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Papers by moti klein

Research paper thumbnail of The Clinical Significance of Fluctuations in the Minute-to-minute Urine Flow Rate and in its Minute-to-minute Variability During Septic Events in Critically Ill Patients

Romanian Journal of Anaesthesia and Intensive Care, 2020

Background Septic events complicated by hemodynamic instability can lead to decreased organ perfu... more Background Septic events complicated by hemodynamic instability can lead to decreased organ perfusion, multiple organ failure, and even death. Acute renal failure is a common complication of sepsis, affecting up to 50-70 % of cases, and it is routinely diagnosed by close monitoring of urine output. We postulated that analysis of the minute-to-minute changes in the urine flow rate (UFR) and also of the changes in its minute-to-minute variability might lead to earlier diagnosis of renal failure. We accordingly analyzed the clinical significance of these two parameters in a group of critically ill patients suffering from new septic events. Methods The study was retrospective and observational. Demographic and clinical data were extracted from the hospital records of 50 critically ill patients who were admitted to a general intensive care unit (ICU) and developed a new septic event characterized by fever with leukocytosis or leukopenia. On admission to the ICU, a Foley catheter was inse...

Research paper thumbnail of Hypotensive Episode Prediction in ICUs via Observation Window Splitting

Hypotension, defined as dangerously low blood pressure, is a significant risk factor in intensive... more Hypotension, defined as dangerously low blood pressure, is a significant risk factor in intensive care units (ICUs), which requires a prompt therapeutic intervention. The goal of our research is to predict an impending Hypotensive Episode (HE) by time series analysis of continuously monitored physiological vital signs. Our prognostic model is based on the last Observation Window (OW) at the prediction time. Existing clinical episode prediction studies used a single OW of 5–120 min to extract predictive features, with no significant improvement reported when longer OWs were used. In this work we have developed the In-Window Segmentation (InWiSe) method for time series prediction, which splits a single OW into several sub-windows of equal size. The resulting feature set combines the features extracted from each observation sub-window and then this combined set is used by the Extreme Gradient Boosting (XGBoost) binary classifier to produce an episode prediction model. We evaluate the p...

Research paper thumbnail of Adult Multisystem Inflammatory Syndrome Mimicking Toxic Shock Syndrome in a Patient Who Recovered from COVID-19

The Israel Medical Association journal : IMAJ, 2022

Research paper thumbnail of The clinical significance of hyperglycemia in nondiabetic critically ill multiple trauma patients

Therapeutic Advances in Endocrinology and Metabolism, 2018

Background: Information is inconsistent regarding the clinical role of acute elevations of blood ... more Background: Information is inconsistent regarding the clinical role of acute elevations of blood glucose level secondary to hospital-acquired infections in nondiabetic critically ill patients during an intensive care unit stay. In this study we investigated the clinical significance of hyperglycemia related to new episodes of ventilator-associated pneumonia in nondiabetic critically ill multiple trauma intensive care unit patients. Materials and Methods: We analyzed the clinical data of 202 critically ill multiple trauma patients with no history of previous diabetes who developed a new ventilator-associated pneumonia episode during their intensive care unit stay. We used a time-from-event analysis method to assess whether acute changes in blood glucose levels that occurred prior to the onset of ventilator-associated pneumonia episodes had a different prognostic significance from those that occurred during such episodes. Glucose levels and other laboratory data were recorded for up t...

Research paper thumbnail of Survival of critically ill patients hospitalized in and out of intensive care*

Critical Care Medicine, 2007

The demand for intensive care beds far exceeds their availability in many European countries. Con... more The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. Five acute care Israeli hospitals. All patients fitting a priori developed study criteria. None. Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time. The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.

Research paper thumbnail of The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right

Archives of Orthopaedic and Trauma Surgery, 2007

Background: It is common practice to link lower back pain with protruding discs. Because pain cau... more Background: It is common practice to link lower back pain with protruding discs. Because pain caused by sacroiliac join dysfunction can mimic discogenic or radicular low back pain, orthopedics often assume that the diagnosis of SI join dysfunction is frequently overlooked. Low back pain is second to common cold as a cause of primary care of ce visits in the USA. Approximately 90% of adults have experienced back pain at some point of time in their lives. In any 12-month period, 7% of adults will consult for this complaint. Purpose: To access the incidence of SI joint dysfunction in patients with lower back pain and positive disc ndings on CT scan or MRI, but without claudication or objective neurological de cits. Methods: From January-July 2003, 200 patients were referred for the rst time for epidural steroid injection due to low back pain. 50 patients with low back pain and disc herniation with positive pain provocation tests for SI joint dysfunction were submitted to uoroscopic diagnostic SI joint in ltration. 35 patients reported low back pain began after a trauma (in 28 a road accident and in 7 a work accident) and 10 after lifting a load. In the remaining patients the cause was unknown. Results: Mean baseline VAS pain score was 7.8 ± 1.77 (range 5-10). 30 minutes after in ltration, the mean VAS score was 1.3 ± 1.76 (with average deviation from mean = 1.30). 46 patients had a VAS score ranging from 0-3, 8 weeks after the uoroscopic guided in ltration. Conclusion: SI joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients. Although patient follow-up was 3 months some conclusions can be drawn from these ndings: (1) the incidence of SI joint dysfunction in patients with low back pain and discopathy on CT or MRI scans and without neurological de cits appears to be higher than previously described, (2) pain in the SI joint dysfunction can radiate towards the calf and foot mimicking radicular pain, (3) uoroscopy guided SI joint in ltration leads to signi cant pain reduction. SI Joint Key Points: • It is common for pain from the SI joint to mimic discogenic or radicular low back pain. • Many patients go on to receive lumbar fusion instead of SI joint fusion, so SI joint disease should be strongly considered in differential diagnosis of low back pain. • Estimation of prevalence of SI joint dysfunction, using fluoroscopic infiltration as the basis of diagnosis, ranges from 13 to 30%. The prevalence is even higher after failed back surgery, reaching about 63%. • The incidence of SI joint dysfunction in patients with low back pain and discopathy on CT or MRI scans, appears to be higher than previously described.

Research paper thumbnail of Retrograde tracheal intubation: beyond fibreoptic endotracheal intubation

Acta Anaesthesiologica Scandinavica, 2004

Flexible fibreoptic laryngoscopy is the method of choice for coping with difficult tracheal intub... more Flexible fibreoptic laryngoscopy is the method of choice for coping with difficult tracheal intubations, a leading cause of catastrophic outcomes in anaesthesia. However, this technique is not always available or feasible. Retrograde intubation is a minimally invasive airway management technique with a flat learning curve and a high level of skill retention. A retrospective review of the anaesthesia records of 24 patients who underwent retrograde intubation. The success rate and the incidence of complications were recorded. Retrograde tracheal intubation was successful in all 24 patients. In 21 patients it succeeded on the first attempt. In two patients it succeeded when the technique was changed from sliding over a guide wire to a pulling technique. The most common complication was a sore throat in almost 60% of the patients. Two patients had mild subcutaneous emphysema and one had minimal bleeding at the puncture site. In these patients retrograde tracheal intubation was easy to perform, had a high success rate and a low incidence of complications. It is a reliable alternative when fibreoptic intubation is precluded, fails or is unavailable.

Research paper thumbnail of Potassium Level Variation Following Packed Cell Transfusion in Critically Ill Adult Patients—How Alert Should We Be?

Journal of Clinical Medicine

One of the most clinically important effects following the administration of packed cell transfus... more One of the most clinically important effects following the administration of packed cell transfusion (PCT) is hyperkalemia, which can cause severe life-threatening cardiac arrhythmias. This retrospective population-based cohort study included adults hospitalized between January 2007 and December 2019 in a general intensive care unit for 24 h or more, with normal levels of serum potassium on admission. We assessed changes in serum potassium levels after administration of one unit of packed cells and sought to identify clinical parameters that may affect these changes. We applied adjusted linear mixed models to assess changes in serum potassium. The mean increase in serum potassium was 0.09 mEq/L (C.U 0.04–0.14, p-value < 0.001) among the 366 patients who were treated with a single PCT compared to those not treated with PCT. Increased serum potassium levels were also found in patients who required mechanical ventilation, and to a lesser degree in those treated with vasopressors. Hy...

Research paper thumbnail of Corrigendum to “Clinical Outcomes of Critically Ill Patients Using Inhaled Nitric Oxide (iNO) during Intrahospital Transport”

Critical Care Research and Practice, 2021

Research paper thumbnail of Estimation of Potassium Changes Following Potassium Supplements in Hypokalemic Critically Ill Adult Patients–A Patient Personalized Practical Treatment Formula

Journal of Clinical Medicine, 2021

Hypokalemia is common among critically ill patients. Parenteral correction of hyperkalemia depend... more Hypokalemia is common among critically ill patients. Parenteral correction of hyperkalemia depends on dosages and patient characteristics. Our aims were to assess changes in potassium levels following parenteral administration, and to derive a formula for predicting rises in serum potassium based on patient characteristics. We conducted a population-based retrospective cohort study of adults hospitalized in a general intensive care unit for 24 h or more between December 2006 and December 2017, with hypokalemia. The primary exposures were absolute cumulative intravenous doses of 20, 40, 60 or 80 mEq potassium supplement. Adjusted linear mixed models were used to estimate changes in serum potassium. Of 683 patients, 422 had mild and 261 moderate hypokalemia (serum potassium 3.0–3.5 mEq/L and 2.5–2.99 mEq, respectively). Following doses of 20–80 mEq potassium, serum potassium levels rose by a mean 0.27 (±0.4) mEq/L and 0.45 (±0.54) mEq/L in patients with mild and moderate hypokalemia, ...

Research paper thumbnail of Timing of sugammadex administration: a case report

Sugammadex is a relatively new drug used to reverse the effects of rocuronium, a nondepolarizingm... more Sugammadex is a relatively new drug used to reverse the effects of rocuronium, a nondepolarizingmuscle relaxing agent to hasten emergence from general anesthesia. Unlike neostigmineand atropine, its use is not associated with re-curarization or cardiac arrhythmias. Sugammadex carries asmall risk of allergic reactions including anaphylactic shock.We present a case report of a 67 years old woman who underwent an urgent operation for small bowelobstruction. Due to atrial fibrillation (AF) the anesthesiologist administered Sugammadex just beforeskin closure. Soon after the injection, peak inspiratory pressures (PIP) increased precipitously followedby hypotension and increasing tachycardia. For anticipated cardioversion, the chest was exposed andit revealed urticarial. There was severe bronchospasm on auscultation. Treatment of anaphylactic shockwas initiated, the patient improved dramatically and fully recovered.This case is presented to alert practitioners to the importance of a sudden...

Research paper thumbnail of Hypothermia in neurosurgical patients: risk and benefits

Detection of abnormal body temperature facilitates proper diagnosis and evaluation of presenting ... more Detection of abnormal body temperature facilitates proper diagnosis and evaluation of presenting complaints. The inability of any patient to maintain normal body temperature is indicative of a vast number of potentially serious disorders, including infections, neoplasms, shock, toxic reactions, and environmental exposures. Neurosurgical patient are especially vulnerable to temperature changes. More frequently, intraoperative thermal dysregulation results in hypothermia. Our chapter relates dif-ferent ethiology, pathophisiology and clinical strategy of intraoperative hypothermia in neurosurgical patients. Key words: intraoperative hypothermia, neurosurgical patients

Research paper thumbnail of Postponing calls to EMS due to religious observances - A nationwide study

The American Journal of Emergency Medicine, 2021

Research paper thumbnail of Albumin levels as a biomarker for second Intravenous Immunoglobulin (IVIG) treatment in Guillain-Barre syndrome (GBS)

Journal of Clinical Neuroscience, 2020

Background: Patients with GBS may develop hypoalbuminemia following treatment with Intravenous Im... more Background: Patients with GBS may develop hypoalbuminemia following treatment with Intravenous Immunoglobulin (IVIG), which is related to a poorer outcome. This report presents a patient with GBS and his clinical response to two courses of IVIG treatments in association with his albumin level. Case report: A previously healthy 21-year-old male was admitted to the GICU due to GBS with severity grade 5 (required assisted ventilation). IVIG treatment was initiated. Over the next two weeks there was no clinical improvement and Albumin level dropped from 4.5 gr/dL to a nadir of 2.3 gr/dL. A second course of IVIG was initiated. After initiation of the second course the patient's albumin began rising to 3.0 gr/dL and a clinical improvement followed this rise. Subsequently, he was weaned from mechanical ventilation within a few days. Conclusions: When considering a second course of IVIG treatment, serum albumin levels may be considered a biomarker as part of the decision algorithm.

Research paper thumbnail of Intra-abdominal pressure may be elevated in patients with open abdomen after emergent laparotomy

Langenbeck's Archives of Surgery, 2020

Purpose To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who... more Purpose To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who were left with open abdomen and temporary abdominal closure after laparotomy, during the first 48 h after admission. Methods A cohort study in a single ICU in a tertiary care hospital. All adult patients admitted to the ICU after emergent laparotomy for acute abdomen or trauma, who were left with temporary abdominal closure (TAC), were included. Patients were followed up to 48 h. IAP was routinely measured at 0, 6, 12, 24, and 48 h after admission to ICU. Results Thirty-nine patients were included, 34 were operated due to acute abdomen and 5 due to abdominal trauma. Seventeen patients were treated with skin closure, 13 with Bogota bag, and 9 with negative pressure wound therapy (NPWT). Eleven patients (28.2%) had IAP of 15 mmHg or above at time 0, (mean pressure 19.0 ± 3.0 mmHg), and it dropped to 12 ± 4 mmHg within 48 h (p < 0.01). Reduction in lactate level (2.4 ± 1.0 to 1.2 ± 0.2 mmol/L, p < 0.01) and increase in PaO 2 /FiO 2 ratio (163 ± 34 to 231 ± 83, p = 0.03) were observed as well after 48 h. Conclusions This is the first large report of IAP in open abdomen. Elevated IAP may be measured in open abdomen and may subsequently relieve after 48 h.

Research paper thumbnail of A positive cumulative fluid balance in critically ill patients: is it really harm for everybody?

Research paper thumbnail of Corrigendum to “Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention”

Case Reports in Surgery, 2019

Research paper thumbnail of Minute-to-minute urine flow rate variability: a retrospective survey of its ability to provide early warning of acute hypotension in critically ill multiple trauma patients

European Journal of Trauma and Emergency Surgery, 2019

Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs... more Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs of hemodynamically significant hemorrhage. In the present study, we analyzed the dynamic minute-to-minute changes in the UFR and also the changes in its minute-to-minute variability in a group of critically ill multiple trauma patients whose blood pressures were normal on admission to the ICU but who subsequently developed hypotension within the first few hours of their ICU admission. Patients and methods The study was retrospective and observational. Demographic and clinical data were extracted from the computerized register information systems initially; the clinical and laboratory data of 100 critically ill patients with multiple trauma who were admitted to the ICU during the study period were analyzed. Of this group, ten patients were eventually included in the study on the basis of the inclusion criteria. Results The minute-to-minute urine flow rate (UFR) and urine flow rate variability (UFRV) both decreased significantly during the periods of hypotension (p values 0.001 and 0.006, respectively). Notably, the decrease in UFRV preceded by at least 30 min a corresponding decline in the systolic and mean arterial blood pressures, which manifested as a flattening of UFRV amplitude which was observed prior to the occurrence of the lowest recorded systolic and mean arterial blood pressures. Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFRV and the decrease in the MAP (R = 0.9, p = 0.001), and SBP (R = 0.86, p = 0.001) and the decreasing urine output per hour (R = 0.88, p < 0.001). Conclusion We found that changes in UFRV correlate strongly with systolic and mean arterial blood pressures. We feel that this parameter could potentially serve as an early signal of hemodynamic deterioration due to occult bleeding in critically ill trauma patients, and might also be able to identify the optimal end-point of hemodynamic resuscitative measures in these patients.

Research paper thumbnail of Minute-to-minute urine flow rate variability: a retrospective survey of its ability to provide early warning of acute hypotension in critically ill multiple trauma patients

European Journal of Trauma and Emergency Surgery, 2019

Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs... more Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs of hemodynamically significant hemorrhage. In the present study, we analyzed the dynamic minute-to-minute changes in the UFR and also the changes in its minute-to-minute variability in a group of critically ill multiple trauma patients whose blood pressures were normal on admission to the ICU but who subsequently developed hypotension within the first few hours of their ICU admission. Patients and methods The study was retrospective and observational. Demographic and clinical data were extracted from the computerized register information systems initially; the clinical and laboratory data of 100 critically ill patients with multiple trauma who were admitted to the ICU during the study period were analyzed. Of this group, ten patients were eventually included in the study on the basis of the inclusion criteria. Results The minute-to-minute urine flow rate (UFR) and urine flow rate variability (UFRV) both decreased significantly during the periods of hypotension (p values 0.001 and 0.006, respectively). Notably, the decrease in UFRV preceded by at least 30 min a corresponding decline in the systolic and mean arterial blood pressures, which manifested as a flattening of UFRV amplitude which was observed prior to the occurrence of the lowest recorded systolic and mean arterial blood pressures. Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFRV and the decrease in the MAP (R = 0.9, p = 0.001), and SBP (R = 0.86, p = 0.001) and the decreasing urine output per hour (R = 0.88, p < 0.001). Conclusion We found that changes in UFRV correlate strongly with systolic and mean arterial blood pressures. We feel that this parameter could potentially serve as an early signal of hemodynamic deterioration due to occult bleeding in critically ill trauma patients, and might also be able to identify the optimal end-point of hemodynamic resuscitative measures in these patients.

Research paper thumbnail of Ethnicity and sepsis characteristics and outcomes. Population based study

European Journal of Internal Medicine, 2013

Two distinct ethnic groups live in Southern Israel: urban Jews and rural Bedouin Arabs. These gro... more Two distinct ethnic groups live in Southern Israel: urban Jews and rural Bedouin Arabs. These groups differ in their socioeconomic status, culture and living environment, and are treated in a single regional tertiary care hospital. We hypothesized that these two ethnic groups have different patterns of sepsis-related intensive care admissions. The study included all adult patients admitted to the Soroka University Medical Center Intensive Care Units between January 2002 and December 2008, with a diagnosis of sepsis. Demographic data, medical history, and hospitalization and outcomes data were obtained. Primary outcome was all-cause mortality. Jewish patients admitted to the ICU (1343, 87%) were on average 17 years older than Bedouin Arabs (199, 13%). For the population &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;65 years, Bedouin Arabs had slightly higher age-adjusted prevalence of ICU sepsis admissions than Jewish patients (39.5 vs. 43.0, p=0.25), while for the population &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;65 years there was a reverse trend (21.8 vs. 19.8 p=0.49). There were no differences in the type of organ failure, sepsis severity or length of hospitalization between the two groups. Twenty eight days/in-hospital mortality was 33.9% in Bedouin Arabs vs. 45.5% in Jews, p=0.004. Following adjustment for comorbidities, age and severity of the disease, survival was unrelated to ethnicity, both at 28 days (odds ratio for Bedouin Arabs 0.86, 95% CI 0.66-1.24) and following hospital discharge (hazard ratio 0.86, 95% 0.67-1.09). Sepsis-related ICU admissions are more prevalent among Bedouin Arabs at younger age compared with the Jewish population. Adjusted for confounders, ethnicity does not influence prognosis.

Research paper thumbnail of The Clinical Significance of Fluctuations in the Minute-to-minute Urine Flow Rate and in its Minute-to-minute Variability During Septic Events in Critically Ill Patients

Romanian Journal of Anaesthesia and Intensive Care, 2020

Background Septic events complicated by hemodynamic instability can lead to decreased organ perfu... more Background Septic events complicated by hemodynamic instability can lead to decreased organ perfusion, multiple organ failure, and even death. Acute renal failure is a common complication of sepsis, affecting up to 50-70 % of cases, and it is routinely diagnosed by close monitoring of urine output. We postulated that analysis of the minute-to-minute changes in the urine flow rate (UFR) and also of the changes in its minute-to-minute variability might lead to earlier diagnosis of renal failure. We accordingly analyzed the clinical significance of these two parameters in a group of critically ill patients suffering from new septic events. Methods The study was retrospective and observational. Demographic and clinical data were extracted from the hospital records of 50 critically ill patients who were admitted to a general intensive care unit (ICU) and developed a new septic event characterized by fever with leukocytosis or leukopenia. On admission to the ICU, a Foley catheter was inse...

Research paper thumbnail of Hypotensive Episode Prediction in ICUs via Observation Window Splitting

Hypotension, defined as dangerously low blood pressure, is a significant risk factor in intensive... more Hypotension, defined as dangerously low blood pressure, is a significant risk factor in intensive care units (ICUs), which requires a prompt therapeutic intervention. The goal of our research is to predict an impending Hypotensive Episode (HE) by time series analysis of continuously monitored physiological vital signs. Our prognostic model is based on the last Observation Window (OW) at the prediction time. Existing clinical episode prediction studies used a single OW of 5–120 min to extract predictive features, with no significant improvement reported when longer OWs were used. In this work we have developed the In-Window Segmentation (InWiSe) method for time series prediction, which splits a single OW into several sub-windows of equal size. The resulting feature set combines the features extracted from each observation sub-window and then this combined set is used by the Extreme Gradient Boosting (XGBoost) binary classifier to produce an episode prediction model. We evaluate the p...

Research paper thumbnail of Adult Multisystem Inflammatory Syndrome Mimicking Toxic Shock Syndrome in a Patient Who Recovered from COVID-19

The Israel Medical Association journal : IMAJ, 2022

Research paper thumbnail of The clinical significance of hyperglycemia in nondiabetic critically ill multiple trauma patients

Therapeutic Advances in Endocrinology and Metabolism, 2018

Background: Information is inconsistent regarding the clinical role of acute elevations of blood ... more Background: Information is inconsistent regarding the clinical role of acute elevations of blood glucose level secondary to hospital-acquired infections in nondiabetic critically ill patients during an intensive care unit stay. In this study we investigated the clinical significance of hyperglycemia related to new episodes of ventilator-associated pneumonia in nondiabetic critically ill multiple trauma intensive care unit patients. Materials and Methods: We analyzed the clinical data of 202 critically ill multiple trauma patients with no history of previous diabetes who developed a new ventilator-associated pneumonia episode during their intensive care unit stay. We used a time-from-event analysis method to assess whether acute changes in blood glucose levels that occurred prior to the onset of ventilator-associated pneumonia episodes had a different prognostic significance from those that occurred during such episodes. Glucose levels and other laboratory data were recorded for up t...

Research paper thumbnail of Survival of critically ill patients hospitalized in and out of intensive care*

Critical Care Medicine, 2007

The demand for intensive care beds far exceeds their availability in many European countries. Con... more The demand for intensive care beds far exceeds their availability in many European countries. Consequently, many critically ill patients occupy hospital beds outside intensive care units, throughout the hospital. The outcome of patients who fit intensive care unit admission criteria but are hospitalized in regular wards needs to be assessed for policy implications. The object was to screen entire hospital patient populations for critically ill patients and compare their 30-day survival in and out of the intensive care unit. Screening teams visited every hospital ward on four selected days in five acute care Israeli hospitals. The teams listed all patients fitting a priori developed study criteria. One-month data for each patient were abstracted from the medical records. Five acute care Israeli hospitals. All patients fitting a priori developed study criteria. None. Survival in and out of the intensive care unit was compared for screened patients from the day a patient first met study criteria. Cox multivariate models were constructed to adjust survival comparisons for various confounding factors. The effect of intensive care unit vs. other departments was estimated separately for the first 3 days after deterioration and for the remaining follow-up time. Results showed that 5.5% of adult hospitalized patients were critically ill (736 of 13,415). Of these, 27% were admitted to intensive care units, 24% to specialized care units, and 49% to regular departments. Admission to an intensive care unit was associated with better survival during the first 3 days of deterioration, after we adjusted for age and severity of illness (p =.018). There was no additional survival advantage for intensive care unit patients (p =.9) during the remaining follow-up time. The early survival advantage in the intensive care unit suggests a window of critical opportunity for these patients. Under economic constraints and dearth of intensive care unit beds, increasing the turnover of patients in the intensive care unit, thus exposing more needy patients to the early benefit of treatment in the intensive care unit, may be advantageous.

Research paper thumbnail of The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right

Archives of Orthopaedic and Trauma Surgery, 2007

Background: It is common practice to link lower back pain with protruding discs. Because pain cau... more Background: It is common practice to link lower back pain with protruding discs. Because pain caused by sacroiliac join dysfunction can mimic discogenic or radicular low back pain, orthopedics often assume that the diagnosis of SI join dysfunction is frequently overlooked. Low back pain is second to common cold as a cause of primary care of ce visits in the USA. Approximately 90% of adults have experienced back pain at some point of time in their lives. In any 12-month period, 7% of adults will consult for this complaint. Purpose: To access the incidence of SI joint dysfunction in patients with lower back pain and positive disc ndings on CT scan or MRI, but without claudication or objective neurological de cits. Methods: From January-July 2003, 200 patients were referred for the rst time for epidural steroid injection due to low back pain. 50 patients with low back pain and disc herniation with positive pain provocation tests for SI joint dysfunction were submitted to uoroscopic diagnostic SI joint in ltration. 35 patients reported low back pain began after a trauma (in 28 a road accident and in 7 a work accident) and 10 after lifting a load. In the remaining patients the cause was unknown. Results: Mean baseline VAS pain score was 7.8 ± 1.77 (range 5-10). 30 minutes after in ltration, the mean VAS score was 1.3 ± 1.76 (with average deviation from mean = 1.30). 46 patients had a VAS score ranging from 0-3, 8 weeks after the uoroscopic guided in ltration. Conclusion: SI joint dysfunction should be considered strongly in the differential diagnosis of low back pain in this group of patients. Although patient follow-up was 3 months some conclusions can be drawn from these ndings: (1) the incidence of SI joint dysfunction in patients with low back pain and discopathy on CT or MRI scans and without neurological de cits appears to be higher than previously described, (2) pain in the SI joint dysfunction can radiate towards the calf and foot mimicking radicular pain, (3) uoroscopy guided SI joint in ltration leads to signi cant pain reduction. SI Joint Key Points: • It is common for pain from the SI joint to mimic discogenic or radicular low back pain. • Many patients go on to receive lumbar fusion instead of SI joint fusion, so SI joint disease should be strongly considered in differential diagnosis of low back pain. • Estimation of prevalence of SI joint dysfunction, using fluoroscopic infiltration as the basis of diagnosis, ranges from 13 to 30%. The prevalence is even higher after failed back surgery, reaching about 63%. • The incidence of SI joint dysfunction in patients with low back pain and discopathy on CT or MRI scans, appears to be higher than previously described.

Research paper thumbnail of Retrograde tracheal intubation: beyond fibreoptic endotracheal intubation

Acta Anaesthesiologica Scandinavica, 2004

Flexible fibreoptic laryngoscopy is the method of choice for coping with difficult tracheal intub... more Flexible fibreoptic laryngoscopy is the method of choice for coping with difficult tracheal intubations, a leading cause of catastrophic outcomes in anaesthesia. However, this technique is not always available or feasible. Retrograde intubation is a minimally invasive airway management technique with a flat learning curve and a high level of skill retention. A retrospective review of the anaesthesia records of 24 patients who underwent retrograde intubation. The success rate and the incidence of complications were recorded. Retrograde tracheal intubation was successful in all 24 patients. In 21 patients it succeeded on the first attempt. In two patients it succeeded when the technique was changed from sliding over a guide wire to a pulling technique. The most common complication was a sore throat in almost 60% of the patients. Two patients had mild subcutaneous emphysema and one had minimal bleeding at the puncture site. In these patients retrograde tracheal intubation was easy to perform, had a high success rate and a low incidence of complications. It is a reliable alternative when fibreoptic intubation is precluded, fails or is unavailable.

Research paper thumbnail of Potassium Level Variation Following Packed Cell Transfusion in Critically Ill Adult Patients—How Alert Should We Be?

Journal of Clinical Medicine

One of the most clinically important effects following the administration of packed cell transfus... more One of the most clinically important effects following the administration of packed cell transfusion (PCT) is hyperkalemia, which can cause severe life-threatening cardiac arrhythmias. This retrospective population-based cohort study included adults hospitalized between January 2007 and December 2019 in a general intensive care unit for 24 h or more, with normal levels of serum potassium on admission. We assessed changes in serum potassium levels after administration of one unit of packed cells and sought to identify clinical parameters that may affect these changes. We applied adjusted linear mixed models to assess changes in serum potassium. The mean increase in serum potassium was 0.09 mEq/L (C.U 0.04–0.14, p-value < 0.001) among the 366 patients who were treated with a single PCT compared to those not treated with PCT. Increased serum potassium levels were also found in patients who required mechanical ventilation, and to a lesser degree in those treated with vasopressors. Hy...

Research paper thumbnail of Corrigendum to “Clinical Outcomes of Critically Ill Patients Using Inhaled Nitric Oxide (iNO) during Intrahospital Transport”

Critical Care Research and Practice, 2021

Research paper thumbnail of Estimation of Potassium Changes Following Potassium Supplements in Hypokalemic Critically Ill Adult Patients–A Patient Personalized Practical Treatment Formula

Journal of Clinical Medicine, 2021

Hypokalemia is common among critically ill patients. Parenteral correction of hyperkalemia depend... more Hypokalemia is common among critically ill patients. Parenteral correction of hyperkalemia depends on dosages and patient characteristics. Our aims were to assess changes in potassium levels following parenteral administration, and to derive a formula for predicting rises in serum potassium based on patient characteristics. We conducted a population-based retrospective cohort study of adults hospitalized in a general intensive care unit for 24 h or more between December 2006 and December 2017, with hypokalemia. The primary exposures were absolute cumulative intravenous doses of 20, 40, 60 or 80 mEq potassium supplement. Adjusted linear mixed models were used to estimate changes in serum potassium. Of 683 patients, 422 had mild and 261 moderate hypokalemia (serum potassium 3.0–3.5 mEq/L and 2.5–2.99 mEq, respectively). Following doses of 20–80 mEq potassium, serum potassium levels rose by a mean 0.27 (±0.4) mEq/L and 0.45 (±0.54) mEq/L in patients with mild and moderate hypokalemia, ...

Research paper thumbnail of Timing of sugammadex administration: a case report

Sugammadex is a relatively new drug used to reverse the effects of rocuronium, a nondepolarizingm... more Sugammadex is a relatively new drug used to reverse the effects of rocuronium, a nondepolarizingmuscle relaxing agent to hasten emergence from general anesthesia. Unlike neostigmineand atropine, its use is not associated with re-curarization or cardiac arrhythmias. Sugammadex carries asmall risk of allergic reactions including anaphylactic shock.We present a case report of a 67 years old woman who underwent an urgent operation for small bowelobstruction. Due to atrial fibrillation (AF) the anesthesiologist administered Sugammadex just beforeskin closure. Soon after the injection, peak inspiratory pressures (PIP) increased precipitously followedby hypotension and increasing tachycardia. For anticipated cardioversion, the chest was exposed andit revealed urticarial. There was severe bronchospasm on auscultation. Treatment of anaphylactic shockwas initiated, the patient improved dramatically and fully recovered.This case is presented to alert practitioners to the importance of a sudden...

Research paper thumbnail of Hypothermia in neurosurgical patients: risk and benefits

Detection of abnormal body temperature facilitates proper diagnosis and evaluation of presenting ... more Detection of abnormal body temperature facilitates proper diagnosis and evaluation of presenting complaints. The inability of any patient to maintain normal body temperature is indicative of a vast number of potentially serious disorders, including infections, neoplasms, shock, toxic reactions, and environmental exposures. Neurosurgical patient are especially vulnerable to temperature changes. More frequently, intraoperative thermal dysregulation results in hypothermia. Our chapter relates dif-ferent ethiology, pathophisiology and clinical strategy of intraoperative hypothermia in neurosurgical patients. Key words: intraoperative hypothermia, neurosurgical patients

Research paper thumbnail of Postponing calls to EMS due to religious observances - A nationwide study

The American Journal of Emergency Medicine, 2021

Research paper thumbnail of Albumin levels as a biomarker for second Intravenous Immunoglobulin (IVIG) treatment in Guillain-Barre syndrome (GBS)

Journal of Clinical Neuroscience, 2020

Background: Patients with GBS may develop hypoalbuminemia following treatment with Intravenous Im... more Background: Patients with GBS may develop hypoalbuminemia following treatment with Intravenous Immunoglobulin (IVIG), which is related to a poorer outcome. This report presents a patient with GBS and his clinical response to two courses of IVIG treatments in association with his albumin level. Case report: A previously healthy 21-year-old male was admitted to the GICU due to GBS with severity grade 5 (required assisted ventilation). IVIG treatment was initiated. Over the next two weeks there was no clinical improvement and Albumin level dropped from 4.5 gr/dL to a nadir of 2.3 gr/dL. A second course of IVIG was initiated. After initiation of the second course the patient's albumin began rising to 3.0 gr/dL and a clinical improvement followed this rise. Subsequently, he was weaned from mechanical ventilation within a few days. Conclusions: When considering a second course of IVIG treatment, serum albumin levels may be considered a biomarker as part of the decision algorithm.

Research paper thumbnail of Intra-abdominal pressure may be elevated in patients with open abdomen after emergent laparotomy

Langenbeck's Archives of Surgery, 2020

Purpose To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who... more Purpose To estimate the change in intra-abdominal pressure (IAP) among critically ill patient who were left with open abdomen and temporary abdominal closure after laparotomy, during the first 48 h after admission. Methods A cohort study in a single ICU in a tertiary care hospital. All adult patients admitted to the ICU after emergent laparotomy for acute abdomen or trauma, who were left with temporary abdominal closure (TAC), were included. Patients were followed up to 48 h. IAP was routinely measured at 0, 6, 12, 24, and 48 h after admission to ICU. Results Thirty-nine patients were included, 34 were operated due to acute abdomen and 5 due to abdominal trauma. Seventeen patients were treated with skin closure, 13 with Bogota bag, and 9 with negative pressure wound therapy (NPWT). Eleven patients (28.2%) had IAP of 15 mmHg or above at time 0, (mean pressure 19.0 ± 3.0 mmHg), and it dropped to 12 ± 4 mmHg within 48 h (p < 0.01). Reduction in lactate level (2.4 ± 1.0 to 1.2 ± 0.2 mmol/L, p < 0.01) and increase in PaO 2 /FiO 2 ratio (163 ± 34 to 231 ± 83, p = 0.03) were observed as well after 48 h. Conclusions This is the first large report of IAP in open abdomen. Elevated IAP may be measured in open abdomen and may subsequently relieve after 48 h.

Research paper thumbnail of A positive cumulative fluid balance in critically ill patients: is it really harm for everybody?

Research paper thumbnail of Corrigendum to “Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention”

Case Reports in Surgery, 2019

Research paper thumbnail of Minute-to-minute urine flow rate variability: a retrospective survey of its ability to provide early warning of acute hypotension in critically ill multiple trauma patients

European Journal of Trauma and Emergency Surgery, 2019

Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs... more Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs of hemodynamically significant hemorrhage. In the present study, we analyzed the dynamic minute-to-minute changes in the UFR and also the changes in its minute-to-minute variability in a group of critically ill multiple trauma patients whose blood pressures were normal on admission to the ICU but who subsequently developed hypotension within the first few hours of their ICU admission. Patients and methods The study was retrospective and observational. Demographic and clinical data were extracted from the computerized register information systems initially; the clinical and laboratory data of 100 critically ill patients with multiple trauma who were admitted to the ICU during the study period were analyzed. Of this group, ten patients were eventually included in the study on the basis of the inclusion criteria. Results The minute-to-minute urine flow rate (UFR) and urine flow rate variability (UFRV) both decreased significantly during the periods of hypotension (p values 0.001 and 0.006, respectively). Notably, the decrease in UFRV preceded by at least 30 min a corresponding decline in the systolic and mean arterial blood pressures, which manifested as a flattening of UFRV amplitude which was observed prior to the occurrence of the lowest recorded systolic and mean arterial blood pressures. Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFRV and the decrease in the MAP (R = 0.9, p = 0.001), and SBP (R = 0.86, p = 0.001) and the decreasing urine output per hour (R = 0.88, p < 0.001). Conclusion We found that changes in UFRV correlate strongly with systolic and mean arterial blood pressures. We feel that this parameter could potentially serve as an early signal of hemodynamic deterioration due to occult bleeding in critically ill trauma patients, and might also be able to identify the optimal end-point of hemodynamic resuscitative measures in these patients.

Research paper thumbnail of Minute-to-minute urine flow rate variability: a retrospective survey of its ability to provide early warning of acute hypotension in critically ill multiple trauma patients

European Journal of Trauma and Emergency Surgery, 2019

Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs... more Purpose Dynamic changes in urine output and neurological status are the recognized clinical signs of hemodynamically significant hemorrhage. In the present study, we analyzed the dynamic minute-to-minute changes in the UFR and also the changes in its minute-to-minute variability in a group of critically ill multiple trauma patients whose blood pressures were normal on admission to the ICU but who subsequently developed hypotension within the first few hours of their ICU admission. Patients and methods The study was retrospective and observational. Demographic and clinical data were extracted from the computerized register information systems initially; the clinical and laboratory data of 100 critically ill patients with multiple trauma who were admitted to the ICU during the study period were analyzed. Of this group, ten patients were eventually included in the study on the basis of the inclusion criteria. Results The minute-to-minute urine flow rate (UFR) and urine flow rate variability (UFRV) both decreased significantly during the periods of hypotension (p values 0.001 and 0.006, respectively). Notably, the decrease in UFRV preceded by at least 30 min a corresponding decline in the systolic and mean arterial blood pressures, which manifested as a flattening of UFRV amplitude which was observed prior to the occurrence of the lowest recorded systolic and mean arterial blood pressures. Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFRV and the decrease in the MAP (R = 0.9, p = 0.001), and SBP (R = 0.86, p = 0.001) and the decreasing urine output per hour (R = 0.88, p < 0.001). Conclusion We found that changes in UFRV correlate strongly with systolic and mean arterial blood pressures. We feel that this parameter could potentially serve as an early signal of hemodynamic deterioration due to occult bleeding in critically ill trauma patients, and might also be able to identify the optimal end-point of hemodynamic resuscitative measures in these patients.

Research paper thumbnail of Ethnicity and sepsis characteristics and outcomes. Population based study

European Journal of Internal Medicine, 2013

Two distinct ethnic groups live in Southern Israel: urban Jews and rural Bedouin Arabs. These gro... more Two distinct ethnic groups live in Southern Israel: urban Jews and rural Bedouin Arabs. These groups differ in their socioeconomic status, culture and living environment, and are treated in a single regional tertiary care hospital. We hypothesized that these two ethnic groups have different patterns of sepsis-related intensive care admissions. The study included all adult patients admitted to the Soroka University Medical Center Intensive Care Units between January 2002 and December 2008, with a diagnosis of sepsis. Demographic data, medical history, and hospitalization and outcomes data were obtained. Primary outcome was all-cause mortality. Jewish patients admitted to the ICU (1343, 87%) were on average 17 years older than Bedouin Arabs (199, 13%). For the population &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;65 years, Bedouin Arabs had slightly higher age-adjusted prevalence of ICU sepsis admissions than Jewish patients (39.5 vs. 43.0, p=0.25), while for the population &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;65 years there was a reverse trend (21.8 vs. 19.8 p=0.49). There were no differences in the type of organ failure, sepsis severity or length of hospitalization between the two groups. Twenty eight days/in-hospital mortality was 33.9% in Bedouin Arabs vs. 45.5% in Jews, p=0.004. Following adjustment for comorbidities, age and severity of the disease, survival was unrelated to ethnicity, both at 28 days (odds ratio for Bedouin Arabs 0.86, 95% CI 0.66-1.24) and following hospital discharge (hazard ratio 0.86, 95% 0.67-1.09). Sepsis-related ICU admissions are more prevalent among Bedouin Arabs at younger age compared with the Jewish population. Adjusted for confounders, ethnicity does not influence prognosis.