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Proceedings of Réanimation 2017, the French Intensive Care Society International Congress

Annals of Intensive Care20177 (Suppl 1) :8

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Physician abstracts

Oral communications

O1 Pulmonary embolism related sudden cardiac arrest admitted alive at hospital: characteristics and outcomes

Wulfran Bougouin1, Eloi Marijon1, Benjamin Planquette2, Nicole Karam1, Florence Dumas3, David Celermajer4, Daniel Jost5, Lionel Lamhaut6, Frankie Beganton7, Alain Cariou8, Guy Meyer9, Xavier Jouven10, Sudden Death Expertise Center
1Cardiologie, Hôpital Européen Georges-Pompidou, Rue Leblanc, Paris, France; 2Usip, Hopital Europeen Georges-Pompidou, Paris, France; 3Service d’accueil des urgences, Hôpital Cochin, Paris, France; 4Cardiology, Sydney medical school, Sydney, Australia; 5Bspp, B.s.p.p., Paris, France; 6Réanimation adulte, Hôpital Necker - Enfants Malades, Paris, France; 7Paris descartes, Inserm U970, Paris, France; 8Réanimation Médicale, Hôpital Cochin, Paris, France; 9Service de Pneumologie et Soins Intensifs, Hopital Europeen Georges-Pompidou, Paris, France; 10Cardiologie, Hôpital Européen Georges-Pompidou, Paris, France
Correspondence: Wulfran Bougouin -

Annals of Intensive Care 2017, 7(Suppl 1):O1

Introduction Pulmonary embolism (PE) is a relatively common cardiovascular condition, occasionally and tragically manifesting as sudden cardiac arrest (SCA). The natural history of SCA complicating PE has been poorly evaluated. Guidelines suggest the consideration of thrombolytic therapy when PE-related SCA is suspected, despite the absence of evidence. In this study, we described the characteristics and management of PE-related SCA in a large regional registry.

Patients and methods In this prospective population-based study, we included all patients admitted at hospital alive after out-of-hospital SCA, in Paris and suburbs, France (6.6 million inhabits), from May 2011 to September 2015. Regarding PE, we collected risk factors, clinical decision rules (Wells rule and Geneva score) and diagnostic strategy.

Results Of 2926 patients hospitalized after SCA, 82 cases were diagnosed as PE-related SCA (2.8%, 95% CI 2.2–3.4). Independent factors associated with SCA due to PE were non-shockable initial rhythm (OR 12.4, 95% CI 4.9–31.0, P < 0.001), past history of thromboembolism (OR 10.4, 95% CI 5.6–19.4, P < 0.001), absence of known heart disease (OR 3.8, 95% CI 2.0–7.3, P < 0.001) and female sex (OR 1.9, 95% CI 1.2–3.0, P = 0.008). Considering non-shockable initial rhythm and previous thromboembolism as major predictors of PE, combination of those factors had a specificity for detection of PE-related SCA of 98% and a sensitivity of 23%, with a positive predictive value of 31% and a negative predictive value of 98% (Fig. 1) .
Fig. 1
Fig. 1

See text for description

Systemic thrombolysis was performed in 47 patients (57%). After adjustment, PE was associated with survival at discharge (OR 2.4, 95% CI 1.2–4.7, P = 0.001), compared with non-PE SCA. Finally, among patients hospitalized for PE-related SCA, only thrombolysis (OR 12.5, 95% CI 1.8–89.1, P = 0.01) and delay from CPR to ROSC < 20 min (OR 6.8, 95% CI 1.3–35.2, P = 0.02) were independently associated with survival to hospital discharge.

Conclusion In this population-based study, PE was not an unusual cause of SCA, and was associated with better survival, challenging the traditional view. Thrombolysis was associated with an increased survival in this population, reinforcing current guidelines.

Competing interests None.

O2 Eligibility for and feasibility of donation after circulatory death Maastricht III (DCD MIII) process in post-anoxic patients: a retrospective analysis

Côme Bureau1, Julien Charpentier1, Omar Ben Hadj Salem1, Lucie Guillemet1, Michel Arnaout1, Matthieu Jamme1, Alexis Ferre1, Guillaume Geri1, Florence Dumas1, Nicolas Mongardon1, Frédéric Pène1, Jean-Daniel Chiche1, Jean-Paul Mira1, Alain Cariou1
1Réanimation médicale, Hôpital Cochin, Paris, France
Correspondence: Côme Bureau

Annals of Intensive Care 2017, 7(Suppl 1):O2

Introduction Donation after circulatory death corresponds to the category III of the Maastricht classification (DCDM III) and may provide mostly kidney and liver transplants with good long-term function. Patients suffering from irreversible brain damages after cardiac arrest are commonly considered candidates for DCDMIII, but little is known regarding the proportion of these patients who could be eligible for this procedure. Using a cohort of post-cardiac arrest patients, our aim was to assess the rate of contra-indications for DCDMIII and to measure the delay between withdrawal of life sustaining treatments (LSTW) and the appearance of low values for common physiological parameters during the agonal phase, which may compromise the process by altering graft function.

Patients and methods Using the Cochin registry (Paris, France), we conducted a retrospective single-centre study from January 2007 to December 2014. We included all patients who died in ICU after LSTW decision because of post-anoxic brain damages. For each patient, we collected exclusion criteria for DCDMIII and the length of time between LSTW implementation and death. We also collected hemodynamic and respiratory parameters during the agonal phase.

Results We included 404 patients in the study, of whom 275 (68%) had at least one exclusion criteria for a DCDMIII process, mostly because of age >65 (190 patients). Other exclusion criteria were: multiple organ failure (n = 88), neoplastic diseases (n = 55, including 46 solid tumours), brain-dead state that occurred after LSTW decision (n = 18), unknown cause of the initial cardiac arrest (n = 13), chronic viral diseases (n = 13), uncontrolled sepsis (n = 4), occurrence of a new refractory cardiac arrest (n = 2), and judicial problems (n = 3).

The 130 potentially eligible patients for DCDMIII included 94 men (72%) with a mean age of 51 years (±7.7). At time of death after LSTW, the mean length of stay in ICU was 11.6 days (±6). The most common aetiology of cardiac arrest was acute myocardial ischemia (n = 59, 45%). LSTW consisted in terminal weaning of mechanical ventilation in 71 patients (55%), extubation in 12 patients (9%) and infusion of vasopressors was stopped in 3 patients (2%).

The average duration of the agonal phase (time between LSTW implementation and death) was 746 min (min) (±162) and this delay was >180 min in 92 patients (71%). After LSTW implementation, an oxygen transcutaneous saturation (SpO2) <70% occurred in 637 min (±545), a mean arterial pressure (MAP) <60 mmHg in 723 min (±586) and a systolic arterial pressure (SAP) <50 mmHg in 733 min (±596). The delay between SpO2 < 70% and death was 154 min (±262), and this delay was 59 min (±160) after MAP < 60 mmHg and 23 min (±134) after SAP < 50 mmHg.

Conclusion In this large cohort of brain damaged patients with LSTW decision, we observed that a high proportion of patients would not have been eligible for a DCDMIIII process. Even in those without contra-indication, the delay between LSTW implementation and the final circulatory arrest was not compatible with French national guidelines. Low values for arterial pressure and oxygenation persisted during a substantial part of time before final circulatory arrest. This information may help in refining the management of the DCDMIII process in this population.

Competing interests None.

O3 Evaluation of the prognostic value of the bispectral index (BIS) and suppression ratio (RS) among patients admitted to the ICU for cardiac arrest

Guylaine Labro1, Francois Belon1, Vinh-Phuc Luu2, Julien Chenet3, Guillaume Besch4, Marc Puyraveau2, Gaël Piton1, Gilles Capellier1
1Réanimation médicale, CHU de Besançon, Besançon, France; 2Centre de méthodologie clinique, CHU de Besançon, Besançon, France; 3Département d’anesthésie et de réanimation, CHU de Besançon, Besançon, France; 4Réanimation chirurgicale, CHU de Besançon, Besançon, France
Correspondence: Guylaine Labro -

Annals of Intensive Care 2017, 7(Suppl 1):O3

Introduction Predicting the neurological outcome of patients admitted to the ICU after a cardiac arrest successfully resuscitated remains difficult [1]. The bispectral index (BIS) allows for the rapid and standardised assessment of the cortical function based upon eletroencephalogram analysis whereas the ratio of suppression (RS) is indicative of the absence of electrical activity of the brain. We aimed to evaluate the prognostic value of the BIS and the RS for predicting neurologic outcome after cardiac arrest.

Patients and methods This was a prospective, single center, observational study performed in a large regional University hospital. Adult patients admitted to the ICU for cardiac arrest between March 2012 and October 2014 were included in the study. The exclusion criteria was pregnancy. The BIS and the RS were collected as soon as possible after ICU admission. The patients were not included in the analysis if they died within 24 h, if they had a low signal quality [defined as high EMG artefacts (≥30 dB)], or if the monitoring of BIS started 24 h after ICU admission. The neurological outcome of the patients was based upon the cerebral performans category (CPC) calculated at 3 months. CPC score of 1 or 2 indicated good outcome, whereas CPC score of 3–5 indicated poor outcome.

Results During the study period 148 patients were admitted to our ICU for a cardiac arrest. The BIS and RS were monitored in 103 patients.17 patients were excluded (early death ≤24 h; low quality of signal; BIS and RS performed ≥24 h after ICU admission). Thus, 86 patients were enrolled in this study. The means age was 57.6 ± 16.8 years, 61 patients (70.9%) were male, the cardiac arrest was out-of-hospital in 63 patients (73.3%), hypoxia was the main cause of cardiac arrest (43%), 60 patients (70.6%) were treated with therapeutic hypothermia. At 3 month of follow-up, a total of 50 patients (58.1%) had died and 55 patients (63.9%) were classified as having a poor outcome. The mean duration from the return of spontaneous circulation (ROSC) to the BIS and RS measurements was 5.7 ± 3.0 h. The BIS values were significantly lower in patient with poor outcome compared with patients with a good outcome (5.9 ± 11.1 vs 37.1 ± 18.0, p < 0.0001). The RS values were significantly higher in patient with poor outcome group compared to those with good neurological outcome (85.9 ± 26.3 vs 18.4 ± 31.3, p < 0.0001). The BIS predicted poor outcome with a likelihood ratio of 23.8 and an area under the curve (AUC) of 0.918 [95% CI (0.839–0.966)]. The optimal sensitivity [78.4%, 95% CI (67.3–89.5)] and specificity [96.5%, 95% CI (89.8–100)] for neurological outcome prediction was obtained using a cut-off value of BIS < 5. The RS predicted poor outcome with a likehood ratio of 23.8 and an AUC of 0.936 [95% CI (0.862–0.977)]. The optimal sensitivity [78.0%, 95% CI (66.9–89.0)] and specificity [96.8%, 95% CI (90.8–100)] for neurological outcome prediction was obtained using a cut-off value of RS > 84. In multivariable logistic regression model, BIS or RS predicted poor outcome with an odds ratio of 65.0 [95% CI (6.1–689.2), p = 0.0005].

Discussion The results of this study using the EEG derived parameters BIS and RS confirm previous findings showing that they are linked to the neurological outcome of patients admitted to the ICU after a cardiac arrest [2]. In particular, a BIS < 5 and/or a RS > 84, measured at ICU admission, were both strongly associated with a poor neurological outcome at 3-months.

Conclusion BIS values may be used to predict long term neurological outcome of patients following cardiopulmonary resuscitation. The ability to accurately predict early non-recovery after cardiac arrest could facilitate discussions with families and limit use of ICU resources in futile cases. BIS and RS values measured at ICU admission might be considered as additional prognostic tools available for the intensivist.

Competing interests None.

  1. 1.

    Sandroni C. Neurological prognostication after cardiac arrest. Curr Opin Crit Care. 2015;21(3):209–14.

  2. 2.

    Seder David B. The bispectral index and suppression ratio are very early predictors of neurological outcome during therapeutic hypothermia after cardiac arrest. Int Care Med. 2010;36:281–88.


O4 Nutrition during targeted temperature management after cardiac arrest: observational study of neurological and infectious outcomes

Maëlle Martin1, Jean-Baptiste Lascarrou1, Aurélie Le Thuaut2, Jean-Claude Lacherade1, Laurent Martin-Lefèvre1, Maud Fiancette1, Isabelle Vinatier1, Christine Lebert1, Konstantinos Bachoumas1, Aihem Yehia1, Matthieu Henry-Laguarrigue1, Gwenhaël Colin1, Jean Reignier3
1Intensive Care, District Hospital Center, La Roche-sur-Yon, France; 2Clinical Research Unit, District Hospital Center, La Roche-sur-Yon, France; 3Medical Intensive Care Unit, University Hospital Center, Nantes, France
Correspondence: Maëlle Martin -

Annals of Intensive Care 2017, 7(Suppl 1):O4

Introduction Cardiac arrest represents one of the greatest medical challenges because of its terrible mortality, morbidity and cost. International guidelines for cardiopulmonary resuscitation led to survival and prognosis improvement, based on the Chain of Survival and the Advanced Life Support, including Targeted Temperature management (TTM) [1]. Although routinely used, guidelines do not provide detailed management of patients with TTM, especially how to adapt associated therapies such as sedation or nutrition. Guidelines encourage early nutrition for intensive care patients, within 24–48 h after admission [2]. Nevertheless, after cardiac arrest, early nutrition (EN) is disputed. Common post-cardiac arrest syndrome with circulatory failure, frequent diarrheic collapse; and supposed lower digestive tolerance in hypothermia do not encourage this practice.

This study first aims to determine if EN is associated with better neurological outcome for patient under TTM. Secondly, we evaluate nutritional tolerance in hypothermia.

Patients and methods We retrospectively included patients under TTM after cardiac arrest in a single mixed intensive care unit from January 2008 to December 2014. Patients fed within 48 h after admission (EN; enteral or parenteral) were compared to those fed after 48 h or not fed [delayed nutrition (DN); after rewarming] concerning neurological and infectious outcomes. Enteral nutrition was initiated at maximal caloric objective define at 20 kCal/kg/day until day 7, with isocaloric product. Incidence of vomiting and use of prokinetic drugs were recorded for enteral nutrition tolerance comparison between <36 and ≥36 °C feeding.

Results Among 203 patients under TTM at 33 °C after cardiac arrest, 142 were early fed. EN was associated with better neurological outcome assessed by Cerebral Performance Category (CPC) at 3 month (42.3 vs 18%; p = 0.001). After propensity adjustment, EN was still protective for good neurological outcome at 3 month (OR 3.1 [1.36–7.05]; p = 0.01). Comparison between EN and DN showed no difference for early-onset pneumonia (p = 0.4); ventilator-associated pneumonia (VAP) (p = 0.07), nosocomial urinary tract infection (p = 0.35), and nosocomial bacteraemia (p = 0.3). Considering death as competing-risk, VAP were not more frequent with EN (HR 1.07 [0.68–1.69], p = 0.76, Fig. 2). Prokinetic use and vomiting were not increased when nutrition was instituted at temperature <36 °C as compared as ≥36 °C (respectively, 27.2% at 36 °C vs 27.3%, p = 0.99; 34 vs 33%, p = 0.87).
Fig. 2
Fig. 2

Probability of acquering VAP according to early or delayed nutrition group

Conclusion EN is associated with better neurological outcome during targeted temperature management. EN is not associated with more adverse event (infectious and poor nutrition tolerance) when instituted at temperature less than 36 °C.

Competing interests None.

  1. 1.

    Nolan JP, et al. European Resuscitation Council and European Society of Intensive Care medicine guidelines for post-resuscitation care 2015. Resuscitation. 2015;95:202–22.

  2. 2.

    Taylor BE et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016;44(2):390–438.


O5 Description of the epidemiological characteristics and outcome of cardiac arrest in children: a French study

Elodie Privat1, Joséphine Escutnaire2, Cyrielle Dumont3, Valentine Baert2, Christian Vilhelm4, Stéphane Leteurtre5, Hervé Hubert4
1Réanimation pédiatrique, C.H. Régional Universitaire de Lille (CHRU de Lille), Lille, France; 2French National Out-of-Hospital Cardiac Arrest Registry (réac), French National Out-of-Hospital Cardiac Arrest Registry (réac), Lille, France; 3Public Health Department, Université Lille 2 - Faculté de Médecine Henri Warembourg, Loos, France; 4Public Health Department, Université Lille 2 - Faculté de Médecine Henri Warembourg, Lille, France; 5Réanimation pédiatrique, Centre Hospitalier Régional Universitaire de Lille, Lille, France
Correspondence: Elodie Privat -

Annals of Intensive Care 2017, 7(Suppl 1):O5

Introduction Cardiac arrest in children has a very poor prognosis. Knowledge of its epidemiological characteristics is necessary to improve the patient care and survival. The French National Cardiac Arrest registry (RéAC), created in 2009, combines all epidemiological data on out-of-hospital cardiac arrests (OHCA). The objective of this study was to describe the epidemiological characteristics and outcomes of OHCA in children under 18 years old.

Materials and methods All patients under 18 years old victims of out-of-hospital cardiac arrest and registered in the French National Cardiac Arrest registry between July 2011 and September 2015 were included. Patients were divided into four groups: infants (under 1 year old), toddlers (1–4 years old), children (5–12 years old) and adolescents (13–17 years old). Variables related to anamnesis, basic cardiopulmonary resuscitation, specialized CPR and outcome of patients were collected.

Results Out of 42,960 registered cardiac arrest, 900 (2%) involved children under 18 years of age. Out of the 900 patients enrolled, 393 (44%) were less than 1 year old. The OHCA occurred mainly at home (67%). The percentage of traumatic cardiac arrest increased with age, reaching up to 49% in adolescents. Respiratory failure was the leading cause of cardiac arrest in toddlers and children (respectively 40 and 31%). Adolescents were more likely to have an initial shockable rhythm (8%) than other groups (p < 10−3). The intraosseous access was used in 33% of the children. Overall survival at 1 month was 8.3% (75/900) and 66.7% (50/75) of these patients had a favorable neurological prognosis. Outcomes description per age is described in Table 1.
Table 1

Outcome description of patients


<1 year (n = 393)

1–4 years (n = 146)

5–12 years (n = 142)

13–17 years (n = 219)



71 (18)

43 (30)

41 (29)

81 (37)


Survival at hospital admission

68 (17)

52 (36)

43 (30)

85 (39)


Survival at day 30

13 (3)

20 (14)

13 (9)

29 (13)


CPC 1 or 2 at day 30

12 (3)

13 (9)

3 (2)

22 (10)


ROSC return of spontaneous circulation, CPC cerebral performance category

Conclusion There were significant differences between the patient’s groups regarding the location, type of cardiac arrest, initial rate, and survival. An age group approach could be considered to improve care strategy and survival of cardiac arrest victims.

Competing interests None.

O6 Contrast-associated acute kidney injury (AKI) in the intensive care unit (ICU): systematic review and meta-analysis

Vincent Robert-Edan1, Karim Lakhal1, Andrew Quartin2, Brian Hobbs3, Cynthia Cely2, Cynthia Bell4, Tai Pham5, Roland Schein2, Yimin Geng6, Chaan Ng7, Stephan Ehrmann8
1Service de réanimation chirurgicale, Hôpital Guillaume et René Laënnec, CHU de Nantes, Nantes, France; 2Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of Miami School of Medicine, Miami, United States of America; 3Department of biostatistics, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America; 4Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center-Houston, Houston, TX, United States of America; 5Réanimation médico-chirurgicale, Hôpital Tenon, Paris, France; 6Research Medical Library, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America; 7Department of Radiology, University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America; 8Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France
Correspondence: Vincent Robert-Edan -

Annals of Intensive Care 2017, 7(Suppl 1):O6

Introduction Avoiding the use of iodinated contrast media (CM) is frequent, fearing it may contribute to AKI. The aim of this systematic review and meta-analysis was to quantify the risk of AKI attributable to CM in ICU patients.

Materials and methods A systematic review until December 31st 2015, through 5 databases, searched for studies evaluating intravascular administration of iodinated CM. Only controlled studies evaluating AKI following CM exposure in ICU patients matched to unexposed patients were included in the meta-analysis. Meta-analysis was performed on patient-level data using a hierarchical Bayesian nested mixed effects multiple logistic regression model. Bayesian methodology allows evaluating how evidence-based physicians would assess the AKI risk attributable to CM according to both their a priori belief and the presentation of the controlled studies identified in the systematic review. Two meta-analyses were performed with different a priori hypotheses. An objective meta-analysis modeled a neutral state of a priori belief (Odds Ratio [OR] of 1 with impartial distribution) yielding a posteriori OR distribution representative of data collected in controlled studies. A subjective meta-analysis modeled the common belief that CM increases the AKI risk, using an a priori OR of 1.37 based on uncontrolled studies holding clinical community consensus. We determined the minimum a priori relative effective sample size (RESS, representing the a priori strength of belief) needed to observe a significant a posteriori OR distribution: how much physicians have to be convinced a priori that CM increases AKI risk to maintain this belief after being confronted with the studies data.

Results Among 5696 references, 10 compared ICU patients receiving CM with an unexposed group and 4 performed risk adjustments for baseline AKI risk. Three studies used patient matching: overall, 280 CM patients were matched with 280 control patients. The resulting a posteriori OR did not reach statistical significance: with no prior assumption, there is no evidence that CM increases the risk of AKI in the ICU.

Using an a priori OR of 1.37 (subjective meta-analysis), the a posteriori distribution of the OR did not reach statistical significance except when modelling a very high a priori belief that CM causes AKI (minimum a priori RESS 4.8-folds higher than the RESS of the objective meta-analysis and 70-folds higher than a neutral objective a priori hypothesis).

Conclusion This systematic review and meta-analysis did not enlighten a risk of AKI attributable to iodinated CM in ICU patients.

Competing interests None.

O7 Iohexol clearance for exploring the link between glomerular filtration rate and acute kidney injury in patients with acute circulatory failure

Charlotte Salmon Gandonnière1, Julie Boisramé-Helms2, Olivier Le Tilly3, Isabelle Benz De Bretagne3, Emmanuelle Mercier1, Julie Mankikian1, Anne Bretagnol4, Ferhat Meziani2, Jean Michel Halimi5, Chantal Barin Le Guellec3, Stephan Ehrmann1, Clinical Research in Intensive Care and Sepsis (CRICS network)
1Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France; 2Réanimation médicale, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France; 3Biochimie et biologie moléculaire, CHRU Hôpitaux de Tours, Tours, France; 4Réanimation médicale polyvalente, Hôpital de La Source, CHR Orléans, Orléans, France; 5Néphrologie, transplantation rénale et hémodialyse, CHRU Hôpitaux de Tours, Tours, France
Correspondence: Charlotte Salmon Gandonnière -

Annals of Intensive Care 2017, 7(Suppl 1):O7

Introduction Acute kidney injury (AKI) is associated with significant morbidity and mortality, particularly in intensive care unit (ICU) patients. In stable patients, glomerular filtration rate (GFR), the best overall index of kidney function, can be estimated measuring the plasma clearance of an exogenous tracer such as iohexol [1]. There is no reliable method to assess GFR in unstable patients, as classical methods such as MDRD (modifications of diet in renal disease) and urinary clearance calculations have shown their limits [2]. The aim of this study was to determine GFR using iohexol plasma clearance (Cliox) at the initial phase of acute circulatory failure and to evaluate its association with subsequent development of AKI.

Patients and methods Multicentric study in 3 French ICUs. Patients suffering from acute circulatory failure were included within 12 h of ICU admission and administered intravenously a non-toxic dose of iohexol (5 mL; 300 mg/mL) followed by collection of 9 blood samples for iohexol plasma concentration determination (5 and 30 min, 1, 3, 6, 9, 12, 18 and 24 h). Iohexol concentrations were determined using high performance liquid phase chromatography and a three-compartment population pharmacokinetic model was implemented to calculate individual iohexol clearances.

Results 100 patients were included. Median age was 65 years (Q1: 55; Q3: 77), baseline MDRD 93 mL/min (73; 116) and SAPS II 59 (45; 75). Most patients were admitted for septic shock. We could calculate Cliox in 85 patients (85%). Failures to calculate Cliox included iodinate contrast media injection outside of the study and early renal replacement therapy. Median Cliox was 38 mL/min (19–58).

76 patients (76%) developed AKI according to the kidney disease, improving global outcome classification (KDIGO): 15 KDIGO 1, 30 KDIGO 2, 31 KDIGO 3. In 59 patients out of 92 for whom enough serum creatinine dosages were available (64%), serum creatinine decreased in the first 24 h of ICU stay, including 44 patients among the the 76 developing AKI (58%). Cliox was inversely related to the severity of AKI: median Cliox for KDIGO 0 patients was 68 mL/min (44; 77), 40 mL/min (30; 58) for KDIGO 1 patients, 36 mL/min (24; 52) for KDIGO 2 patients and 16 mL/min (9; 22) for KDIGO 3 patients. In 40 out of 82 patients (49%) the difference between MDRD (calculated from serum creatinine at the time of inclusion) and Cliox exceeded 20 mL/min, and in most cases (90%) MDRD overestimated estimated GFR (eGFR). For AKI patients, eGFR according to MDRD was >60 mL/min in 18 patients. According to MDRD, 8 patients had glomerular hyperfiltration defined by an eGFR > 130 mL/min. Only 4 patients had hyperfiltration according to Cliox. For the 2 patients with eGFR > 130 mL/min with both methods, one suffered denutrition; his Cliox was 138 mL/min, while MDRD was 281 mL/min. For the 6 patients with hyperfiltration according to MDRD and not Cliox, 4 had denutrition, 1 had a very low baseline serum creatinine (18 μmol/L), and one suffered morbid obesity. Four patients with eGFR > 130 mL/min according to MDRD had a maximum KDIGO score of 2.

Discussion Our study confirms that variations of serum creatinine are not a good marker of GFR. We hypothesize this to be related to the large amount of fluid infusion at the acute phase following ICU admission and the influence of nutritional factors. The MDRD formula tended to overestimate eGFR. Cliox may enable to overcome the limits of the MDRD formula at the acute phase of critical illness, as it seems not to be influenced by nutritional factors or fluid infusion, unlike creatinine variations.

Conclusion The close link between Cliox and AKI is very encouraging for the development of this method of eGFR assessment in critically ill patients. Cliox could be used for early determination of AKI risk and for drug dosage adaptation, as it is a better reflection of instantaneous GFR than MDRD.

Competing interests None.

  1. 1.

    Macedo E, Bouchard J, Soroko SH, Chertow GM, Himmelfarb J, Ikizler TA, et al. Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients. Crit Care Lond Engl. 2010;14(3):R82.

  2. 2.

    Bröchner-Mortensen J. A simple method for the determination of glomerular filtration rate. Scand J Clin Lab Invest. 1972;30(3):271–4.


O8 Effect of renal replacement therapy strategies in septic-shock patients with severe acute kidney injury: a post hoc analysis of a randomized controlled trial

Stéphane Gaudry1, David Hajage2, Frédérique Schortgen3, Laurent Martin-Lefèvre4, Florence Tubach5, Bertrand Pons6, Eric Boulet7, Alexandre Boyer8, Guillaume Chevrel9, Nicolas Lerolle10, Dorothée Carpentier11, Nicolas de Prost3, Alexandre Lautrette12, Anne Bretagnol13, Julien Mayaux14, Saad Nseir15, Jean-Damien Ricard16, Didier Dreyfuss17, AKIKI Study group
1Service de réanimation médico-chirurgicale, CHU Louis Mourier, Colombes, Colombes, France; 2Département d’épidémiologie et de recherche clinique, Hôpital Louis-Mourier - APHP, Colombes, France; 3Réanimation médicale, Hôpital Henri Mondor, Créteil, France; 4Réanimation polyvalente, Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon, France; 5Département d’epidémiologie et recherche clinique, Unité de Recherche Clinique Paris Nord, Paris, France; 6Réanimation - Grands Brulés, CHU Pointe à Pitre - Abymes, POINTE A PITRE, France; 7Val d’oise, Hôpital René Dubos, Pontoise, France; 8Réanimation médicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; 9Essonnes, C.H. Sud Francilien, Corbeil-Essonnes, France; 10Réanimation médicale, Centre Hospitalier Universitaire d’Angers, Angers, France; 11Réanimation médicale, Centre Hospitalier Universitaire Rouen, Rouen, France; 12Réanimation médicale, CHU Gabriel-Montpied, Clermont-Ferrand, France; 13Réanimation médicale polyvalente, Hôpital de La Source, CHR Orléans, Orléans, France; 14Réanimation médicale, Hôpital Pitié-Salpêtrière, Paris, France; 15Centre de Réanimation, Centre Hospitalier Régional Universitaire de Lille, Lille, France; 16Service de Réanimation Médico-Chirurgicale, CHU Louis Mourier, Colombes, France; 17Inserm, iame, umr 1137, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
Correspondence: Stéphane Gaudry -

Annals of Intensive Care 2017, 7(Suppl 1):O8

Introduction Acute kidney injury is particularly common in septic-shock patients and is associated with high mortality. The putative effect of renal replacement therapy (RRT) on the prognosis of such patients is highly debated; some advocating that outcome might improve owing to modulation of inflammation. We aimed to compare outcomes of septic-shock patients with severe acute kidney injury (stage 3 of KDIGO classification) treated with an early RRT strategy (all patients immediately received RRT) with those treated with a delayed RRT strategy (patients received late RRT or no RRT at all).

Patients and methods We did a post hoc subgroup analysis in a subset of septic-shock patients with severe acute kidney injury (stage 3 of KDIGO classification) from a multicenter randomized controlled trial. In the trial, patients from 31 intensive care were randomly assigned (1:1) to either an early or a delayed RRT initiation strategy. With the early strategy, RRT was initiated within 6 h after inclusion criteria were met. With the delayed strategy, RRT was started if at least one of the following criteria was met: severe hyperkalemia, metabolic acidosis, pulmonary edema, serum urea concentration greater than 40 mmol/l, or oliguria for more than 72 h after randomization. The primary outcome was overall survival at day 60.

Results Of the 413 septic-shock patients (on a total of 620 patients), 209 were managed with early strategy and 204 with delayed strategy. The Kaplan–Meier estimates of mortality at day 60 did not differ significantly between the early and delayed strategies; 101 deaths occurred among 209 patients in the early-strategy group (48.5%; 95% confidence interval [CI] 41.3–54.9), and 99 deaths occurred among 204 patients in the delayed-strategy group (48.5%, 95% CI 41.2–55.0; P = 0.97) (Fig. 3). A total of 97 patients (47.5%) in the delayed-strategy group did not receive renal-replacement therapy. The number of days RRT-free days was significantly higher in the delayed strategy group (21 [5–29] vs 17 [2–25], p < 0.001). Median length of stay in hospital did not differ significantly between groups (20 [8–39] vs 19 [7–40] days, p = 0.9).
Fig. 3
Fig. 3

Probability of survival and timing of RRT initiation

Conclusion The timing of RRT in septic-shock patients with severe acute kidney injury did not significantly influence mortality. However, a conservative strategy avoided many unnecessary RRT sessions.

Competing interests None.

O9 Dose response multicentre investigation on fluid assessment (DOREMIFA) in critically ill patients: the French cohort

René Robert1, Franscesco Garzotto2, Eric Kipnis3, Ciro Tetta4, Claudio Ronco2, DO-RE-MI-FA Group
1Service de Réanimation médicale, CHU de Poitiers, Poitiers, France; 2International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy; 3Réanimation chirurgicale, Centre Hospitalier Régional Universitaire de Lille, Lille, France; 4Research extracorporeal therapies, Fresenius Medical Care, Bad Homburg vor der Höhe, Germany
Correspondence: René Robert -

Annals of Intensive Care 2017, 7(Suppl 1):O9

Introduction There is growing evidence that fluid accumulation beyond the correction of hypovolaemia is associated with increased morbidity, mortality and a longer hospital stay. We recently published a prospective cohort observational study “The Dose Response Multicentre Investigation on Fluid Assessment (DoReMIFA) in critically ill patients” aimed to investigate the impact of fluid balance and fluid accumulation on mortality for both AKI and (Non) N-AKI patiens as for those who receive renal replacement therapy (AKI-RRT).

Aim of the present is to assess the fluid administration of the French subgroup of patients.

Patients and methods We analysed 209 (12.05%) of the 1734 enrolled patients, from the 2 French ICUs. Fluid overload (FO) was defined as the ratio between cumulative fluid balance and the initial body weight, in percentage. Maximum fluid overload (MFO) referred to the peak value of FO during the entire ICU stay. TMFO represented the number of days between. ICU admission and day of MFO. Velocity of fluid accumulation was defined by Fluid overload slope (FOSL) as the MFO/TMFO ratio. A boxplots for the three groups (N-AKI, AKI and AKI-RRT) illustrated the MFO for both survivors and non-survivors during the ICU stay. A Kaplan–Meier analysis was performed to evaluate the time to death for the three groups (N-AKI, AKI and AKI-RRT). The time to death was evaluated by a Cox proportional hazard regression analysis.

Results 53% of patients had AKI (38% stage 1, 20% Stage 2, 42% Stage3). The Kaplan–Meier analysis including the first 28 days of ICU, highlighted a significant survival benefit for patients without AKI, in particular for longer ICU stay. The AKI and AKI-RRT group had, conversely form the entire study population, similar survival rates. In all cohorts as in N-AKI, AKI and AKI-RRT non-survivors had a higher MFO than survivors. Again, the AKI-RRT and AKI groups had similar levels of MFO, with a lower over-hydration for the RRT group. Cox regression analysis of the velocity of fluid accumulation showed that for every increase of one unit of the FOSL, the hazard of death increased significantly by a factor of 1.44. The hazard ratio decreased to 1.41 when adjusting for SAPS II score.

Discussion The fluid assessment in critically ill patients enrolled on the French ICUs confirm the findings of the Doremifa study. Fluid overload is strongly correlated with mortality at any degree. A lower degree of fluid overload for the AKI-RRT group, when compared with the AKI population, and a similar survival curve between the 2 groups, may suggest that CRRT has a protective effect. More analysis are needed to confirm this hypothesis, an early initiation of the treatment have to be also investigated.

Conclusion The velocity of fluid accumulation, as in the findings of the main study, contribute to worse patients outcome.

Competing interests Fresenius medical care: fees for travelling and hotel.

O10 Doppler-based renal resistive index in assessing renal dysfunction reversibility in ICU patients: results of a multicenter cohort study

David Schnell1, Bourmaud Aurelie2, Marie Reynaud3, Christophe Clec’h4, Julie Boisramé-Helms5, Mourad Benyamina6, François Vincent7, Alexandre Lautrette8, Christophe Mariat9, Caroline Bornstain7, Stephane Rouleau10, Christophe Leroy8, Yves Cohen11, Jerome Morel3, Matthieu Legrand6, Jeremy Terreaux12, Michaël Darmon12
1Service de reanimation, Service de Réanimation polyvalente, Angoulême, France; 2Département de santé publique, Institut de Cancérologie de la Loire Lucien Neuwirth, Saint-Priest-en-Jarez, France; 3Réanimation polyvalente b, Hospital Center University De Saint-Étienne, Saint-Priest-en-Jarez, France; 4Réanimation medico-chirurgicale, Hopital Avicenne, Bobigny, France; 5Réanimation, CHU de Strasbourg, Strasbourg, France; 6Anesthésie réanimation et traitement chirurgical des grands brûlés, APHP - Hopital Saint-Louis, Paris, France; 7Réanimation polyvalente, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, Montfermeil, France; 8Réanimation médicale, CHU Gabriel-Montpied, Clermont-Ferrand, France; 9Néphrologie, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France; 10Service de réanimation, Hospital Center D’angoulême, Angoulême, France; 11Réanimation médico-chirurgicale, Hôpital Avicenne, Bobigny, France; 12Réanimation médicale, CHU Saint-Etienne - Hôpital Nord, Saint-Étienne, France
Correspondence: Michaël Darmon -

Annals of Intensive Care 2017, 7(Suppl 1):O10

Introduction Doppler-based renal resistive index (RI) measurement may hold promise in differentiating transient from persistent AKI in selected critically ill patients. Although several studies have suggested adequate performance in predicting short-term reversibility of AKI, most of these studies were performed in limited patient samples [1]. Additionally, a recent study has identified discrepant results regarding its diagnostic performance [2] suggesting confirmatory studies to be required.

The main objective of this study was to assess diagnostic performance of RI in predicting persistent AKI in critically ill patients. Secondary objectives were to assess diagnostic performance of semi-quantitative assessment of renal perfusion (SQP) using color-Doppler in predicting persistent AKI and performance of both tests in predicting needs for renal replacement therapy (RRT).

Patients and methods Prospective multicenter study performed in eight ICUs from December 2013 to April 2016. This study was declared to

Adult patients requiring mechanical ventilation were included in this study. Patients with mild to severe chronic kidney diseases, arrhythmia, or obstructive renal dysfunction were excluded from this study. Patients with hospital stay shorter than 72 h and in whom renal reversibility could not be assessed were secondarily excluded.

Acute kidney injury (AKI) was defined according to the KDIGO definition.

Transient AKI was defined as AKI with recovery within the first 3 days following inclusion.

Intra-renal RI was calculated as (peak systolic velocity − end-diastolic velocity)/peak systolic velocity.

SQP was assessed using a scale ranging from 0 (absence of renal perfusion) to 3 (renal vessels identifiable until the arcuate arteries in the entire field of view).

Results are reported as number (%), median (IQR) and area under curve (95% CI).

Results Overall, 371 patients were included. Median age was 76 years (66–89) and 236 patients were of male gender (63.6%). Most of the patients were admitted with medical conditions (n = 253; 68.2%) and 162 patients (43.7%) had sepsis at ICU admission. Median LOD score was of 8 (5–11) at study inclusion and 198 patients required vasopressors (53.4%).

Of the included patients, 253 (68.2%) had an AKI at study inclusion, including 158 patients (42.6%), 35 (9.4%) and 60 (16.2%) with AKI stage 1, 2 and 3 respectively. Doppler-based RI was obtained in 365 patients (98.4%), semi-quantitative assessment of renal perfusion in 367 (98.9%). Patients with AKI had a higher RI at ICU admission [0.70 (0.62–0.77) vs. 0.65 (0.59–0.70); P = 0.0001] and a lower SQP [2(1–3) vs. 2 (2–3); P = 0.0003].

Twenty patients were discharged before day 3 leaving 351 patients in the final analysis, including 118 (33.6%), 97 (27.6%) and 136 patients (38.7%) no AKI, transient AKI or persistent AKI respectively.

Resistive index at inclusion was of respectively 0.65 (0.59–0.70), 0.69 (0.62–0.77) and 0.71 (0.62–0.77) in patients without AKI, with transient AKI and with persistent AKI (P = 0.0005). Resistive index failed to demonstrate any interest in predicting persistent AKI (Area under ROC curve: 0.58; 95% CI 0.52–0.64).

Semi-quantitative assessment of renal perfusion was of respectively 2 (2–3), 2 (2–3), and 2 (1–3) in patients without AKI, with transient AKI and with persistent AKI (P = 0.002)]. Semi-quantitative assessment of renal perfusion failed to demonstrate any interest in predicting persistent AKI (Area under ROC curve: 0.59; 95% CI 0.52–0.65).

Overall, 46 patients (12.4%) required RRT during ICU stay. In these patients, RI and SQP were of respectively 0.75 (0.65–0.77) [vs. 0.67 (0.60–0.74) in non-RRT patients; P = 0.0003] and 2 (1–2) [vs. 2 (2–3) in non-RRT patients; P = 0.0003]. Both test displayed a poor performance in predicting subsequent renal replacement therapy at study inclusion [AUC ROC curve of respectively 0.67 (0.59–0.74) and 0.65 (0.57–0.73) for RI and semi-quantitative perfusion].

Conclusion Our results suggest that renal perfusion monitoring using Doppler-based resistive index or color-Doppler, although feasible in ICU setting, failed to predict short term AKI reversibility and displayed a poor performance in predicting needs for renal replacement therapy.

Competing interests None.

  1. 1.

    Ninet et al. J Crit Care. 2015.

  2. 2.

    Dewitte et al. Crit Care. 2012.


O11 Neurologic outcomes and adjunctive steroids in adults with severe tuberculous meningitis: the tuberculous meningitis in ICU (TBM in ICU) multicenter study

Marie Cantier1, Adeline Morisot2, Emmanuel Guérot3, Bruno Megarbane4, Keyvan Razazi5, Damien Contou5, Eric Mariotte6, Emmanuel Canet6, Etienne De Montmollin7, Vincent Dubée8, Eric Boulet9, Stéphane Gaudry10, Guillaume Voiriot11, Julien Mayaux12, Frédéric Pène13, Mathilde Neuville1, Jean-François Timsit1, Romain Sonneville1, ENCEPHALITICA Study Group
1Service de réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard-APHP, Paris, France; 2Centre mémoire, clinique rainier iii, Hospital Center Princesse Grace, Monaco, Monaco; 3Réanimation médicale, Hopital Europeen Georges-Pompidou, Paris, France; 4Service de Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; 5Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 6Service de réanimation médicale, Hôpital Saint-Louis (AP-HP), Paris, France; 7Réanimation, C.H. Général Saint Denis hôpital Delafontaine, Saint-Denis, France; 8Réanimation médicale, Hôpital Saint-Antoine, Paris, France; 9Val d’oise, Hôpital René Dubos, Pontoise, France; 10Service de réanimation médico-chirurgicale, CHU Louis Mourier, Colombes, France; 11Service de réanimation médicale, Hôpital Tenon (AP-HP), Paris, France; 12Réanimation médicale, Hôpital Pitié-Salpêtrière, Paris, France; 13Réanimation Médicale, Hôpital Cochin, Paris, France
Correspondence: Marie Cantier -

Annals of Intensive Care 2017, 7(Suppl 1):O11

Introduction Tuberculous meningitis (TBM) is frequently associated with neurological complications requiring admission in intensive care unit (ICU). Adjunctive steroids reduce mortality, but may have no effect on disabling neurologic deficits in survivors. Moreover, the benefit of steroids is controversial in immunocompromised patients and in patients with severely altered mental status at hospital presentation. We aimed to identify indicators of poor functional outcome in adult patients with severe forms of TBM requiring ICU admission. In particular, we investigated the effect of adjunctive steroids on functional outcomes and 1-year mortality.

Patients and methods We conducted a retrospective cohort study (January 1st 2004 to June 15th 2016) in consecutive TBM cases admitted to the medical ICUs of 12 university-affiliated hospitals, located in the Paris area, France. We used multivariate logistic regression analysis to identify factors associated with a poor functional outcome. A poor functional outcome was defined as a score of 3–6 on the modified Rankin scale (mRS) 90 days after ICU admission. In a secondary analysis, we used Cox proportional hazards modeling to evaluate the risks of death at 1 year. Data are presented in median (interquartile range) or numbers (percentage).

Results A total of 95 patients were studied, including 44 (46%) immunocompromised patients. At ICU admission, the Glasgow Coma Scale score was 11 (8–14), 64 (67%) patients had Medical Research Council (MRC) grade 3 illness, and 66 (69%) required invasive mechanical ventilation. Brain MRI was performed in 79/95 (83%) cases. Antituberculous therapy was administered to 90/95 (95%) patients (5 died before treatment could be started), and 76/90 (84%) patients received adjunctive steroids. The duration of ICU stay was 10 (4–24) days.

A poor functional outcome was reported for 55/90 (61%) patients at 90 days (5 patients were lost to follow-up). The following factors were independently associated with a poor outcome at 90 days: older age (per 1-year increment, adjusted odds ratio (aOR): 1.04, 95% CI 1.0–1.08, p = 0.035), cerebrospinal fluid (CSF) protein level >1.9 g/L (aOR: 8.85, 95% CI 2.49–39.64, p = 0.002), hydrocephalus on MRI (aOR: 8.6, 95% CI 2.05–46.5, p = 0.006). By contrast, the use of adjunctive steroids had a protective effect (aOR: 0.15, 95% CI 0.02–0.87, p = 0.045).

The Kaplan–Meier estimated 1-year mortality was 51% (0.39–0.61). The following factors were independently associated with mortality: CSF protein levels >1.9 g/L [adjusted relative risk (aRR): 2.47, 95% CI 1.17–5.25, p = 0.018], hydrocephalus on MRI (aRR: 3.45, 95% CI 1.50–7.91, p = 0.003), brain infarction on MRI (aRR: 2.40, 95% CI 0.99–5.81, p = 0.051). The use of adjunctive steroids had a protective effect on 1-year mortality (aRR = 0.16, 95% CI 0.05–0.45, p = 0.0006).

Conclusion Despite antituberculous therapy and supportive care, severe forms of TBM are characterized by a poor outcome in more than 50% of cases. Elevated CSF protein levels, hydrocephalus and brain infarction on MRI at ICU admission represent major indicators of poor outcome. Our data suggest that use of adjunctive steroids is associated with reduced disability and mortality, irrespective of immune status and severity of illness. We conclude that adjunctive steroids may benefit to all patients with a suspicion of TBM admitted to the ICU.

Competing interests None.

O12 Value of diaphragmatic echography for predicting respiratory insufficiency in 123 patients with neuromuscular disorders

Abdallah Fayssoil1, Tania Stojkovic2, Anthony Behin2, Adam Ogna3, Frédéric Lofaso4, Pascal Laforet2, Karim Wahbi2, Helene Prigent4, Denis Duboc5, David Orlikowski3, Bruno Eymard2, Djillali Annane6
1Neurologie et reanimation polyvalente, Institute De Myologie et CHU Raymond Poincaré, Garches, France; 2Neurologie, Institute De Myologie, Paris, France; 3Réanimation polyvalente et pole ventilation à domicile, CHU Raymond Poincare, Garches, France; 4Service d’explorations fonctionnelles respiratoires, Hôpital Raymond-Poincaré (AP-HP), Garches, France; 5Cardiologie, Hôpital Cochin, Paris, France; 6Réanimation médico-chirurgicale, Hôpital Raymond-Poincaré, Garches, France
Correspondence: Abdallah Fayssoil -

Annals of Intensive Care 2017, 7(Suppl 1):O12

Introduction Diaphragm is the main muscle of ventilation. Diaphragmatic echography is a non invasive tool used in Intensive Care Unit. We sought to compare diaphramatic echography and spirometric function in neuromuscular disorders.

Patients and methods We included retrospectively patients with neuromuscular disorders followed in 2 neuromuscular centers (Pitié and Garches, France). Ultrasonographic (US) analysis of the right and the left hemidiaphragm, using M-mode, was performed during quiet breathing and deep breathing. For the right hemidiaphragmatic analysis, the transducer was placed on the anterior subcostal region at the right mid-clavicular line. For the left hemidiaphragmatic analysis, the transducer was placed on the anterior subcostal region between the anterior and midaxillary lines.

Results 123 patients with muscular dystrophies (DM1, PROMM, DMD, BMD, LGMD, FSH, mitochondriopathies and other myopathies) were included in our study. Mean age was 39 ± 14 years. Mean Walton score was 2.6 ± 2. Mean forced vital capacity (FVC) was 74 ± 28% of predicted value and mean PCO2 was 42 ± 6 mmHg. Mean right hemidiaphragmatic excursion (RHDE) during quite breathing was 14.5 ± 6 mm and 44.7 ± 22 mm during deep breathing. Mean left hemidiaphragmatic excursion (LHDE) during quite breathing was 14.3 ± 6 mm and 34 ± 22 mm during deep breathing. FCV was significantly correlated with RHDE during quite breathing (r = 0.55, p < 0.001), with LHDE during quite breathing (r = 0.57, p < 0.001), with RHDE (r = 0.71, p < 0.001) and LHDE (r = 0.78, p < 0.001) during deep breathing. RHDE during deep breathing predicts a FVC < 60% with AUC at 0.86. RHDE during deep exhalation predicts a peak expiratoty flow <270 l/min with AUC at 0.78.

Conclusion Diaphragmatic echography may predict respiratory insufficiency in neuromuscular disorders.

Competing interests None.

O13 Brain injury during veno-arterial extracorporeal membrane oxygenation

Loic Le Guennec1, Clémentine Cholet1, Matthieu Schmidt1, Nicolas Bréchot1, Guillaume Hekimian1, Sébastien Besset1, Guillaume Lebreton2, Ania Nieszkowska1, Jean Louis Trouillet1, Pascal Leprince2, Alain Combes1, Charles-Edouard Luyt1
1Service de réanimation médicale, Groupe Hospitalier Pitié Salpêtrière, Paris, France; 2Service de chirurgie cardiaque, Groupe Hospitalier Pitié Salpêtrière, Paris, France
Correspondence: Loic Le Guennec -

Annals of Intensive Care 2017, 7(Suppl 1):O13

Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to provide cardiac support in patient suffering refractory cardiogenic shock. Its use is increasing and associated with neurological complications, mainly cerebrovascular. The frequency of those events and their impact on patients are not well described. We therefore study the epidemiology, risk factors and impact of cerebral complications occurring in VA-ECMO patients.

Patients and methods Observational study conducted in a tertiary referral center (2006–2014) on patients developing a neurological complication (ischemic stroke or intracranial bleeding) while on VA-ECMO versus those who did not.

Results The main clinical characteristics of the patients are reported in Table 2. Among 873 consecutive patients who had received VA-ECMO, 72 developed cerebral complications on ECMO: ischemic stroke in 47 (5%) with and cerebral bleeding in 25 (3%), occurring after a median [IQR) of 11 [7–21.5] and 6 [5–11] days of ECMO support, respectively.
Table 2

Admission characteristics, hemostasis disorders during VA-ECMO and patient outcomes according to brain damage or not


No brain damage

Patients with brain damage

(n = 800)

Ischemic stroke (n = 47)

Cerebral bleeding (n = 25)

Age (years)

50 ± 15

50 ± 16

48 ± 18

Male sex [n (%)]

568 (71)

32 (68)

12 (48)


72 [54–85]

70 [61–86]

74 [57–90]

SOFA score

5 [3–14]

5 [3–8]

3 [3–7]

Biologic values (J1 ECMO)

 Lactates (mmol/L)

6 [2.7–11.1]

5 [2.9–10.1]

4 [4.0–10.0]

 PT (%)

45 [30–62]

54 [34–65.8]

47 [27.5–54]


1.6 [1.2–2.3]

1.4 [1.1–1.8]

1.8 [1.4–3]

 Fibrinogen (g/L)

3.0 [2.0–5.0]

3.0 [2.4–5.0]

4.0 [1.7–4.0]

 Platelets (×109/L)

155 [96–215]

163 [100–246]

86 [56.5–164]

Type of ECMO


698 (87)

35 (74)

20 (80)

 Switch to central ECMO

38 (5)

2 (4)

4 (16)


107 (13)

12 (26)

5 (25)

 Intra-aortic balloon pump

265 (33)

16 (34)

5 (25)

Results are expressed as mean ± SD, number (%) or median [27th–75th percentile interquartile range]

No specific risk factor of ischemic stroke was found in univariable analysis except body mass index >26 (OR 2.16, 95% CI 1.15–4.05). Hematological failure (defined as platelets <50 000/mL) at ECMO initiation (OR CI 3.64, 95% 1.30–10.21) and platelets <20,000/mL during ICU stay (OR 3.01, 95% CI 1.22–7.40) were significantly associated with cerebral bleeding in univariable analysis. Age, comorbidities, renal replacement therapy, and intra-aortic balloon pump use were not associated with neurological complications. Twenty-three (49%) patients with ischemic stroke and 21 (84%) with intracranial bleeding died versus 385 (48%) of patients without brain injury.

Conclusion Neurological events occurred frequently in patients on VA-ECMO. Ischemic stroke is the most frequent, occurs late during ECMO support and does not seem to be associated with higher mortality than patients without brain injury. Cerebral bleeding occurs early and is associated with high mortality rate. Low platelets count at ECMO initiation and during ECMO support are associated with cerebral bleeding.

Competing interests None.

O14 Does heart rate variability predict clinical outcome of patients with subarachnoid hemorrhage in the neurointensive care unit?

Marion Griton1, Musa Sesay1, Nadia Sibaï De Panthou1, Thomas Bienvenu1, Matthieu Biais1, Karine Nouette-Gaulain1
1Neuro ICU, CHU - Hôpitaux de Bordeaux, Bordeaux, France
Correspondence: Marion Griton -

Annals of Intensive Care 2017, 7(Suppl 1):O14

Introduction Patients with subarachnoid hemorrhage (SAH), admitted to the neurointensive care unit (NICU) are exposed to complications including rebleeding, vasospasm, hydrocephalus, pain and sepsis. The autonomic nervous system (ANS) is a warning system which can be assessed noninvasively by heart rate variability (HRV). Many reports have shown a relationship between HRV and outcome in myocardial infarction, stroke and renal insufficiency. To our knowledge very few papers have addressed this issue in the NICU. The aim of this study was to check whether HRV could predict outcome in patients with SAH admitted to the NICU.

Patients and methods Following Institutional Review Board approval, patients with SAH, admitted to the NICU were included in this prospective monocentric study. Those with persistent arrhythmia, cardiac pacing or younger than 18 years were excluded. All subjects were assessed everyday starting from their arrival at NICU, i.e. day 2 after SAH, to day 7. HRV was measured between 2 and 4 p.m. during 10-min. HRV was achieved by connecting a computer to the electrocardiogram (ECG) monitor. Online power spectrum was calculated from the ECG R–R interval using the maximum entropy method (MemCalc™, Suwa Trust, Japan). Low (LF: 0.04–0.15 Hz) and high frequency (HF: 0.15–0.4 Hz) spectra were associated with sympathetic (Σ) and vagal activities respectively. Entropy and coefficient of variation of RR intervals (CVVR) were also measured.

Concomitantly, we noted demographic, hemodynamic, respiratory and comorbidity data. The severity of SAH was classified using the five points World Federation of Neurological Surgeons (WFNS) score (were 1 = less severe and 5 = very severe) and the four point Fisher scale (where 1 = less severe and 4 = very severe). Outcome at discharge was assessed by the modified Rankin scale, a poor outcome was defined by either death or Rankin score of 4–5 which means severe disability and inability to walk without assistance Outcome was defined as good or poor based on the absence or presence of Rankin score of 4–5 and/death. Univariate and multiple logistic regression models were applied on these data to determine the predictive (s) factor (s) of poor outcome.

Results The inclusion criteria were fulfilled by 125 patients, but complete data was only available in 53 of them. Among them, five died before discharge, 10 were discharged with a Rankin score of 4 or 5. The most significant modifications of our study parameters were observed on day 2 after SAH. These observations are summarized in Table 3. Consequently, on day 2 after hemorrhage, LF (p = 0.02), VLF (p = 0.03), entropy (p < 0.001) and CVVR (p < 0.01) were significantly decreased in patients with poor prognosis. This trend was sustained The multivariate logistic regression model revealed an odds ratio [95% confidence interval] for LF = 0.997 [0.995–1.000]; Entropy = 0.919 [0.0.872–0968]; VLF = 0.997 [0.995–1.000] and CVVR 0.586 [0.388–0.885] considered as significant predictors of poor outcome.
Table 3

Univariate analysis of data in the study population


Good outcome

Poor outcome

p value

No of patients (%)

38 (72)

15 (28)


Mean age (years)

56.2 ± 11.7

59.6 ± 12.1


Female sex

23 (60)

9 (60)



10 (26)

7 (47)


Fisher grade 4

18 (47)

9 (60)


HRV on day 2

 LF (ms)

519 ± 528

171 ± 385


 HF (ms)

513 ± 863

224 ± 505



50.3 ± 12.0

34.3 ± 16.4



1.97 ± 1.41

1.87 ± 2.27


 VLF (ms)

1471 ± 2152

184 ± 364


 CVVR (%)

4.18 ± 2.01

2.25 ± 2.31


Discussion These results corroborate previous reports showing that a decrease in HRV, particularly the sympathetic pathway, at admission, is associated with poor outcome (1).The mechanisms are not clearly known. Ischemic or hemorrhagic lesions had been observed in the hypothalamus of patients with poor outcome after SAH, which is the predominant modulator of autonomic system (2).

Conclusion This study suggests that early assessment of HRV in the NICU could predict outcome in patients with SAH. A decrease in HRV at admission of patients was significantly associated with poor outcome. Further studies are required to confirm this finding.

Competing interests None.

  1. 1.

    Brain J Neurol. 1963; 86: 301–14.

  2. 2.

    Am J Emerg Med. 2012; 30: 651–56.


O15 Electrical muscle stimulation and bicycling combined to early standard rehabilitation versus early standard rehabilitation alone: impact on global muscle strength at ICU discharge—an open-label, single-centre, assessor-blinded randomised trial

Guillaume Fossat1, Florian Baudin1, Cécile Coulanges2, Sabrine Bobet1, Arnaud Dupont3, Léa Courtes1, Anne Bretagnol1, Dalila Benzekri1, Toufik Kamel1, Grégoire Muller1, Nicolas Bercault1, François Barbier1, Isabelle Runge1, Mai-Anh Nay1, Marie Skarzynski1, Armelle Mathonnet1, Thierry Boulain1
1Réanimation médicale polyvalente, Hôpital de La Source, CHR Orléans, Orléans, France; 2Service de pneumologie, Hôpital de La Source, CHR Orléans, Orléans, France; 3Service de réanimation chirurgicale, Hôpital de La Source, CHR Orléans, Orléans, France
Correspondence: Thierry Boulain -

Annals of Intensive Care 2017, 7(Suppl 1):O15.

Introduction Early Standard Rehabilitation (ESR), first passive and then passive/active, is recommended for critically ill patients in whom it reduces the duration of mechanical ventilation (MV), improves functional status, muscle strength and quality of life after hospital discharge. The early addition of leg bicycling on a cyclo-ergometer and of electrical muscle stimulation (EMS) is now part of common practice in the ICU. Whether it can preserve or improve muscle strength and further increase the beneficial effects of ESR is little known.

Patients and methods Single-centre, randomised study comparing the effects of the combination of early and daily leg bicycling + EMS of the quadriceps + ESR (intervention group) versus ESR alone (usual care group) on the global muscle strength assessed by the MRC score at ICU discharge by a physiotherapist blinded to the randomization group (NCT02185989). All consecutive patients were potentially eligible if they were deemed to need more than 72 h of care in ICU. Main non-inclusion criteria were resuscitated cardiac arrest, presence of pacemaker or implantable defibrillator, acute cerebral disease requiring deep sedation for at least 72 h, known neuromuscular disease, and amputation of a lower limb. Randomization was stratified by sex, MV or not at study entry, and day of admission (Thursday/Friday vs other days). The interventions were applied right from Day 1 (within 72 h of admission), 5 days/week. Protocoled ESR consisted of daily multistep program (from 10 passive mobilisations of each joint in comatose patients to passive/active muscle work, transfer to chair, standing and walking, depending on patient’s level of wakefulness/cooperation). In the intervention group, 30 min passive/active leg bicycling (even in bed-ridden patients) and 54 min EMS of the quadriceps were performed 5 days/week in addition to ESR, according to pre-established programs.

Results From July 2014 to June 2016, 314 patients were included (as planned per protocol) and 313 were analysable (1 consent withdrawal): 155 in usual care group and 158 in intervention group. Among the whole population, ICU mortality was 18%, SAPSII 46 ± 18, admission SOFA 8 (IQR 6; 12), patients treated with MV 85%. Clinical characteristics at study entry were similar between groups. Primary endpoint: 124 and 121 patients upon the 131 and 125 ICU survivors in usual care and intervention groups respectively, could be assessed for the primary endpoint. The discharge MRC score was 53 (IQR 44; 60) and 51 (44; 58) in usual care and intervention groups, respectively (P = 0.86), and was also not different between groups in patients under MV at time of study entry: 52 (IQR: 44; 58) (n = 95) and 49 (43; 57) (n = 89) (P = 0.26). Secondary endpoints: There was no between-group difference in discharge functional status as assessed by the ICU mobility scale in the whole population (P = 0.54) (P = 0.64 in patients under MV at study), or by the change in the Katz index from inclusion to discharge (P = 0.39) (P = 0.47 in patients under MV at study entry), or in the day-28 ventilator-free days [21 days (17; 22) vs 20 days (18; 21); P = 0.34]. The thickness of the rectus femoris muscle, assessed by echography at inclusion and discharge in survivors, showed a lower decline in the intervention group: −1.8 mm (−4.4; −0.2) vs −0.7 mm (−1.5; −0.25); P = 0.009. The impact on delirium occurrence in ICU is still under analysis. Data concerning physical and mental status at 6 months are not fully available yet.

Safety: We observed no serious adverse event related to the studied interventions.

Conclusion Although safe and resulting in lower decline in muscle thickness as observed on echography (not blinded assessment), the addition of daily leg bicycling and EMS to ESR did not result in higher global muscle strength as assessed by the MRC score (blinded assessment) at ICU discharge in a mixed and heterogeneous population of critically ill patients. Exploratory subgroup analyses are underway and perhaps will help to identify subsets of patients in whom the studied intervention might be beneficial and might deserve further investigations.

Competing interests None.

O16 Post-intensive care syndrome: a population-based observational study of healthcare use

Youenn Jouan1, Noémie Teixera2, Claire Hassen-Khodja3, Antoine Guillon1, Christophe Gaborit3, Leslie Grammatico-Guillon3, Stephan Ehrmann1
1Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France; 2Service des urgences, CHRU Hôpitaux de Tours, Tours, France; 3Service d’information médicale, épidémiologie et économie de la santé, CHRU Hôpitaux de Tours, Tours, France
Correspondence: Youenn Jouan -

Annals of Intensive Care 2017, 7(Suppl 1):O16

Introduction Intensive care unit (ICU) admission is known to lead, among survivors, to numerous and persistent disabilities and impairments after discharge, forming the “post intensive care syndrome” (PICS). However, PICS consequences in term of healthcare use is less studied. Recent data tend to demonstrate that ICU survivors have increased healthcare use after ICU. However, little is known about healthcare use for the most severely ill patients, which are supposed to be at higher risk of PICS, and, to our knowledge, no epidemiological data are available in France.

Patients and methods We conducted a retrospective multicenter study using comprehensive administrative hospital discharge databases of the Centre Val de Loire region, France (2.5 millions of inhabitants). Based on an ICD-10 algorithm, we included all adult patients admitted in an ICU for septic shock or acute respiratory distress syndrome (ARDS) during 2011 and invasively ventilated at least 5 days. Performance of the selection algorithm was validated through review of a subsample of medical charts. Comorbidities were also extracted from ICD-10 coding and reported using a scoring system derived from Charlson Comorbidity Index. Healthcare use and comorbidities were analyzed 2 years before (pre-ICU period) and 2 years after ICU (post-ICU period).

Results 552 patients were selected, of which 249 (45%) died during the hospital stay. Among the 303 survivors, 293 (97%) had complete data required for analysis and none was lost for follow up. Mean ± SD age was 61 ± 14 years, SAPS2 49 ± 17 and median ventilation duration was 10 days (Q1 = 7; Q3 = 20). Regarding chronic comorbidities during the pre-ICU period, cardiac disease was reported for 26% of the patients, respiratory disease for 16%, kidney disease for 13%, and hepatic disease for 12%.

Healthcare resources utilization analysis during the pre-ICU period revealed that 58% of the patients required hospitalization, 54% ambulatory care, 57% emergency admissions and 10% rehabilitation facilities. Twenty-three percent of the patients had no healthcare use.

During the post-ICU period, the 2-year mortality rate was 15%. Healthcare resources utilization was significantly increased during the post-ICU period compared to the pre-ICU period for hospitalizations (72%, p < 0.001), ambulatory care (73%, p < 0.001) and rehabilitation facilities (54%, p < 0.001). No patient had no healthcare use. Regarding chronic comorbidities, cardiac, respiratory and renal diseases were significantly more frequent compared to the pre-ICU period (respectively 32, 27, and 21%, p < 0.001 for the three conditions). Time trend analysis of the healthcare use in the post-ICU period revealed that the first 9 months were at high healthcare use (essentially hospitalizations and rehabilitation facilities), and emergency admissions tended to increase at the end of the 2-years follow-up.

Discussion Patients admitted to ICU for acute respiratory distress syndrome and septic shock frequently have a significant healthcare resources utilization during the 2 years before. The 2 years following admission is characterized by a more important healthcare use, together with a significant increase in comorbidities.

Conclusion Our study highlights the epidemiological impact of PICS at the population level in a French region, underpinning observational and interventional research within and beyond the ICU.

Competing interests None.

O17 A pilot study of 6-months evaluation of social, psychological, financial and emotional consequences of an ICU stay in survivors critically ill patients

Cécile Rebière1, Elie Azoulay2, Benoit Misset3, Stephane Ruckly4, Jean-François Timsit5, Maïté Garrouste-Orgeas1
1Réanimation, Fondation Hopital Saint Joseph, Paris, France; 2Réanimation médicale, Hôpital Saint-Louis, Paris, France; 3Réanimation médicale, Hospital Center University, Rouen, France; 4Statistics Department, Outcomerea Research Group, Paris, France; 5Réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard, Paris, France
Correspondence: Maïté Garrouste-Orgeas -

Annals of Intensive Care 2017, 7(Suppl 1):O17

Introduction Consequences of hospitalization in critically ill patients have been recognized for several years with physical, cognitive and psychological consequences published under the denomination of the post intensive care syndrome which will become a new challenge for intensivists. The impact of social, personal and financial consequences has been less reported. The primary objective of this pilot study is to report the social, financial, psychological, physical and emotional consequences in a group of critically ill patients compared to a group of patients never hospitalized in ICU. The second objective is to investigate patient’s perceptions to better understand their memories of their hospitalization through a qualitative approach.

Patients and methods We designed a case control study in three ICUs belonging to the Outcomerea research group (July 2014–May 2015). Case patients were adult patients ventilated for more than 48 h. We excluded patients not speaking or understanding French and patients who denied participation. Clinical and demographics characteristics of the cases were extracted from the Outcomerea database. They were interviewed 6-months after ICU discharge. Control patients, matched on age and sex and never hospitalized in ICU, were interviewed face-to-face during an hospital consultation. All patients completed the same questionnaires in a random order, exploring emotional and post traumatic-stress syndrome (Impact of Event Scale-revised, cut-off >22), self-sufficiency in daily activities (activity of daily Living, ADL), quality of life (first question of the SF-36), and questions about their place of living, of working and financial conditions, need of psychological help and marital status. We used a phenomenological approach to report patient’s perceptions.

Results Of the 96 eligible patients, 20 (20.8%) died at 6 months, 39 (40.6%) were excluded and 37 were entered in the analysis and compared to 37 control patients. Characteristics of the case patients were: age (median: 65, range: 47–73), 64% male, SAPS II (51, 37–64), ICU stay (12 days, 8–19), hospital stay (29 days, 22–41). The median IES-R score was significantly higher in cases (14, 8–31) vs control (6, 3–10), p < 0.01. IES-R > 22 was found in 13 (35.1%) cases patients versus 1 (2.7%) of control patients (p < 0.01). Activities of daily living without help were significantly most often performed in control versus cases for bathing (n = 37, 100% vs n = 33, 89%, p = 0.04) and continence (n = 37, 100% vs n = 33, 89% p = 0.04). Perception of the quality of life was not significantly different between cases and controls but increasing quality of life was much important in cases (n = 15, 40.6%) versus control (3, 8.1%), p < 0.01. See Table 4.
Table 4

Functional and personal changes in cases and controls


Cases n = 37

Control n = 37

p value

Return home within 1 month

17 (45.9%)

37 (100%)


Need of help at home

22 (59.4%)

5 (13.5%)


Change in working conditions

12 (32.4%)

3 (8.1%)


Change in financial conditions

10 (27%)

7 (18.9%)


Psychologist help

17 (45.9%)

5 (13.5%)


Use of medications

9 (24.3%)

8 (21.6%)


Change in marital status

2 (5.4%)

3 (8.1%)


Eating disorders

8 (21.6%)

5 (13.5%)


Disorder of sexual life

12 (32.4%)

7 (18.9%)


Three themes were found in the qualitative analysis: the ICU stay seen as a traumatized period, a period without memories and support from families and friends. Their representations in the verbatims were 13 (35.1%), 13 (35.1%) and 3 (8.1%).

Conclusion This pilot study reported substantial neuropsychological and functional alterations related to the ICU stay and emphasized the need for better estimating these modifications in a multicenter study. Addressing these consequences adds to the role of intensivists for elaborating prevention programs and promoting post intensive care syndrome to non ICU practitioners to collaborate together for the best future of ICU patients.

Competing interests None.

  1. 1.

    Harvey MA, Davidson JE. Postintensive care syndrome: right care, right now and…later. Crit Care Med. 2016;44:381–5.

  2. 2.

    Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40:502–9.


O18 To understand or not to understand brain death: impact on grief symptoms in relatives who experienced organ donation request

Nancy Kentish-Barnes1, Jacques Duranteau2, Julien Charpentier3, Marie Thuong4, Liliane Joseph2, Laurent Martin-Lefèvre5, Anne Renault6, Olivier Lesieur7, Anne-Gaelle Si Larbi8, Gérald Viquesnel9, Benjamin Zuber10, Sophie Marque11, Stanislas Kandelman12, Nicolas Pichon13, Bernard Floccard14, Marion Galon15, Sylvie Chevret16, Elie Azoulay17
1Réanimation médicale, Assistance Publique Hôpitaux de Paris, Hôpital Saint Louis, Paris, France; 2Réanimation chirurgicale, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; 3Réanimation Médicale, Hôpital Cochin, Paris, France; 4Val d ‘oise, CH René Dubos, Pontoise, France; 5Réanimation polyvalente, Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon, France; 6Réanimation médicale, CHU Brest, Brest, France; 7Réanimation, Centre Hospitalier la Rochelle, La Rochelle, France; 892151, Hospital Foch, Suresnes, France; 9Réanimation chirurgicale, C.H.U de Caen, Caen, France; 10Intensive care unit, Hospital Center De Versailles, Le Chesnay, France; 11ICU, C.H. Sud Francilien, Corbeil-Essonnes, France; 12Anesthésie réanimation, Hôpital Beaujon (AP-HP), Clichy, France; 13Service de réanimation polyvalente, Centre Hospitalier Universitaire de Limoges, Limoges, France; 14Département anesthésie-réanimation, Hôpital Édouard Herriot, Lyon, France; 15Réanimation médicale, AP-HP Hôpital Saint Louis, Paris, France, France; 16Service de biostatistique et information médicale, Hôpital Saint-Louis, Paris, France; 17Réanimation médicale, Hôpital Saint-Louis, Paris, France
Correspondence: Nancy Kentish-Barnes -

Annals of Intensive Care 2017, 7(Suppl 1):O18

Introduction In the ICU context, in the case of organ donation, patients’ relatives are at the centre of the decision process: within a limited time frame, they will be told that the patient is brain dead and will be asked to consider organ donation. Qualitative studies have put forward that understanding brain death facilitates decision-making and impacts on the final decision (donation vs non donation). However the impact of understanding brain death on relatives’ grieving process has never been evaluated. In this study, we searched for correlation between semi-quantitative answers to questions related to understanding of brain death and experience of the process in a questionnaire completed by relatives 1 month after the patient’s death and post-traumatic related symptoms (PTSD) and complicated grief.

Patients and methods This is an ancillary study of a larger prospective, observational study in 28 ICUs in France that aimed to compare grief symptoms of relatives of donor patients versus relatives of non-donor patients. For each brain dead patient, the relative who served as the surrogate was included at time of organ donation discussion. Relatives were assessed at 3 time points during a telephone interview: at 1 month, to complete a questionnaire regarding their experience in the ICU and description of the organ donation request and procedure, including understanding of brain death; at 3 months to complete the Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale-Revised (IES-R) for PTSD symptoms; at 9 months, to complete the IES-R and the Inventory of Complicated Grief (ICG).

Results 202 relatives were included in the study. At 1 month after the patient’s death, 79.2% of relatives completed the questionnaire, at 3 months 70.3% completed the HADS and the IES-R and at 9 months 61.4% completed the IES-R and the ICG.

One month after the death, 35% of relatives declared having difficulties in understanding brain death and 32% experienced decision-making as difficult. Results show that experience of the decision making process impacts on relatives’ well-being. At 3 months, compared to relatives who did not find the decision difficult, those who did find it difficult more often presented significant PTSD symptoms (40.54 vs 65.88%, p = 0.016). At 9 months, compared to relatives who understood brain death, those who did not understand brain death had higher global ICG score [23 (12.5–36.5) vs 36 (28–43.75), p = 0.010] and more often presented complicated grief symptoms (46.15 vs 75%, p = 0.026). There was a trend in increased prevalence of PTSD related symptoms with 60% in the group of relatives who did not understand brain death versus 47.2% in the group that did, but this was not significant (p = 0.33).

Discussion Results show that difficulty experienced during organ donation discussion and decision impacts on relatives’ well-being in the months that follow the patient’s death. Support to relatives should be proposed in this context. Interestingly, understanding of brain is a key component of relatives’ experience: on top of possibly impacting on the decision itself, it significantly impacts on relatives’ grieving process 9 months after the patient’s death. Promoting better understanding of brain death, proposing clearer explanations, by using various media, may improve both relatives’ understanding and well-being.

Conclusion Our study shows that understanding of brain death is a key component of relatives’ experience that significantly impacts on the grieving process. Efforts should be made to improve relatives’ understanding of brain death.

Competing interests None.

O19 Impact of ICU end-of-life care on relatives’ grief symptoms

Nancy Kentish-Barnes1, Valérie Seegers2, Stéphane Legriel3, Alain Cariou4, Samir Jaber5, Jean Yves Lefrant6, Bernard Floccard7, Anne Renault8, Isabelle Vinatier9, Armelle Mathonnet10, Danielle Reuter11, Olivier Guisset12, Christophe Cracco13, Amélie Seguin14, Jacques Durand-Gasselin15, Marine Thirion16, Zoé Cohen-Solal1, Elie Azoulay11
1Réanimation médicale, Assistance Publique Hôpitaux de Paris, Hôpital Saint Louis, Paris, France; 2Umr 669, Inserm, Paris, France; 3Réanimation, Centre Hospitalier de Versailles, Le Chesnay, France; 4Réanimation Médicale, Hôpital Cochin, Paris, France; 5DAR B, Hôpital Saint Eloi, Montpellier, France; 6Réanimation chirurgicale, Hopital Carémeau, Nîmes, France; 7Département anesthésie-réanimation, Hôpital Édouard Herriot, Lyon, France; 8Réanimation médicale, CHU Brest, Brest, France; 9Réanimation polyvalente, Hopital Les Oudaries, La Roche-sur-Yon, France; 10Réanimation médicale, Centre Hospitalier Régional d’Orléans, Orléans, France; 11Réanimation médicale, Hôpital Saint-Louis, Paris, France; 12Réanimation médicale-hôpital saint-andré, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France; 13Service de reanimation, Service de Réanimation polyvalente, Angoulême, France; 14Réanimation médicale, Centre Hospitalier Universitaire de Caen, Caen, France; 15Réanimation, Hôpital Sainte-Musse, Toulon, France; 16Val d’oise, Centre hospitalier Victor Dupouy (Argenteuil), Argenteuil, France
Correspondence: Nancy Kentish-Barnes -

Annals of Intensive Care 2017, 7(Suppl 1):O19

Introduction Relatives of patients who die in the ICU experience a considerable burden of harm such as symptoms of anxiety and depression, posttraumatic stress disorder (PTSD) symptoms and quality-of-life alterations. Improving the quality of dying and death is recognized as a priority. Nevertheless, specific data are needed to understand what specific aspects of ICU care affect the relatives’ grieving process. This study aims at providing information on potential links between anxiety/depression, PTSD related symptoms, complicated grief and components of ICU end-of-life care in order to specify ICU practices that may affect the risk of developing these symptoms.

Patients and methods This is an ancillary study of the CAESAR study—a prospective, observational study in 41 ICUs in France. Eligible patients were adults who died after at least 48 h in the ICU. For each patient, the relative who served as the surrogate was included at time of death. Relatives were assessed 21 days then 3, 6, and 12 months after the death during a telephone interview. At 21 days they completed the CAESAR scale; at 3 months, they completed the Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale-Revised (IES-R) and at 6 and 12 months they completed the IES-R and the Inventory of Complicated Grief. In this study, we searched for correlation between semi-quantitative answers to CAESAR questions (and not scores) and outcomes.

Results 475 patients and their relatives were included. Response rates were 90.5, 81.3, 59.4 and 45.2%, at day-21, 3, 6 months and at 1 year, respectively.

5 domains are associated with significant increased risk of developing ICU burden (p ≤ 0.05 for each variable).
  1. 1.

    Quality of care and symptom control. Perception that pain was not under control and that the patient had difficulties in breathing is associated with increased risk of developing anxiety and depression at 3 months, PTSD related symptoms at 6 and 12 months, complicated grief at 6 months. Dissatisfaction with quality of care is associated with increased risk of developing anxiety and depression at 3 months, PTSD related symptoms at 3 months, complicated grief at 12 months.

  2. 2.

    Quality of communication. Dissatisfaction with communication with either doctors or nurses is associated with increased risk of developing anxiety and depression at 3 months, PTSD related symptoms at 3 and 6 months, complicated grief at 6 months.

  3. 3.

    Kindness. Perception that the team was not kind enough is associated with increased risk of developing anxiety and depression at 3 months, PTSD related symptoms at 3, 6 and 12 months.

  4. 4.

    Preparation for death. Relatives who were not informed that the patient was dying, who were unable to express important things or to say goodbye were more at risk of developing anxiety and depression at 3 months, PTSD related symptoms at 3, 6 and 12 months and complicated grief at 6 and 12 months.

  5. 5.

    Presence at time of death is associated with increased risk of developing PTSD related symptoms and complicated grief at 6 and 12 months.


Discussion Relatives are sensitive to interaction between the ICU team and themselves as well as between the team and the patient. Quality of communication (both verbal and non verbal) and support, as well as preparation for the death, are key components of relatives’ experience that impact on grief symptoms in the months that follow the patient’s death.

Conclusion Quality of care and support during the dying process are at the heart of the relatives’ experience. This study puts forward practices that may be improved in order to promote both palliative care and family centered care in the ICU and, in fine, decrease grief symptoms in bereaved relatives.

Competing interests None.

O20 Complicated grief after organ donation of brain-dead patients: evaluation of the donors’relatives 6 months after the death

Hélène Foulgoc1, Julien Rogier1, Elsa Delobbe1
133, CHU - Hôpitaux de Bordeaux, Bordeaux, France
Correspondence: Hélène Foulgoc -

Annals of Intensive Care 2017, 7(Suppl 1):O20

Introduction In 2015, 1824 organ donations were performed in France. We already know that complicated grief after the death of a relative in the intensive care unit is frequent but the population of organ donors’relatives hasn’t been studied. Currently, there doesn’t exist any sector to orientate donors’ families. The purpose of our study is to investigate the complicated grief donors’ relatives, its associated diseases and risk factors.

Patients and methods Prospective, single-center, observational study. During the first meeting with the transplantation coordination team of our hospital, it was proposed to the organ donors’ relatives to participate. The relatives who had accepted received the ICG, IDS-SR and PCLS questionnaires at 1, 3 and 6 months after the death. The primary endpoint was the presence of complicated grief, defined by an ICG > 25, among the relatives of organ donors after 6 months from the death. The secondary end points were the presence of major depressive disorders (IDS-SR ≥ 15) and post-traumatic stress disorders (PTSD) (PCLS ≥ 44) at 6 months and the analysis of complicated grief‘s risk factors: about the deceased person (age, sex, cause of the death, place of the death, time between the hospital’s entrance and the death) and about the relative (sex, age, relationship with the donor, occupational category, PCLS ≥ 44 and IDS-SR ≥ 15 6 months after the death).

Results From December 2014 to January 2016, 81 donors’ relatives were included. An average of 3.24 relatives per donor was included. 16 of the 29 relatives who responded at 6 months had an ICG > 25. The prevalence of complicated grief is 55.2% [95 CI = 37–73]. The prevalence of major depressive disorder and PTSD are respectively 72% [95 CI = 55.7–88.3] and 31% [95 CI = 14.2–47.8] (Table 1). No variable were significantly associated with a complicated grief at 6 months from the death.

Discussion Even if only 36% of the relatives completed the scales at 6 months, this study shows a high risk of complicated grief among donor’s relatives. But we can see that the prevalence of complicated grief in this population is closed to the prevalence find after the death of a relative in the intensive care unit. Because of the lake of responses at 6 months, we can’t conclude on the risk factors.

Conclusion 55.2% of donor’s relatives developed a complicated grief 6 months after the death. The establishment of dedicated channels to orientate these bereaved persons seems important. Further studies should be conducted to define better the complicated grief’s risk factors following an organ donation.

Competing interests None.

  1. 1.

    Prigerson HG, Maciejewski PK, Reynolds CF, Bierhals AJ, Newsom JT, Fasiczka A, et al. Inventory of complicated grief: a scale to measure maladaptive symptoms of loss. Psychiatry Res. 1995;59(1–2):65–79.

  2. 2.

    Kentish-Barnes N, Chaize M, Seegers V, Legriel S, Cariou A, Jaber S, et al. Complicated grief after death of a relative in the intensive care unit. Eur Respir J. 2015.


O21 Impact of fluid-induced hyperchloremia on acid base balance and outcomes in septic shock: post hoc analysis of the “Hyper2S”study

Frédérique Schortgen1, Pierre Asfar2, Boisramé-Helms Julie3, Julien Charpentier4, Emmanuel Guérot5, Bruno Megarbane6, David Grimaldi7, Grelon Fabien8, Nadia Anguel9, Lasocki Sigismond10, Henry-Lagarrigue Matthieu11, Frédéric Gonzalez12, Legay François13, Christophe Guitton14, Maleka Schenck15, Doise Jean-Marc16, Didier Dreyfuss17, Peter Radermacher18, for the HYPER2S Investigators and REVA Research Network
1Réanimation médicale, Hôpital Henri-Mondor (AP-HP), Créteil Cedex, France; 2Réanimation, C.H.U. d’Angers, Angers, France; 3Réanimation médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; 4Réanimation Médicale, Hôpital Cochin, Paris, France; 5Réanimation médicale, Hopital Europeen Georges-Pompidou, Paris, France; 6Service de Réanimation Médicale et Toxicologique, CHU Lariboisière, Paris, France; 7Service de réanimation polyvalente, Centre Hospitalier de Versailles, Le Chesnay, France; 8Réanimation, C.H. - Le Mans, Le Mans, France; 9Réanimation médicale, CHU de Bicêtre, Le Kremlin Bicêtre, France; 10Réanimation chirurgicale, C.H.U. d’Angers, Angers, France; 11Réanimation polyvalente, Hospital Center Departmental De Vendée, La Roche-sur-Yon, France; 12Réanimation medico-chirurgicale, hopital avicenne, Bobigny, France; 13Réanimation, C.H. de Saint Brieuc, Saint-Brieuc, France; 14Réanimation médicale, C.H.U. Hôtel Dieu, Nantes, France; 15Réanimation médicale, C.H.R.U. Hôpitaux Universitaires Strasbourg, Strasbourg, France; 16Réanimation, C.H. Chalon sur Saône William Morey, Chalon-sur-Saône, France; 17Réanimation polyvalente, Hôpital Louis-Mourier (AP-HP), Colombes cedex, France; 18Institut für anästhesiologische pathophysiologie und verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
Correspondence: Frédérique Schortgen -

Annals of Intensive Care 2017, 7(Suppl 1):O21

Introduction The harmfulness of fluid-induced hyperchloremia (H-Cl) remains debated. Large randomized trial showed that chloride-rich crystalloids did not worsen outcome [1]. The volume of fluids, however, was limited and the incidence of H-Cl was not recorded.

Patients and methods In a post hoc analysis of the database of the RCT “Hyper2S”, a study comparing normal to 3% hypertonic saline for 72 h in 434 patients with septic shock, we assessed the incidence and the impact of H-Cl (≥110 mmol/L) on adverse events and mortality. Cl, pH, bicarbonate (Bic) and lactate (Lac) were recorded at H0-12-24-72. Episodes of hyperlactatemia (H-Lac > 2 mmol/L), metabolic acidosis (pH < 7.35 + Bic < 22) either H-Cl (pH < 7.35 + Bic < 22 + Cl ≥ 110 + Lact ≤ 2) or H-Lac (pH < 7.35 + Bic < 22 + Lact > 2) were recorded. Acute kidney injury (AKI) was defined by doubling creatinine or dialysis.

Results 413 patients without missing data were analysed. H-Cl and HCl-acidosis were recorded in 257 (62%) and 77 (19%) patients, respectively, H-Lact and H-Lact-acidosis in 294 (71%) and 209 (51%) patients, respectively. Baseline severity scores were similar in patients with and without H-Cl but vasopressor dose was higher in patients with H-Cl (Table 5). The chloride load was significantly higher in patients with H-Cl (Table 5). Both, H-CL acidosis and H-Lac acidosis were more frequent in patients with than without H-Cl episode (Table 5). H-Cl was not associated with AKI or mortality (Table 5). The mortality of patients who experienced H-Cl acidosis (25%) was similar to patients who never experienced metabolic acidosis (28%), p = 0.65.
Table 5

Characteristics and outcome of patients with and without H-Cl (results are number and % of patients and medians IQR)


No H-Cl (n = 156)

H-Cl (n = 257)


Characteristics at inclusion

 SAPS II (points)