one PLIS study during hospitalization. Data collected included PLIS on admission, demographics, Sequential Organ Failure Assessment (SOFA) scores, and patient outcomes. The primary outcome was the need for intensive care unit (ICU) admission. RESULTS: A total of 109 patients and 293 PLIS studies were included in our analysis. The mean age was 60.9, and overall mortality was 18.3%. Median PLIS score was 5.0 (3.0-6.0) vs. 2.0 (1.0-3.0) in ICU and non-ICU patients respectively (p<0.001). Total PLIS scores were directly associated with SOFA scores (inter-class correlation 0.63, p<0.001), and multivariate analysis showed that every increase in one PLIS point was associated with a higher risk for ICU admission (O.R 2.09, 95% C.I 1.59-2.75) and in-hospital mortality (O.R 1.54, 95% C.I 1.10-2.16). CONCLUSIONS: The PLIS for COVID-19 patients is simple and associated with SOFA score, ICU admission, and in-hospital mortality. Further studies are needed to demonstrate whether the PLIS can improve outcomes and become an integral part of the management of COVID-19 patients.

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.

Central venous catheter insertion- guidewire migration ratio: Right heart to inferior vena cava.

BACKGROUND: Central Venous Catheters (CVC) are being used in both intensive care units and general wards for multiple purposes. A previous study Galante et al. (2017) observed that during CVC insertion through Subclavian Vein (SCV) or the Internal Jugular Vein (IJV) the guidewire is sometimes advanced to the Inferior Vena Cava (IVC), and at other times to the right atrium. The rate of IVC wire cannulation and the association with side and point of insertion is unknown. OBJECTIVE: In this study, we describe guidewire migration location during real time CVC cannulation (right atrium versus IVC) and report the association between the insertion site and side of the CVC and the location of guidewire migration, Right Atrium (RA)/Right Ventricle (RV) versus IVC guidewire migration. METHODS: This is a retrospective study in the medical intensive care unit among patients that have received CVC during the study years 2014-2020. The rate of IVC versus right atrium/right ventricle wire migration during the procedure were analyzed. The association between the side and point of CVC insertion and the wire migration site was analyzed as well. RESULTS: One hundred and sixty-six patients were enrolled. 33.7% of wires migrated to the IVC and 66.3% to the versus right atrium/right ventricle. The rate of wire migration to the IVC was similar in the IJV site and the SCV site. There was no association between the side of CVC insertion and wire migration to the IVC. CONCLUSION: About a third of all wire migrations, during CVC Seldinger technique insertion, were identified in the IVC, with no potential for wire associated arrhythmia. There was no association between CVC insertion point (SCV versus IJV) nor the side of insertion and the site of guidewire migration.

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.

Acute thrombotic microangiopathic kidney injury due to Echis coloratus envenomation.

Introduction: We describe two cases of Echis coloratus envenomation associated with thrombotic microangiopathic acute kidney injury (AKI).Case presentation: Two patients, 39 and 70 years old, were hospitalized due to E. coloratus envenomation. Both were treated with anti-venom and blood products due to coagulopathy. Several hours after admission both developed acute kidney injury (creatinine 10.63 and 7.63 mg/dL) associated with hemolysis (lactate dehydrogenase 3858 and 2698 U/L) schistocytosis (49 and 6%) and thrombocytopenia (26 and 30 × 103/µL). A disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 activity was measured only in patient number 2 and was within the normal limits. Both patients were treated with hemodialysis and plasmapheresis (4-6 courses). Both were discharged with normal platelet count, and no hemolysis. Their renal function improved gradually and hemodialysis was discontinued.Discussion: Following E. coloratus envenomation, both patients described developed hemolytic uremic syndrome-like thrombotic microangiopathy, with thrombocytopenia, intravascular hemolysis and severe AKI. Both recovered after combined treatment with hemodialysis and plasmapheresis.Conclusions:E. coloratus envenomation can cause HUS-like TMA.

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.

A new admission method may select applicants with a distinct personality profile.

BACKGROUND: There is little data to suggest that a specific admission method can select students with a distinct personality profile. We have recently introduced a new admission process that combines a computerized personality test, with a single interview. The purpose of the current study was to find whether the new method selects applicants with a different personality profile and attitudes compared with the previous method. METHOD: Using a validated personality questionnaire (HEXACO) and attitudes questionnair, that were filled anonymously between November 2014 and May 2015, the authors compared two groups of students: group A comprising students accepted with the new method (first and second year) with group B comprising students accepted with the previous method (third to sixth year). RESULTS: In group A, 157 responded out of 250 (63%), while in group B 194 out of 352 (55%). Group A students ranked significantly higher in honesty-humility, extraversion, agreeableness and openness to experience, and lower in emotionality. Physicians' role in society was perceived to be more meaningful among Group A students (M = 4.19, SD = 0.50, N = 152) compared to Group B students (M = 3.86, SD = 0.57, N = 184). CONCLUSIONS: The new method may select applicants with a distinct personality profile and different attitudes toward the physicians' role in the society.

A Burkholderia pseudomallei Infection Imported from Eritrea to Israel.

Although it has been predicted that melioidosis is probably endemic in the Horn of Africa, no confirmed cases have ever been detected in the region. We have recently isolated Burkholderia pseudomallei from an Eritrean patient in Israel. The isolate was assigned a novel multilocus sequence type (ST-1479). The observation has important epidemiological implications in an era of massive human migration.

Admission cell free DNA levels predict 28-day mortality in patients with severe sepsis in intensive care.

AIM: The aim of the current study is to assess the mortality prediction accuracy of circulating cell-free DNA (CFD) level at admission measured by a new simplified method. MATERIALS AND METHODS: CFD levels were measured by a direct fluorescence assay in severe sepsis patients on intensive care unit (ICU) admission. In-hospital and/or twenty eight day all-cause mortality was the primary outcome. RESULTS: Out of 108 patients with median APACHE II of 20, 32.4% have died in hospital/or at 28-day. CFD levels were higher in decedents: median 3469.0 vs. 1659 ng/ml, p<0.001. In multivariable model APACHE II score and CFD (quartiles) were significantly associated with the mortality: odds ratio of 1.05, p = 0.049 and 2.57, p<0.001 per quartile respectively. C-statistics for the models was 0.79 for CFD and 0.68 for APACHE II. Integrated discrimination improvement (IDI) analyses showed that CFD and CFD+APACHE II score models had better discriminatory ability than APACHE II score alone. CONCLUSIONS: CFD level assessed by a new, simple fluorometric-assay is an accurate predictor of acute mortality among ICU patients with severe sepsis. Comparison of CFD to APACHE II score and Procalcitonin (PCT), suggests that CFD has the potential to improve clinical decision making.