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.

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.

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.

Background: Nitric oxide (NO) plays a key role in various physiological processes. Inhaled NO (iNO) has been studied for treating acute respiratory distress syndrome (ARDS). During the COVID-19 pandemic, interest grew in its potential role for patients with COVID-19 ARDS, with studies showing improved oxygenation over 48 h. Methods: This is a retrospective study of adult patients with severe COVID-19 ARDS and refractory hypoxemia admitted to the medical ICU requiring mechanical ventilation and treated with iNO. The effect on oxygenation, respiratory, and ventilation parameters is measured. Significant improvement is defined as an increase in PaO₂/FiO₂ ≥ 20% from a baseline. Results: This study includes 87 patients (55 men, mean age 58.7 ± 15.2) with 164 iNO connections (mean 1.9 per patient). iNO is independently associated with a significant PaO₂/FiO₂ ratio improvement, with an OR of 1.26 (95% CI 1.09–1.46), even after accounting for these potential confounders. The time to maximal PaO₂/FiO₂ improvement is 14.5 ± 5.0 h for men and 78.5 ± 5.5 h for women, with respective ratio increases of 42.5 ± 8.1 and 52.5 ± 13.6 mmHg. Conclusions: Our study demonstrates that severe ARDS COVID-19 patients may benefit from inhaled nitric oxide, with delayed oxygenation improvements lasting up to 96 h and slower responses observed in women, raising the possibility that current guidelines against its use could be reconsidered.