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Purpose To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. Methods An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. Results The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. Conclusions These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Background Since the first COVID-19 patient in Saudi Arabia (March, 2020) more than 338,539 cases and approximately 4996 dead were reported. We present the main characteristics and outcomes of critically ill COVID-19 patients that were admitted in the largest Ministry of Health Intensive Care Unit (ICU) in Saudi Arabia. Methods This retrospective study, analyzed routine epidemiologic, clinical, and laboratory data of COVID-19 critically ill patients in King Saud Medical City (KSMC), Riyadh, Saudi Arabia, between March 20, 2020 and May 31, 2020. Severe acute respiratory syndrome coronavirus-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction assays performed on nasopharyngeal swabs in all enrolled cases. Outcome measures such as 28-days mortality, duration of mechanical ventilation, and ICU length of stay were analyzed. Results Three-hundred-and-fifty-two critically ill COVID-19 patients were included in the study. Patients had a mean age of 50.63 ± 13.3 years, 87.2% were males, and 49.4% were active smokers. Upon ICU admission, 56.8% of patients were mechanically ventilated with peripheral oxygen saturation/fraction of inspired oxygen (SpO 2 /FiO 2 ) ratio of 158 ± 32. No co-infections with other endemic viruses were observed. Duration of mechanical ventilation was 16 (IQR: 8–28) days; ICU length of stay was 18 (IQR: 9–29) days, and 28-day mortality was 32.1%. Multivariate regression analysis showed that old age [Odds Ratio (OR): 1.15, 95% Confidence Intervals (CI): 1.03–1.21], active smoking [OR: 3, 95% CI: 2.51–3.66], pulmonary embolism [OR: 2.91, 95% CI: 2.65–3.36), decreased SpO 2 /FiO 2 ratio [OR: 0.94, 95% CI: 0.91–0.97], and increased lactate [OR: 3.9, 95% CI: 2.4–4.9], and d -dimers [OR: 2.54, 95% CI: 1.57–3.12] were mortality predictors. Conclusion Old age, active smoking, pulmonary embolism, decreased SpO 2 /FiO 2 ratio, and increased lactate and d -dimers were predictors of 28-day mortality in critically ill COVID-19 patients.

Objectives To evaluate the safety of therapeutic plasma exchange (TPE) in adult patients with serious/life-threatening COVID-19 requiring intensive care unit (ICU) admission, and associated 28-day mortality. Serious and life threatening COVID-19 are defined as per published literature (please, refer to the full protocol, Additional file 1 ). The rationale is that TPE can remove interleukins-3, 6, 8, 10, interferon-gamma and tumor necrosis factor-alpha. Thus, it may reduce the cytokine release syndrome associated with fulminant COVID-19 disease. Trial design Pilot, interventional, open-label, randomized controlled multicenter trial. Participants Inclusion criteria are: 1) age ≥ 18 years old; 2) intubation and intensive care unit (ICU) admission; 3) serious and/or life-threatening COVID-19 (please, refer to the full protocol, Additional file 1 ). SARS-CoV-2 infection is confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR) assays using QuantiNova Probe RT-PCR kit (Qiagen) in a Light-Cycler 480 real-time PCR system (Roche, Basel, Switzerland). Exclusion criteria are: 1) previous allergic reaction to plasma exchange or its ingredients (i.e., sodium citrate), 2) two consecutive negative RT-PCR tests for SARS-CoV-2 at least 24 hours apart, 3) mild COVID-19 not requiring ICU admission and 4) terminally ill patients receiving palliative care. The primary site will be King Saud Medical City (KSMC), Riyadh, Kingdom of Saudi Arabia (KSA). Also, the study will run in ICUs (Ministry of Health Cluster 1; Riyadh) and other centers in KSA pending their institutional review board (IRB) approval. Interventions and comparator The intervention group will receive TPE, plus empiric treatment for COVID-19. TPE is administered using the Spectra Optia TM Apheresis System equipped with commercially available cartridges). The first dose is 1.5 plasma volumes, followed by one plasma volume on alternate days or daily for five to seven total treatments. Spectra Optia TM Apheresis System operates with acid-citrate dextrose anticoagulant (ACDA) as per Kidney Disease Improving Global Outcomes (KDIGO) 2019 guidelines. Plasma is replaced with albumin 5% or fresh frozen plasma in patients with coagulopathy (prothrombin time >37 seconds; international normalized ratio >3; activated partial thromboplastin time >100 or fibrinogen level <100 mg/d). TPE sessions are performed daily over four hours and laboratory markers measured daily. The comparators are controls not receiving TPE but usual empiric treatment for COVID-19 as per institutional, national and international recommendations. Both groups will receive standard ICU supportive care. Main outcomes Primary study end-point is 28-day mortality and safety of TPE in serious and/or life-threatening COVID-19. Safety will be evaluated by the documentation of any pertinent adverse and/or serious adverse effects related to TPE as per institutional, national and international (Food and Drug Administration) guidelines. Secondary outcomes are: i) improvement in Sequential Organ Function Assessment (SOFA) score ; ii) changes in inflammatory markers: serum C-reactive protein, lactate dehydrogenase, ferritin, d-dimers and interleukin-6; iii) days on mechanical ventilation and ICU length of stay. Randomization Eligible consented patients are randomized (1:1 allocation) after stratification by ICU center and two PaO2/FIO2 ratio categories (> 150 and ≤ 150). Randomization occurs in variable block sizes of four to eight patients. A web-based randomization service, randomize.net , is used to allocate patients to their respective strata prior to the intervention or control therapy. Blinding (masking) Given the visibility of TPE machinery, the intervention will be unblinded; hence, no enrollment concealment will be expedited. The lack of allocation concealment will be mitigated by several measures (please, refer to the full protocol, Additional file 1 ). Numbers to be randomized (sample size) This pilot randomized trial aims to recruit a convenience sample of patients with serious and/or life-threatening COVID-19. Therefore, at least 20 patients are to be randomized to each group per participating center. We are hoping to consent and randomize approximately 60 patients in each group over a 3 to 6 months period giving a total of 120 participants. Trial Status The protocol version 1 was approved 29/04/2020. Recruitment is ongoing, and began on 01/05/2020. We estimate completion by 29/10/2020. Trial registration Registered at ISRCTN on 18/05/2020 (ISRCTN21363594; doi.10.1186/ ISRCTN21363594). Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1 ). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.

Background Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE). Case presentation A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition. Conclusion Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.

We present a case series of three patients with COVID-19 who were admitted to our intensive care unit due to acute respiratory distress syndrome, brain infarction, pulmonary embolism, and antiphospholipid antibodies. We applied therapeutic plasma exchange on all cases. On intensive care unit admission, all patients had low (<10) Glasgow Coma Scale, and central nervous imaging showed multiple brain infarctions. COVID-19 was confirmed by reverse transcriptase polymerase chain reaction assays. Patients underwent rescue therapeutic plasma exchange using the Spectra OptiaTM Apheresis System (Terumo BCT Inc., USA), which operates with acid-citrate dextrose anticoagulant as per Kidney Disease Improving Global Outcomes 2019 guidelines. A dose of 1.5 plasma volume was used for the first dose and then 1 plasma volume daily for a total of five doses. Plasma was replaced with Octaplas LG® (Octapharma AG, USA), which is an artificial fresh frozen plasma product that has undergone viral inactivation by prion reduction technology. We administered ARDS-net/prone positioning ventilation, empiric antiviral treatment, therapeutic anticoagulation, and intensive care unit supportive care. Laboratory tests showed lymphocytopenia; elevated levels of D-dimer, fibrinogen, total bilirubin, C-reactive protein, lactate dehydrogenase, and ferritin; as well as low levels of ADAMTS-13 activity and antibody. Serology tests depicted positive IgM and IgG antiphospholipid antibodies (anti-cardiolipin and anti-β2-glycoprotein I antibodies). No side effects of therapeutic plasma exchange were recorded. After the completion of therapeutic plasma exchange, patients improved clinically and gradually recovered neurologically (after 27–32 days). To conclude, in life-threatening COVID-19, especially when immune dysregulation features such as antiphospholipid antibodies exist, therapeutic plasma exchange could be an effective rescue therapy.

Objective Quick-look ultrasound with a skin mark (UM) has been frequently used for central vein cannulation. The aim of this study is to compare this method with landmark (LM) and ultrasound-guided (UG) cannulation of jugular and femoral veins by inexperienced operators. Design Prospective randomized single-center study. Setting A medical intensive care unit (ICU) of a university medical center. Patients Patients requiring jugular or femoral central cannula placement. Intervention Each inexperienced resident randomly inserted a central venous line using the UM, LM or UG technique. Measurements and findings The primary outcome was the success rate, and secondary outcomes were the placement time, number of attempts, mechanical complication rate, and catheter colonization rate. A total of 118 patients were randomly assigned to the three groups. The mean age of patients included in the study was 65 ± 15 years, and the mean Simplified Acute Physiology Score 2 (SAPS2) was 57 ± 20. The success rate was higher in the UG group than in the LM and UM groups (100, 74, and 73 %, respectively; p  = 0.01). The total number of mechanical complications was higher in the LM and UM groups than in the UG group (24 and 36 versus 0 %, respectively; p  = 0.01). The number of attempts and the access time were higher in the LM group than in the UG group, but not compared with the UM group. No difference in terms of catheter colonization was observed between the three groups. Conclusions Ultrasound-guided cannulation of the internal jugular or femoral vein by inexperienced residents appears to be more reliable than the LM or UM methods and was associated with a lower mechanical complication rate among ICU patients.

In circulatory failure, fluid administration limited by lung sonography protocol uses lung ultrasound artifacts and makes sequential diagnosis of obstructive, cardiogenic, hypovolemic, and septic shock. Lung ultrasound is used along with simple cardiac and vena cava analysis. Whenever echocardiography cannot be performed, fluid administration limited by lung sonography protocol is favored because of its simplicity and could prove contributive. It is based on the presence (B profile) or the absence (A profile) of interstitial pulmonary edema. However, the latter does not represent actual alveolar edema, and transthoracic echocardiography is still used by intensivists as a pivotal hemodynamic measure. Tissue Doppler imaging facilitates the estimation of left ventricular filling pressures, whereas assessing right ventricular function is of prognostic value in states of shock due to massive pulmonary embolism and acute respiratory distress syndrome. In mechanically ventilated patients, poor acoustic windows are evident and performing transesophageal echocardiography may be necessary. Whenever noninvasive hemodynamic measures are inconclusive, in a deteriorating patient, a pulmonary artery catheter may be placed. Ultrasound is not a therapy but a guide for treatment, and physicians should aim to treat underlying pathologies. Despite its limitations, general chest ultrasound (lung and cardiac ultrasound) is a powerful diagnostic and monitoring tool reflecting an era of genuine “visual” medicine.

Ultrasound assessment of optic nerve sheath diameter (ONSD) has been suggested as a non-invasive measure of intracranial pressure. Numerous small studies suggest its validity; however, discrepancy exists around normal values for ONSD. In this study we sought to define a normal value range for ONSD in a population of healthy adult volunteers. ONSD was measured in healthy adult volunteers and a normal range was defined using descriptive statistics. A regression analysis was used to determine relationship between ONSD measurements and sex, age, height and weight. One hundred twenty adults were recruited (age 18-65 [mean 29.3]) with 55 male and 65 female subjects. Mean ONSD was 3.68 mm (95% confidence interval [CI], 2.85-4.40). Upon regression analysis, mean ONSD did not vary with age, weight, or height but did vary with sex. Mean ONSD measurements for men were 3.78 mm (95% CI, 3.23-4.48) compared with 3.60 mm (95% CI, 2.83-4.11) for women. This study has defined the range of ONSD in a healthy cohort of volunteers. The lack of relationship to age, weight and height is similar to other studies but this is the first study to find a difference depending on sex suggesting the possible need for separate reference ranges for men and women.

Introduction Edwardsiella tarda uncommonly infects humans. The usual presentation is mild gastroenteritis, but systemic manifestations may occur. Lethal infections are rarely documented in patients with underlying disorders. Case presentation A previously healthy 37-year-old Southeast Asian woman presented to our hospital with recent onset of abdominal pain, fever, and vomiting. Her condition rapidly deteriorated with signs and symptoms of fulminant septic shock; thus, she was intubated, supported with intravenous vasopressors and fluids, and transferred to the intensive care unit. An abdominal computed tomographic scan with contrast revealed multiple liver abscesses. Blood cultures were obtained and computed tomography–guided percutaneous drainage of the liver abscesses with supplementary cultures was performed; thereafter, empirical broad-spectrum antibiotics were initiated. All cultures grew E. tarda , whereas an antibiogram showed resistance to broad-spectrum antibiotics and sensitivity to ciprofloxacin and aminoglycosides; thus, the antibiotic regimen was updated accordingly. The patient made an uneventful recovery and was discharged from the intensive care unit 14 days after admission. Conclusion E. tarda human infection can present as liver abscess and fulminant septic shock. E. tarda strains can be resistant to broad-spectrum antibiotics; hence, culture-based antibiotics should be used accordingly. Clinicians should be aware of this rare and potentially lethal infection.

Peripheral neuropathies including Guillain‐Barré syndrome may be linked to life‐threatening COVID‐19. Plasma exchange is a safe rescue therapy in severe COVID‐19 with associated neurological manifestations and thromboinflammation. Peripheral neuropathies including Guillain‐Barré syndrome may be linked to life‐threatening COVID‐19. Plasma exchange is a safe rescue therapy in severe COVID‐19 with associated neurological manifestations and thromboinflammation.