OBJECTIVE: Mean arterial pressure (MAP) plays a significant role in regulating tissue perfusion and urine output (UO). The optimal MAP target in critically ill patients remains a subject of debate. We aimed to explore the relationship between MAP and UO. DESIGN: A retrospective observational study. SETTING: A general ICU in a tertiary medical center. PATIENTS: All critically ill patients admitted to the ICU for more than 10 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: MAP values and hourly UO were collected in 5,207 patients. MAP levels were categorized into 10 groups of 5 mm Hg (from MAP < 60 mm Hg to MAP > 100 mg Hg), and 656,423 coupled hourly mean MAP and UO measurements were analyzed. Additionally, we compared the UO of individual patients in each MAP group with or without norepinephrine (NE) support or diuretics, as well as in patients with acute kidney injury (AKI). Hourly UO rose incrementally between MAP values of 65–100 mm Hg. Among 2,226 patients treated with NE infusion, mean UO was significantly lower in the MAP less than 60 mm Hg group (53.4 mL/hr; 95% CI, 49.3–57.5) compared with all other groups (p < 0.001), but no differences were found between groups of 75 less than or equal to MAP. Among 2500 patients with AKI, there was a linear increase in average UO from the MAP less than 60 mm Hg group (57.1 mL/hr; 95% CI, 54.2–60.0) to the group with MAP greater than or equal to 100 mm Hg (89.4 mL/hr; 95% CI, 85.7–93.1). When MAP was greater than or equal to 65 mm Hg, we observed a statistically significant trend of increased UO in periods without NE infusion. CONCLUSIONS: Our analysis revealed a linear correlation between MAP and UO within the range of 65–100 mm Hg, also observed in the subgroup of patients treated with NE or diuretics and in those with AKI. These findings highlight the importance of tissue perfusion to the maintenance of diuresis and achieving adequate fluid balance in critically ill patients.

Background: Measuring energy expenditure (EE) by indirect calorimetry (IC) has become the gold standard tool for critically ill patients to define energy targets and tailor nutrition. Debate remains as to the optimal duration of measurements or the optimal time of day in which to perform IC.Methods: In this retrospective longitudinal study, we analyzed results of daily continuous IC in 270 mechanically ventilated, critically ill patients admitted to the surgical intensive care unit in a tertiary medical center and compared measurements performed at different hours of the day.Results: A total of 51,448 IC hours was recorded, with an average 24‐h EE of 1523 ± 443 kcal/day. Night shift (00:00–8:00) was found to have significantly lower EE measurements (mean, 1499 ± 439 kcal/day) than afternoon (16:00–00:00; mean, 1526 ± 435 kcal/day) and morning (8:00–16:00; mean, 1539 ± 462 kcal/day) measurements (P < 0.001 for all). The bi‐hourly time frame that most closely resembled the daily mean was 18:00–19:59, with a mean of 1521 ± 433 kcal/day. Daily EE measurements of the continuous IC at days 3–7 of admission showed a trend toward a daily increase in 24‐h EE, but the difference was not statistically significant (P = 0.081).Conclusions: Periodic measurements of EE can differ slightly when performed at various hours of the day, but the error range is small and may not necessarily have a clinical impact. When continuous IC is not available, a 2‐h EE measurement between 18:00 and 19:59 can serve as a reasonable alternative.

Background: Predicting whether extracorporeal membrane oxygenation (ECMO) treatment duration affects prognosis is important both medically and economically. Methods: We conducted a retrospective, multicenter study to better understand the outcomes of patients treated with veno-venous (VV) ECMO over a prolonged duration, analyzing data from the Israel ECMO registry. The study included all adult patients treated with VV-ECMO due to COVID-19-induced respiratory failure. The primary outcomes were survival rates up to 180 days from cannulation. Results: One hundred and eighty-eight patients were included in the study. The median age was 50 years (IQR 42, 50), and 69% were male. Patients were mechanically ventilated for a median of 2.5 days before cannulation (IQR 0.5, 5). The mean ECMO support duration was 29.9 days, with a maximal duration of 189.9 days. The survival rate for 180 days was 56%. We found no change in survival for patients on ECMO for 14, 28, or 56 days. Every day of mechanical ventilation before cannulation correlated with an 11% greater risk for prolonged ECMO treatment (p = 0.01). Conclusions: COVID-19-induced ARDS patients treated with VV-ECMO for prolonged duration had the same prognosis as those treated for short periods of time. The longer the duration of mechanical ventilation before ECMO cannulation, the higher the risk for prolonged ECMO treatment.

Objectives: Chest X-ray (CXR) is routinely required for assessing Central Venous Catheter (CVC) tip position after insertion, but there is limited data as to the movement of the tip location during hospitalization. We aimed to assess the migration of Central Venous Catheter (CVC) position, as a significant movement of catheter tip location may challenge some of the daily practice after insertion. Design and settings: Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units in Tel Aviv Sourasky Medical Center ’Ichilov’, Israel, between January and June 2019. Patients: We identified 101 patients with a CVC in the Right Internal Jugular (RIJ) with at least two CXRs during hospitalization. Measurements and results: For each patient, we measured the CVC tip position below the carina level in the first and all consecutive CXRs. The average initial tip position was 1.52 (±1.9) cm (mean±SD) below the carina. The maximal migration distance from the initial insertion position was 1.9 (±1) cm (mean±SD). During follow-up of 2 to 5 days, 92% of all subject’s CVCs remained within the range of the Superior Vena Cava to the top of the right atrium, regardless of the initial positioning. Conclusions: CVC tip position can migrate significantly during a patient’s early hospitalization period regardless of primary location, although for most patients it will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned.

A hiatal hernia causing or aggravating ascites by compressing the hepatic veins has been rarely reported in adults. We report a patient with a known hiatal hernia who was presented with refractory ascites. Echocardiography and CT examination demonstrated a huge hiatal hernia compressing the right atrium and the inferior vena cava. A right-sided heart catheterization demonstrated a significant pressure gradient between the inferior vena cava and the right atrium. Liver biopsy showed a nodular pattern and congestion without fibrosis. Hernioplasty was performed and an improvement in the rate of the accumulation of ascetic fluid was observed. Three months later and during a follow-up period of 3 years, the ascites was mild and there was no need for any therapeutic paracentesis. The outcome indicates that the huge hiatal hernia, by creating hepatic venous outflow obstruction, was the underlying mechanism for ascites aggravation. J Med Cases. 2014;5(11):573-575 doi: http://dx.doi.org/10.14740/jmc1559w