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.

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.

Outcomes of non-COVID-19 critically ill patients with hematologic malignancies a 10-year single-center retrospective analysis.

We report the outcomes of patients with haematological malignancies admitted to ICUs and define pre-ICU prognostic factors for in-hospital mortality. In a retrospective, single-center study, we included all patients with haematologic malignancies admitted to ICUs between 2009 and 2019. The primary outcome was in-hospital mortality. One hundred and forty-four patients with hematologic malignancies were admitted to ICUs during the study period. Fifteen (10.4%) were in remission, 36 (25.0%) were in remission after hematopoietic stem cell transplantation. Acute Leukemias and aggressive lymphomas were the most common diagnoses, occurring in 34.7%. The in-hospital mortality was 49%. The main predictors for in-hospital mortality were age >65 years, post allogeneic hematopoietic stem cell transplantation, non-remission, respiratory rate >22 bpm, bilirubin >2 mg/dl, PH< 7.35, and time from hospital admission to ICU transfer ≥3 days. In-hospital mortality of patients with hematologic malignancies admitted to ICU was 49%. We identified pre-ICU parameters that predict in-hospital mortality.

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.

[Atrial fibrillation in medical intensive care unit patients: characteristics and consequences].

BACKGROUND: There is scarcity of data on atrial fibrillation (AF) prevalence and outcomes in critically ill patients admitted to the non-cardiac Intensive Care Unit (ICU). AIM: The purpose of our study was to prospectively assess the incidence, risk factors and prognosis of new onset atrial fibrillation in a medical non-cardiac ICU population. METHODS: A prospective single center observational study was conducted in an 8-bed adult Medical Intensive Care Unit (MICU). The patients at the MICU were continuously monitored throughout their stay, once an irregularly irregular rhythm was recorded, a confirmative 12-leads ECG was performed and the incidence, duration of the atrial fibrillation and clinical signs of the patient were logged into the computerized patient file. RESULTS: A total of 209 patients were included in the study; 23 of these patients developed AF during the hospital stay. Out of the 209 patients, 26% died during the period of hospitalization. There were a few significant differences between the AF group and the non-AF group including age (67 vs. 49, p < 0.001), proportion of Arab Bedouins (4% vs. 28%, p = 0.01), prevalence of coronary heart disease (39% vs. 10%, p < 0.001), paroxysmal atrial fibrillation (52% vs. 3%, p < 0.001), hypertension (70% vs. 31%, p < 0.001 and dyslipidemia 166% vs. 24%, p < 0.001). The APACHE II scores were similar in both groups. In the AF group, there were more patients with sepsis at admission compared with the non-AF group. Age, length of stay, paroxysmal atrial fibrillation (PAF) and dyslipidemia were independent factors for the AF development. AF occurrence adjusted for APACHE-II score was not a significant predictor of death during hospitalization (OR = 1.55, p = 0.38). CONCLUSIONS: The development of AF is more prevalent in patients with PAF. Development of AF was not found to be an independent mortality risk factor.

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.

Temporal trends in patient characteristics and survival of intensive care admissions with sepsis: a multicenter analysis*.

OBJECTIVE: To estimate in-hospital, 1-yr, and long-term mortality and to assess time trends in incidence and outcomes of sepsis admissions in the intensive care unit. DESIGN: A population-based, multicenter, retrospective cohort study. PATIENTS: Patients hospitalized with sepsis in the intensive care unit in seven general hospitals in Israel during 2002-2008. INTERVENTIONS: None. MEASUREMENTS: Survival data were collected and analyzed according to demographic and background clinical characteristics, as well as features of the sepsis episode, using Kaplan-Meier approach for long-term survival. MAIN RESULTS: A total of 5,155 patients were included in the cohort (median age: 70, 56.3% males; median Charlson comorbidity index: 4). The mean number of intensive care unit admissions per month increased over time, while no change in in-hospital mortality was observed. The proportion of patients surviving to hospital discharge was 43.9%. The 1-, 2-, 5-, and 8-yr survival rates were 33.0%, 29.8%, 23.3%, and 19.8%, respectively. Mortality was higher in older patients, patients with a higher Charlson comorbidity index, and those with multiorgan failure, and similar in males and females. One-year age-standardized mortality ratio was 21-fold higher than expected, based on the general population rates. CONCLUSIONS: Mortality following intensive care unit sepsis admission remains high and is correlated with underlying patients' characteristics, including age, comorbidities, and the number of failing organ systems.

The effect of rosuvastatin on incident pneumonia: results from the JUPITER trial.

BACKGROUND: Evidence from observational studies have raised the possibility that statin treatment reduces the incidence of certain bacterial infections, particularly pneumonia. We analyzed data from a randomized controlled trial of rosuvastatin to examine this hypothesis. METHODS: We analyzed data from the randomized, double-blind, placebo-controlled JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin). In this trial, 17,802 healthy participants (men 50 years and older and women 60 and older) with a low-density lipoprotein (LDL) cholesterol level below 130 mg/dL (3.4 mmol/L) and a high-sensitivity C-reactive protein level of 2.0 mg/L or greater were randomly assigned to receive either rosuvastatin or placebo. We evaluated the incidence of pneumonia on an intention-to-treat basis by reviewing reports of adverse events from the study investigators, who were unaware of the treatment assignments. RESULTS: Among 17,802 trial participants followed for a median of 1.9 years, incident pneumonia was reported as an adverse event in 214 participants in the rosuvastatin group and 257 in the placebo group (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.69-1.00). In analyses restricted to events occurring before a cardiovascular event, pneumonia occurred in 203 participants given rosuvastatin and 250 given placebo (HR 0.81, 95% CI 0.67-0.97). Inclusion of recurrent pneumonia events did not modify this effect (HR 0.81, 95% CI 0.67-0.98), nor did adjustment for age, sex, smoking, metabolic syndrome, lipid levels and C-reactive protein level. INTERPRETATION: Data from this randomized controlled trial support the hypothesis that statin treatment may modestly reduce the incidence of pneumonia. (ClinicalTrials.gov trial register no. NCT0023968.).

Diabetic ketoacidosis: clinical characteristics, precipitating factors and outcomes of care.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes mellitus (DM). OBJECTIVES: To evaluate the clinical characteristics, hospital management and outcomes of patients with DKA. METHODS: We performed a retrospective cohort study of patients hospitalized with DKA during the period 1 January 2003 to 1 January 2010. Three groups were compared: patients with mild DKA, with moderate DKA, and with severe DKA. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30 days all-cause mortality, length of hospital stay, and complication rate. RESULTS: The study population comprised 220 patients with DKA. In the mild (78 patients) and moderate (116 patients) groups there was a higher proportion of patients with type 1 DM (75.6%, 79.3%) compared with 57.7% in the severe group (26 patients, P = 0.08). HbA1c levels prior to admission were high in all three groups, without significant difference (10.9 +/- 2.2, 10.7 +/- 1.9, and 10.6 +/- 2.4 respectively, P = 0.9). In all groups the most frequent precipitating factors were related to insulin therapy and infections. The patients with severe DKA had more electrolyte abnormalities (hypokalemia, hypomagnesemia, hypophosphatemia) compared with the mild and moderate forms of the disease. While 72.7% of the entire cohort was hospitalized in the general medical ward, 80.8% of those with severe DKA were admitted to the intensive care unit. The in-hospital mortality rate for the entire cohort was 4.1%, comparable with previous data from experienced centers. Advanced age, mechanical ventilation and bedridden state were independent predictors associated with 30 day mortality: hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02-1.11; HR 6.8, 95% CI 2.03-23.1; and HR 3.8, 95% CI 1.13-12.7, respectively. CONCLUSIONS: Patients with DKA in our study were generally poorly controlled prior to their admission, as reflected by high HbA1c levels. Type 2 DM is frequently associated with DKA including the severe form of the disease. The most common precipitating factors for the development of DKA were related to insulin therapy and infections. Advanced age, mechanical ventilation and bedridden state wer independent predictors of 30 day mortality.

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.

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.

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.

Ionic currents in the presence of supporting electrolytes.

We analyze one-dimensional charge conduction within an ionic solution in the presence of supporting electrolytes that do not discharge on the electrodes. For thin Debye layers, numerical simulations predict current abatement, in agreement with experimental knowledge; in addition, they reveal unconventional features absent from classical analyses of binary solutions, such as high cation concentration near the electrodes. We derive a companion asymptotic description of the problem in the singular thin-Debye-layer limit, reproducing these attributes. The asymptotic analysis reveals a nested boundary-layer structure about the reactive electrodes and furnishes a universal current-voltage relation.

[Bedside percutaneous tracheostomy in critically ill medical patients: clinical characteristics, outcome and complications].

BACKGROUND: Tracheostomy is a surgical procedure, frequently used in patients with respiratory failure requiring prolonged mechanical ventilation. It is associated with fewer complications and may facilitate weaning from mechanical ventilation. Over the past 15 years, bedside percutaneous tracheostomy (PDT) has been widely employed as the primary method for performing tracheostomy in intensive care units. However, the ideal technique and timing for this procedure is still controversial. OBJECTIVES: To characterize the patients who underwent bedside percutaneous tracheostomy (PDT) in the Medical Intensive Care Unit (MICU) in terms of complications, clinical characteristics upon admission, short and long term outcome. METHODS: This retrospective cohort study included all patients hospitalized at the MICU from January 2003 to December 2007 who underwent bedside PDT. The patients' demographic data, past diagnosis, reason for admission to the ICU and a wide variety of data regarding procedure performance and complications were retrieved from the patients' charts. The information was subsequently computerized and analyzed. RESULTS: The study population included 126 patients who underwent bedside PDT. Overall, 63.5% were men and the average age was 59.8 years. Patients who survived for 30 days after the procedure had a lower burden of background morbidity as reflected by their Charlson score. The one year mortality rate was 56.6%, of which 70% of the patients died in the first month following the procedure. Overall complication rate was low and occurred in 9 patients (7.1%). There was no procedure-related mortality. The most common pathogens isolated from patients' sputum were Acinetobacter spp. and Pseudomonas aeruginosa. The survival rate was highest among the group of patients who underwent tracheostomy during the first 10 days after initiation of mechanical ventilation. CONCLUSIONS: Bedside PDT is a simple, safe and readily available procedure with low morbidity rates when performed by an experienced operator. However, long term outcome remains poor Survival rates were lower among patients who underwent the procedure within ten days of mechanical ventilation.