Open Access

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

Annals of Intensive Care20177(Suppl 1):8

https://doi.org/10.1186/s13613-016-0223-8

Published: 10 January 2017

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 - wulfran.bougouin@gmail.com

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

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 come.bureau@gmail.com

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 - guylainelabro@hotmail.fr

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.

References
  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 - maellemart1@gmail.com

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

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.

References
  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 - elodie.privat@hotmail.fr

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

Variablesa

<1 year (n = 393)

1–4 years (n = 146)

5–12 years (n = 142)

13–17 years (n = 219)

p

ROSC

71 (18)

43 (30)

41 (29)

81 (37)

<10−3

Survival at hospital admission

68 (17)

52 (36)

43 (30)

85 (39)

<10−3

Survival at day 30

13 (3)

20 (14)

13 (9)

29 (13)

<10−3

CPC 1 or 2 at day 30

12 (3)

13 (9)

3 (2)

22 (10)

<10−3

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 - vincent.re@gmail.com

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 - charlotte.salmon.gandonniere@gmail.com

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.

References
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    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.

     
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    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 - stephanegaudry@gmail.com

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

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 - rene.robert@chu-poitiers.fr

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 - michael.darmon@chu-st-etienne.fr

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 Clinicaltrial.gov.

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.

References
  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 - mariecantier@gmail.com

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 - fayssoil2000@yahoo.fr

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 - loic.leguennec@yahoo.fr

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

Characteristic

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)

SAPS II

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]

 ACT

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

 Peripheral

698 (87)

35 (74)

20 (80)

 Switch to central ECMO

38 (5)

2 (4)

4 (16)

 Central

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 - marion.griton@chu-bordeaux.fr

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

0.004

Female sex

23 (60)

9 (60)

0.86

WFNS IV–V

10 (26)

7 (47)

<0.001

Fisher grade 4

18 (47)

9 (60)

<0.001

HRV on day 2

 LF (ms)

519 ± 528

171 ± 385

0.02

 HF (ms)

513 ± 863

224 ± 505

0.24

 Entropy

50.3 ± 12.0

34.3 ± 16.4

<0.001

 LF/HF

1.97 ± 1.41

1.87 ± 2.27

0.85

 VLF (ms)

1471 ± 2152

184 ± 364

0.02

 CVVR (%)

4.18 ± 2.01

2.25 ± 2.31

0.006

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.

References
  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 - thierry.boulain@chr-orleans.fr

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 - youenn.jouan@gmail.com

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 - mgarrouste@hpsj.fr

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

Variables

Cases n = 37

Control n = 37

p value

Return home within 1 month

17 (45.9%)

37 (100%)

<0.01

Need of help at home

22 (59.4%)

5 (13.5%)

<0.05

Change in working conditions

12 (32.4%)

3 (8.1%)

<0.05

Change in financial conditions

10 (27%)

7 (18.9%)

0.6

Psychologist help

17 (45.9%)

5 (13.5%)

<0.05

Use of medications

9 (24.3%)

8 (21.6%)

1

Change in marital status

2 (5.4%)

3 (8.1%)

1

Eating disorders

8 (21.6%)

5 (13.5%)

0.54

Disorder of sexual life

12 (32.4%)

7 (18.9%)

0.3

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.

References
  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 - nancy.kentish@aphp.fr

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 - nancy.kentish@aphp.fr

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 - helene_f@hotmail.fr

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.

References
  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 - frederique.schortgen@aphp.fr

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)

P

Characteristics at inclusion

 SAPS II (points)

55 (46–63)

56 (48–65)

0.65

 SOFA (points)

10 (8–12)

10 (8–12)

0.31

 Vasopressor dose (µg/kg/min)

0.32 (0.20–0.66)

0.44 (0.23–0.80)

0.04

 Serum creatinine (µmol/L)

137 (79–208)

132 (80–191)

0.31

Evolution from H0 to H72

 Volume of fluid resuscitation (L)

1.4 (0.6–2.3)

2.2 (1.1–3.9)

<0.001

 Chloride load (all fluids) (mmol)

287 (129–491)

690 (293–1127)

<0.001

 Mean pH

7.36 (7.29–7.40)

7.32 (7.26–7.37)

<0.001

 ≥1 episode metab. acidosis [n (%)]

82 (53)

204 (79)

<0.001

 ≥1 episode H-Cl acidosis [n (%)]

NA

77 (30)

 ≥1 episode H-Lact acidosis [n (%)]

41 (26)

149 (58)

<0.001

Outcomes

   

 AKI [n (%)]

96 (64)

146 (58)

0.42

 D28 mortality [n (%)]

60 (38)

95 (37)

0.76

Conclusion H-Cl is frequent in septic shock patients resuscitated with chloride-rich fluids but does not increase AKI or mortality. H-Lact is more frequent in patients with H-Cl, which is an important bias for the interpretation of the origin of acidosis and attributable mortality.

Competing interests None.

Reference
  1. 1.

    Young P. JAMA. 2015;314:1701–10.

     

O22 Grief symptoms in relatives of brain dead patients: comparison of relatives of donor and non-donor patients

Nancy Kentish-Barnes1, Jacques Duranteau2, Julien Charpentier3, Marie Thuong4, Liliane Joseph2, Laurent Martin-Lefèvre5, Anne Renault6, Anne-Gaelle Si Larbi7, Olivier Lesieur8, 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; 792151, Hospital Foch, Suresnes, France; 8Réanimation, Centre Hospitalier la Rochelle, La Rochelle, 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 - nancy.kentish@aphp.fr

Annals of Intensive Care 2017, 7(Suppl 1):O22

Introduction Long after the death of a loved one, end-of-life decisions can remain with the living and have been implicated in post ICU burden. In the case of organ donation, the 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. Attention has been focused on how relatives make the decision to donate or not to donate the patient’s organs but only very few studies have focused on the impact of organ donation decision making on their psychological well-being during the months that follow the patient’s death. The goal of this study was to describe the grieving process of relatives who were approached about organ donation in the context of brain death and to compare grief symptoms of relatives of donor patients (DPs) versus relatives of non-donor patients (NDPs).

Patients and methods We conducted a prospective, observational study in 28 ICUs in France. 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; 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). The primary outcome measure was the IES-R (at 3 and 9 months).

Results 202 relatives were included in the study among which 158 were relatives of DPs and 44 of NDPs. 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.

Relatives’ experience of ICU and decision-making varies between the 2 groups. Relatives of NDPs are less satisfied with communication with ICU team than relatives of DPs (26.6 vs 8%, p = 0.021). Relatives of NDPs were more often shocked by organ donation request than relatives of DPs (64.52 vs 19%, p < 0.0001). During organ donation discussions, relatives of NDPs more often declared an absence of support from the ICU team (19.35 vs 1.59%, p = 0.0008) and more often felt under pressure (41.94 vs 7.14%, p < 0.0001).

At 3 months, there was no difference in the IES-R score between relatives of DPs (31 [21–41]) and NDPs (31.5 [11.25–34]) (p = 0.29). Similarly there were no differences in HADS score (13 [9–20] and 13.5 [8.25–20] respectively, p = 1.00) and anxiety and depression subscores. At 9 months, there was no difference in the IES-R score between relatives of DP (26 [12.75–38]) and NDP (33.5 [21.25–43.25]) (p = 0.17). Similarly there were no differences in ICG score (25.5 [14.37–25] and 32.5 [17.43–25] respectively, p = 0.11).

Discussion Relatives of DPs and NDPs have different experience of quality of communication and quality of support during the patient’s ICU stay. More than the decision itself, quality of the organ donation process impacts on relatives’ grief symptoms.

Conclusion The decision (donation vs no donation) has no impact on grief symptoms in the months following the patient’s death. However, experience of the request and of the decision itself, as well as quality of communication and support, are elements that effect relatives’ experience and grieving process.

Competing interests None.

O23 Implementation and impact of the surviving sepsis campaign protocol: results of a quasi-experimental study in Democratic Republic of Congo (DRC)

Joseph Nsiala Makunza1, Mejeni Kamdem Nathalie1, Akilimali Pierre2, Kilembe Manzanza Adolphe3
1Anesthésie-Réanimation, Cliniques universitaires de Kinshasa, Kinshasa, Democratic Republic of the Congo; 2Statistics, School Of Public Health, Kinshasa, Democratic Republic of the Congo; 3Anesthéthésie-réanimation, Cliniqes Universitaires de Kinshasa, Kinshasa, Democratic Republic of the Congo
Correspondence: Joseph Nsiala Makunza - mnsiala78@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):O23

Introduction In developed countries, the application of the “Surviving Sepsis Campaign” (SSC) protocols in the management of sepsis and septic shock has been associated with increased survival [1].

In the context of a fragile health system, the application of these protocols may be expected to prove to be difficult to undertake and the impact may also be expected to vary [2].

Patients and methods We conducted a prospective, quasi-experimental before and after study in the university hospital of Kinshasa (DRC) comparing 33 consecutive patients in septic shock treated according to usual care versus 39 patients treated according to a protocol type EGDT from 1st February 2014 to 31st July 2014 (pre- protocol phase) and 1st September 2014 to 28th February 2015 (post- protocol phase). Between the 2 phases, we have drawn and implemented a local protocol based on SSC recommendations. A kit consisting of central venous catheters, devices capable of measuring central venous pressure, flow regulator (Dosiflow R) and lactate reader was available.

In the absence of electrically driven syringe pumps, catecholamines were administered by continuous perfusion using a flow regulating device (Dosiflow). We drew up calculating tables based on a standard dilution and a variable administration rate controlled by the flow regulating device, thus permitting precise and constant dose administration in millilitres/hour (ml/h).

The main outcome measures were: the rate of compliance with 6-h sepsis care bundles and the hospital mortality until J30. The Student’s and U Mann–Whitney tests were used to compare quantitative variables, and the chi-square test to compare qualitative variables. Kaplan–Meier survival curves were used and the differences between the two curves were analyzed using the log rank test.

This study received the approval of ethics committee and was registered 23th January 2014 under number ESP/CE/053/14.

Results Baseline characteristics of patients were similar in both two groups. Lung infection was the main source of septic shock and antibiotics administration delay was less than 3 h in the two groups. In contrast, blood cultures and blood lactate were performed only in patients of the EGDT group.

Patients of the EGDT group received more IV fluids (+1226 ml on average), more catecholamines (+24, 9%) and were more often transfused (+13, 7%) than the patients treated in the habitual fashion. Protocol compliance was substantially improved, passing from 0 to 50%. The absolute risk reduction of mortality was 17% (100 vs 83%; p = 0.0037) when all the therapeutic measures had been employed.

The Kaplan–Meier survival curves showed that the patients in the pre-protocol group had a significantly greater risk of dying compared with those in the post-protocol group. The average length of stay was 2.2j vs 5.2j p = 0.0037.

Discussion Our results in terms of compliance with the sepsis bundle were satisfying given that even in highly developed countries the compliances rates are often below 50% [3]. Ignorance of the very existence of these recommendations and logistical factors are often quoted as the reasons why compliance is so poor

The positive impact that we observed on mortality was found in similar studies [4].

Other more recent randomized controlled studies have not found significant differences but this may be explained by the similarity of treatment protocols in the two groups [5].

Our study is coherent according to current literature but there exist certain limits which might be expected in this kind of study.

Our research was implemented in only one centre and these results cannot be extrapolated to all sub-Saharan Africa, nor even to our own country. As in all before/after studies, comparison with a historic control group is liable to introduce a bias based on confusion. We sought to minimize this bias however by choosing a short study period (12 months) with the same therapeutic team during the entire study.

Conclusion Despite a difficult socio-economic context, the implementation of a local protocol based on the recommendations of the SSC was associated with improved outcome in septic shock patients in our hospital compared to usual care.

We thus intend to continue and to widen the application of this protocol in an effort to evaluate if this positive effect will be observed in a greater number of patients.

Competing interests None.

References
  1. 1.

    Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38(2):367–74.

     
  2. 2.

    Baelani I, Jochberger S, Laimer T, Otieno D, Kabutu J, Wilson I, Baker T, Dünser MW. Availability of critical care resources to treat patients with severe sepsis or septic shock in Africa: a self-reported, continent-wide survey of anaesthesia providers. Crit Care. 2011;15(1):R10.

     
  3. 3.

    Rhodes A, Phillips G, Beale R, Cecconi M, Chiche JD, De Backer D, et al. The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study). Intensive CareMed. 2015; 41(9):1620–8.

     
  4. 4.

    Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med. 2014;40:1623–33 5.

     
  5. 5.

    Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, et al. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med. 2015; 41(9):1549–60.

     

O24 Characteristics and 1-year prognosis of tetanus patients admitted to the ICU

Rafael Mahieu1, Thomas Reydel1, Adel Maamar2, Angéline Jamet3, Nicolas Chudeau4, Julien Huntzinger5, Steven Grange6, Anne Courte7, Stephan Ehrmann8, Jérémie Lemarie9, Sébastien Gibot9, Michaël Darmon10, Christophe Guitton11, Julia Champey12, Jean Dellamonica13, Ferhat Meziani14, Damien Du Cheyron15, Nicolas Lerolle1
1Réanimation médicale, Centre Hospitalier Universitaire d’Angers, Angers, France; 2Réanimation médicale, Centre hospitalier universitaire de Rennes, Rennes, France; 3Réanimation médicale, CHU de Poitiers, Poitiers, France; 4Réanimation médico-chirurgicale, C.H. - Le Mans, Le Mans, France; 5Réanimation médicale, Centre hospitalier Bretagne Atlantique, Vannes, France; 6Réanimation médicale, Centre Hospitalier Universitaire Rouen, Rouen, France; 7Réanimation polyvalente, Centre Hospitalier Yves le Foll, Saint-Brieuc, France; 8Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France; 9Réanimation médicale, hôpital central, C.H.U. de Nancy, Nancy, France; 10Réanimation Médicale, CHU Saint-Etienne - Hôpital Nord, Saint-Étienne, France; 11Réanimation médicale, C.H.U. Hôtel Dieu, Nantes, France; 12Réanimation médicale, C.H.U. Grenoble, Grenoble, France; 13Réanimation médicale, Centre Hospitalier Universitaire Archet, Nice, France; 14Réanimation médicale, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France; 15Réanimation médicale, Centre Hospitalier Universitaire de Caen, Caen, France
Correspondence: Rafael Mahieu - rafael.mahieu@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):O24

Introduction Despite being a fully preventable infectious disease, tetanus is still responsible for about 500,000 death worldwide. In developed countries, the incidence is strongly associated with a lack of vaccination coverage in the elderly. In the USA or in France, people over 65 year-old have a twice to tenfold increase in annual incidence of tetanus versus younger patients [1]. Considering the long lasting effects of tetanus toxin up to 6 weeks, elderly people admitted in intensive care units (ICU) are of particular risk of complications. Prognostics factors are well known in developing countries with a mortality rate above 20% but clinical data in developed countries are missing. We conducted a multi-center retrospective study in France on 90-day and 1-year mortality in patients with tetanus admitted in ICU.

Patients and methods This study was conducted over 15 French ICUs. All adults patients admitted for tetanus from January 2000 to December 2014 were included. Data were retrospectively collected from medical files. Long-term vital outcome was obtained by interrogating town hall registries.

Results Seventy patients were recruited over the study period. Median age was 80 years [IQ range 73–84], 86% were women. Median Charlson comorbidity index score was 4 [3–5] and Knaus chronic health score status was distributed equally between category A or B (50% each). All patients had trismus and 56% had generalized form at presentation. The median incubation period was 10 days [IQR 8–14]. Mechanical ventilation (MV) was performed in 90% of patients for a median duration of 36 days [IQR 26–46]. Median SAPS II score at ICU admission was 33 [IQR 26–40], corresponding to an predicted hospital mortality rate of 14%. Median length of stay in ICU was 41 days [IQR 24–53]. Ninety-day and one-year mortality rates were 13% (n = 9) and 16% (n = 11) respectively. Kaplan–Meier survival curve is presented Fig. 4.
Fig. 4

Overall survival of tetanus patients admitted in ICU

Death typically occurred within the first week (55%) due of severe arrhythmia at admission or during the fourth ICU week (withdrawal of life sustaining therapies in 3 patients or multiple organ dysfunction syndrome due to nosocomial infections in 2). Ventilator-associated pneumoniae incidence was 15 episodes per 1000 ventilation-days (total of 2234 ventilator-days observed) corresponding to 48% of ICU patients receiving MV.

Mortality was associated with older age (83 [81–85] versus 79 [73–84] years, p = 0.06) and baclofen use (intrathecal or intravenous, 4/9 non survivors vs. 8/61 in survivors, p = 0.04). Shorter incubation period (under the median delay of 10 days), generalized tetanus, wound debridement (performed in 11 patients) and higher SAPSII (above 30) were significantly associated with longer duration of MV.

Discussion In-hospital mortality rate was low and consistent with SAPS II estimation [2], despite long-term mechanical ventilation in an elderly population. Surprisingly, baclofen use was associated with an increased risk of death and may be linked to drug-related adverse events. Association of wound debridement with MV duration may either be related to higher bacterial inoculum in larger wound or to per-procedure toxin release.

Conclusion Long-term follow-up for tetanus-related ICU admission highlights the favorable outcome of this elderly population despite very prolonged MV and frequent infectious complications.

Competing interests None.

References
  1. 1.

    Centers for Disease Control and Prevention (CDC). Tetanus surveillance—United States, 2001–2008. MMWR Morb Mortal Wkly Rep. 2011;60(12):365–9.

     
  2. 2.

    Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270(24):2957–63.

     

O25 The clinical spectrum of purpura fulminans in adult patients: a national multicenter retrospective study of 306 patients

Damien Contou1, Romain Sonneville2, Gwenhaël Colin3, Remi Coudroy4, Frédéric Pène5, Jean-Marc Tadié6, Martin Cour7, Gaetan Beduneau8, Antoine Marchalot9, Laurent Guérin10, Sebastien Jochmans11, Stephan Ehrmann12, Nicolas Terzi13, Sebastien Preau14, François Barbier15, Christian Brun-Buisson1, Armand Mekontso Dessap1, Nicolas de Prost1, for the Purpura Fulminans Study Group
1Réanimation Médicale, Hôpital Henri Mondor, Créteil, France; 2Service de réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard-APHP, Paris, France; 3Réanimation polyvalente, Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon, France; 4Réanimation médicale, CHU de Poitiers, Poitiers, France; 5Réanimation Médicale, Hôpital Cochin, Paris, France; 6Réanimation médicale, Centre Hospitalier Universitaire de Rennes, Rennes, France; 7Réanimation Médicale, Hospices Civils de Lyon - Groupement Hospitalier Edouard Herriot, Lyon, France; 8Réanimation médicale, Centre Hospitalier Universitaire Rouen, Rouen, France; 9Service de réanimation médicale, Centre Hospitalier de Dieppe, Dieppe, France; 10Réanimation médicale, Hôpital Ambroise Paré (AP-HP), Boulogne-Billancourt, France; 11Service de Réanimation, Centre Hospitalier Marc Jacquet, Melun, France; 12Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France; 13Service de réanimation médicale, Clinique de Réanimation Médicale, Grenoble, France; 14Réanimation médicale, Centre Hospitalier Régional Universitaire de Lille, Lille, France; 15Loiret, Hôpital Régional Orléans La Source, Orléans, France
Correspondence: Damien Contou - damien.contou@aphp.fr

Annals of Intensive Care 2017, 7(Suppl 1):O25

Introduction The available data on Purpura Fulminans in adult patients are scarce, old and mainly limited to patients with meningococcal infections. Our aims were:
  1. 1.

    to describe the clinical features.

     
  2. 2.

    to identify predictive factors of in-ICU mortality.

     
  3. 3.

    to compare the presentation and outcomes between causative micro-organisms.

     
  4. 4.

    to report the rate of limb amputation and identify predictive factors for limb amputation in adult patients admitted in intensive care unit for an infectious Purpura Fulminans.

     

Patients and methods We performed a 16-year national multicenter retrospective study in 56 ICUs in France from 2000 to 2016. Infectious PF was defined by the association of a sudden and extensive purpura, whatever its causative microorganism, together with the need for vasopressor support. Patients with a noninfectious purpura or with a purpura in a context of infectious endocarditis were excluded from the study.

Results (1) Clinical features upon ICU admission A total of 306 patients were included in the study for an incidence of 0.35 patients per year and per center. Patients were young (median age 34 years [21–53]) and had no previously known comorbidity in 69% of cases. Symptoms before ICU admission included fever (77%), digestive symptoms (61%), headache (45%), myalgia (25%) and lower limb pain (21%), for which 16% of the patients consumed non-steroidal anti-inflammatory drugs before admission. Before ICU admission, 77% of patients had a purpura notified and 75% received a parenteral β-lactam antibiotic. A successful resuscitation of an out-of-hospital cardiac arrest was recorded for 5% of patients. Mean coma Glasgow score at ICU admission was 15 [13–15] and 20% of patients had a neck stiffness. A lumbar puncture was performed in 56% of patients and showed a meningitis (pleocytosis > 10/mm3) in 45% of them. A bacteremia was documented in 66% of cases (n = 202/306) and a positive cerebrospinal fluid culture was obtained for 51% of lumbar punctures performed (n = 85/171). In all, the two predominantly identified microorganisms were Neisseria meningitidis (n = 195/306, 63%), mainly serogroup B (39%) and C (34%), and Streptococcus pneumoniae (n = 67/306, 22%).

(2) Patients’ outcomes In-ICU mortality was 41% (n = 126/306). Compared to ICU non-survivors, ICU survivors were younger (29 vs. 43 years, p < 0.0001), had more frequently received a β-lactam antibiotic before ICU admission (83 vs. 64%, p < 0.0001), had more frequent neck stiffness (26 vs. 12%, p = 0.004) and cytological meningitis (51 vs. 31%, p = 0.029) and were more frequently documented with Neisseria meningitidis (69 vs. 56%, p = 0.04). Age (OR 1.02/year, 95% CI [1.01–1.04]; p = 0.002) and SOFA score (OR 1.44/point, 95% CI [1.30–1.58]; p < 0.0001) upon ICU admission were the only variables independently associated with ICU mortality.

(3) Impact of the identified microorganism As compared with others, patients with pneumococcal PF were older (p < 0.0001), had more frequent asplenia (48 vs. 2%, p < 0.0001), higher SAPS 2 and SOFA scores together with a higher ICU mortality (52 vs. 36%, p = 0.04), and required more frequent limb amputation (31 vs. 9%, p < 0.0001).

(4) Surviving patients requiring amputations 22% of ICU survivors (n = 39/180) eventually required amputation during their ICU stay with a median of 3 [2–4] limbs amputated. Among ICU survivors (n = 180/306, 59%), those who were amputated (n = 39/180, 22%) were older (42 vs. 26 years, p = 0.016) and presented with higher SOFA and SAPS 2 scores, lower platelets counts (38 vs. 87.103 mm−3, p < 0.0001), more severe kidney injury and higher arterial lactate (7 vs. 5 mmol/L, p < 0.001) and creatine kinase (856 vs. 159 IU/L, p < 0.001) levels than those who were not amputated. By multivariable regression analysis, the following risk factors for limb amputation were identified among ICU survivors: SOFA score upon ICU admission (OR 1.34/point, 95% CI [1.14–1.59]; p < 0.0001), Streptococcus pneumoniae PF (OR 5.05, 95% CI [1.73–14.74]; p = 0.003), and platelets transfusion (OR 6.06, 95% CI [2.20–16.73]; p < 0.0001).

Conclusion Purpura Fulminans is a rare disease mainly affecting young healthy patients. Most patients had an extensive purpura identified before ICU admission and those receiving antibiotics before ICU admission had a lower mortality than others. Neisseria meningitidis and Streptococcus pneumoniae were the main micro-organisms identified. The overall ICU mortality was high and limb amputations were needed in almost one quarter of ICU survivors. Patients with Streptococcus pneumonia PF had a poorer outcome with a higher ICU mortality and a higher risk of limb amputation.

Competing interests None.

References
  1. 1.

    Vincent J-L, Nadel S, Kutsogiannis DJ, Gibney RTN, Yan SB, Wyss VL, et al. Drotrecogin alfa (activated) in patients with severe sepsis presenting with purpura fulminans, meningitis, or meningococcal disease: a retrospective analysis of patients enrolled in recent clinical studies. Crit Care Lond Engl. 2005;9(4):R331–43.

     
  2. 2.

    Giraud T, Dhainaut J-F, Schremmer B, Regnier B, Desjars P, Loirat P, et al. Adult overwhelming meningococcal purpura: a study of 35 cases, 1977–1989. Arch Intern Med. 1991;151(2):310–6.

     

O26 Cerebral NIRS profiles during premedication for neonatal intubation

Meryl Vedrenne-Cloquet1, Sophie Breinig2, Camille Jung3, Maxime Brussieux3, Marie-Odile Marcoux2, Xavier Durrmeyer1
1Service de réanimation néonatale, C.H. Intercommunal Créteil, Créteil, France; 2Service de réanimation néonatale et pédiatrique, Hospital Center University Toulouse - Casselardit Ancely, Toulouse, France; 3Centre de recherche clinique, C.H. Intercommunal Créteil, Créteil, France
Correspondence: Meryl Vedrenne-Cloquet - meryl_vedrenne@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):O26

Introduction To date, there is no consensus on which anesthetic protocol should be used before neonatal intubation. As a result, awake intubation, although strongly discouraged by current recommendations, is still common in neonates, especially in France. Many experts consider Propofol, a short-acting anesthetic agent, an appropriate drug for premedication before neonatal intubation. Propofol is known to decrease systemic vascular resistance leading to low arterial blood pressure, which consequently raises concerns about its hemodynamic tolerance. However in neonates, low mean arterial blood pressure (MABP) is poorly correlated with low systemic or cerebral blood flow. NIRS (Near InfraRed Spectroscopy) allows cerebral tissue oxygenation monitoring, reflecting cerebral blood flow.

The aim of our study was to compare cerebral oxygenation profiles between a combination of a synthetic opioid plus a muscle-blocker and propofol, used as premedication prior to neonatal endotracheal intubation.

Patients and methods Observational prospective study, conducted in 2 of the 8 centers participating in a randomized, controlled, double-blind, multicenter trial (PRETTINEO study, ClinicalTrial.gov identifier NCT01490580). Patients were randomly assigned (1:1) between “atropine-propofol” and “atropine-atracurium-sufentanil” before elective or semi-urgent intubation in the neonatal intensive care unit. Randomization was stratified on weight and center. Exclusion criteria included low blood pressure defined as a MABP (in mmHG) below gestational age (in weeks). Physiological parameters, including pulse oxymetry (SpO2) and regional cerebral oxygen saturation (rScO2), were collected 1 min prior to induction of anesthesia, and then up to 60 min after. To investigate the balance between oxygen delivery and consumption, cerebral fractional tissue oxygen extraction (FTOE) was calculated as FTOE = (SpO2 − rScO2)/SpO2. The analyzed parameters included changes in rScO2 and FTOE over time and their relative change from baseline value in both treatment groups.

Results From March to August, 2016, 65 neonates were assessed for eligibility. Among them, 28 were finally included in this ancillary study. Their mean (SD) gestational age at birth was 32 (5) weeks. Median [IQR] age and mean (SD) weight at the time of intubation were 0.5 [0.2–5.4] days and 1886 (900) g respectively. At the time this abstract was conceived, data validation had not been completed. Results will be available at the time of the meeting.

Discussion To our knowledge, only two studies to date have investigated the cerebral hemodynamic effects of propofol in neonates. Both reported persistent low MABP after a propofol bolus but a very short decrease in rScO2. Only one studied propofol before intubation and suggested that low rScO2 could be attributable to low SpO2 during the procedure, but not to low MABP (Smits et al., J Pediatr, 2016). None of them compared propofol to another anesthetic protocol. Our study is thus the first to compare cerebral oxygenation between two currently acceptable regimens of anesthesia for premedication before neonatal intubation.

Conclusion This observational study is expected to provide useful information about cerebral oxygenation in neonates during intubation and to disentangle the effects of the drugs from the effects of the procedure. We also expect this study will en courage Neonatologists to avoid awake intubation.

Competing interests None.

References
  1. 1.

    Vanderhaegen J, Naulaers G, Van Huffel S, Vanhole C, Allegaert K. Cerebral and systemic hemodynamic effects of intravenous bolus administration of propofol in neonates. Neonatology. 2010;98(1):57–63.

     
  2. 2.

    Smits A, Thewissen L, Caicedo A, Naulaers G, Allegaert K. Propofol dose-finding to reach optimal effect for (semi-)elective intubation in neonates. J Pediatr. 2016; pii: S0022-3476(16)30651-5. doi:https://doi.org/10.1016/j.jpeds.2016.07.049 (Epub ahead of print).

     

O27 A prospective multicentric study of severe cutaneous infections in pediatric intensive care: the SCIPIC cohort

Renaud Blondé1, François Angoulvant2, Jérôme Grasset3, Jérôme Naudin4, Stéphane Dauger4, GFRUP, RMEF
1Mayotte, CHM, Mamoudzou, France; 2Urgences pédiatriques, CHU Necker-Enfants Malades, Paris, France, France; 3Iriseo, Iriseo - 3D Supports multimédia Interactifs, Saint-Victurnien, France; 4Réanimation et surveillance continue pédiatriques, CHU Robert Debré, Paris, France
Correspondence: Stéphane Dauger - stephane.dauger@aphp.fr

Annals of Intensive Care 2017, 7(Suppl 1):O27

Introduction Cellulitis (CEL) and Necrotizing Fasciitis (NF) are life-threatening skin infections much more frequent in adults than in children. Therefore, despite major differences in epidemiology, microbiology, and outcome, clinical guidelines for management are directly adapted from adult ICU experience. We designed a prospective multicentric cohort study to describe the clinical course of CEL/NF requiring admission to PICU.

Patients and methods This study was approved by the IRB Paris Nord and the French Data Protection Authority (CCTIRS/CNIL). After parents’ consent was obtained, thirty centers (France, French Polynesia, Mayotte and La Réunion Islands, French Caraibs Islands, Switzerland, Belgium, Canada, Netherlands, Norway) included on a secure-dedicated-website all patients aged from 28 days to 18 years and admitted to PICU for a suspected or confirmed CEL/NF with association of the three following signs: (i) area of skin inflammation, (ii) rapid evolution or skin necrosis, (iii) variation in core temperature (>38.5 °C or <36 °C). Premature infants (<37 weeks of gestation) and patients with Stevens Johnson syndrome, Purpura Fulminans or Hereditary Angioedema were excluded. We collected all data concerning past medical history, first clinical signs, PICU stay, antibiotherapy, microbiology (Staphylococcus and Streptococcus species were send to French Reference Centers), radiological diagnosis, surgery and outcome 1 year after discharge. Data are presented as mean ± SD according to their Gaussian distribution.

Results 50 patients (age: 5.9 ± 5.2 months and weight: 24.2 ± 18.1 kg) were included from October 2011 to April 2016. The diagnosis was suspected 3.5 ± 2.7 days after a known risk factor (46%; surgery: 12; NSAIDs: 10; varicella: 9; cancer: 4). Only two patients had travelled abroad. Skin lesions observed on 10.6 ± 16% of body surface were erythema (28), necrosis (13) and bulla (10) and were located on face (17), legs/feet (16), abdomen/pelvis (14), arms/hands (13) and trunk (10). On admission, mortality and organ dysfunction scores were as follow: PRISM = 9.3 ± 7.5; PIM2 = 12.6 ± 23.3; PELOD D1 = 12.6 ± 3.2 and POPC = 1.6 ± 1.0. Main biological tests showed: hemoglobin: 10.0 ± 2.2 g/dl; neutrophils: 10320 ± 8740/mm3; platelets: 197700 ± 140764 mm3; CRP: 189 ± 122 mg/l; PCT: 69.3 ± 75.3 mg/l; fibrinogen: 5.2 ± 2.2 g/l; ASAT: 108 ± 166 UI/l and ALAT: 61 ± 82 UI/l; protidemia: 53 ± 13 g/l. 28 patients (56%) showed low blood pressure for age including 14 with oliguria, needing fluid challenges (45 ± 26 ml/kg) and vasopressors for 3 ± 1 days. 29 patients (68%) were ventilated invasively for 8.2 ± 10.5 days, with PEEP = 7±3 cmH2O and FIO2 = 58 ± 27% during the first 3 days. 80% of patients received continuous intravenous analgesia (morphine and benzodiazepines). Half of patients were transfused with blood products and also a half received albumin. While MRI was performed in only 7 cases, CT scan and ultrasound were performed to confirm diagnosis in 23 cases (46%, 14 on day 1) and in 21 cases (42%, 15 on day 1), respectively. 28 patients (56%) were operated. One bacterial strain alone was identified in 36 cases (72%) and at least two in eight cases (16%), including Staphylococcus aureus (17), GAβHS (13), Escherichia coli (5), Pseudomonas aeruginosa (4). Antibiotics used were penicillin G (26), clindamycin (21), 3rd generation cephalosporin (12) and rifampicin (9). A third of patients received immunoglobulins and five children (10%) received hyperbaric oxygen (22 sessions). Length of stay in PICU was 12.5 ± 14.7 days. Three patients (6%) died and only two (4%) were readmitted to PICU because of failure directly link to skin lesion. POPC score on discharge was 1.9 ± 1.3. Long term follow-up at 1 year is ongoing.

Discussion This study reports the largest prospective multicentric international cohort of pediatric skin infections needing PICU admission to date. Surgery was the first risk factor reported in our cohort, before varicella. Severe circulatory and respiratory failures on admission in a context of deep biological inflammatory syndrome required aggressive treatments during the first 3 days. Lower part of the body was more frequently involved than reported before in childhood. The diagnosis was quickly suspected and confirmed mainly by ultrasound and CT scan, with the use of MRI still very rare. More than a half of patients have been operated after classical treatments associating immunoglobulins and antitoxin-antibiotics. Infection appeared mainly monobacterial as usually described in children but gram-negative strains are emerging. Mortality was still low and sequella were rare.

Conclusion Cellulitis (CEL) and Necrotizing Fasciitis (NF) are still rare in childhood, with low mortality and few sequella if aggressive treatment including surgery is emergently performed. However, it seems that epidemiology has changed during the last decade in high-income countries. Statistical analysis of this database is ongoing to identify predictors of surgical requirements and to describe more precisely bacterial strains involved.

Competing interests None.

References
  1. 1.

    de Prost N, Sbidian E, Chosidow O, Brun-Buisson C, Amathieu R; Henri Mondor Hospital Necrotizing Fasciitis Group. Management of necrotizing soft tissue infections in the intensive care unit: results of an international survey. Intensive Care Med. 2015;41(8):1506–8.

     
  2. 2.

    Endorf FW, Garrison MM, Klein MB, Richardson A, Rivara FP. Characteristics, therapies, and outcome of children with necrotizing soft tissue infections. Pediatr Infect Dis J. 2012;31(3):221–3.

     

O28 Immunosuppression induced by septic shock in children: a prospective observational study before a multicenter therapeutic trial

Solenn Remy1, Karine Kolev-Descamp1, Julie Demaret2, Guillaume Monneret2, Etienne Javouhey1
1Réanimation pédiatrique, Hôpital Femme Mère Enfant, Bron/Lyon, France; 2Laboratoire d’immunologie cellulaire, Hospices Civils de Lyon - Groupement Hospitalier Edouard Herriot, Lyon, France
Correspondence: Solenn Remy - solenn.remy@hotmail.fr

Annals of Intensive Care 2017, 7(Suppl 1):O28

Introduction Immunosuppression induced by sepsis is well described in adults. Therapeutic trials with immunomodulatory treatments are already underway, using HLA-DR expression on monocytes (mHLA-DR) or lymphopenia as biomarkers of immunosuppression. Pediatric patients with Septic Shock (SS) have been much less studied. Thus, the main objective of this study was to explore post-sepsis immunoparalysis in a pediatric cohort study. Both sides of cellular immunity were assessed: innate immunity (mHLA-DR) and adaptive immunity (lymphocyte subsets). We also wanted to obtain normal values of mHLA-DR in healthy children, according to age.

Materials and methods We performed a single-center prospective study with children under 18 years-old, admitted in Pediatric Intensive Care Unit for SS (“Surviving Sepsis Campaign” criteria), between September 2014 and July 2016. We recruited controls from healthy children hospitalized for an elective surgery, without any criteria of infection. mHLA-DR, total lymphocyte count, and lymphocyte sub-populations’ proportions (CD4+ and CD8+ T cells, regulatory T cells, NK cells, and B cells) were determined by flow cytometry. Samples were analyzed at Day 1, 3 and 7, after sepsis onset. Clinical data were collected prospectively, especially severity scores [PIM2, PELOD2 and Cumulative Vasopressor Index (CVI)], and secondary nosocomial infection occurrence.

Results 30 controls and 26 patients were recruited. mHLA-DR in healthy children presented no variation according to age, and was similar to healthy adults. At each time points, mHLA-DR in SS group was decreased, comparing with controls. The medians of mHLA-DR were respectively 6.066 IQR [3.737–16.310], 6.308 IQR [3.185–8.965] and 9.323 IQR [6.384–12.738], versus 29.668 ab/c IQR [24.335–39.199] in the control group (p < 0.0001 at D1, D3 and D7; Mann–Whitney). mHLA-DR at D3 was significantly correlated with the Cumulative Vasopressor Index (Spearman’s correlation coefficient r = −0.50; p = 0.031). Patients secondarily infected presented a lower mHLA-DR at D3 than patients without secondary infection: respectively 4398 ab/c [2437–6212] versus 8474 ab/c [5904–10844] (p = 0.022, Student t test) (Fig. 5).
Fig. 5

See text for description

Total lymphocytes and CD4 T cells were decreased at D1 and D3. This lymphopenia corrected between D3 and D7. NK cells were decreased at each time points. B lymphocytes were decreased comparing to controls at D1 and D7 (not D3), but much less pronounced than T cells. Regulatory T cells percentage was initially comparable to controls. Then, a gradual increase was observed, which became statistically significant at D7, compared to controls (p = 0.0058; Mann–Whitney). No significant difference was observed between patients with or without secondary infections, according to any lymphocyte subsets.

Concerning clinical data, patients contracting a secondary infection stayed significantly longer at the hospital than others: respectively 33.5 days [19.5–58.0] versus 14.0 [7.5–21.0] (p = 0.0094; Mann–Whitney).

Conclusion For the first time, we reported that healthy children presented mHLA-DR values with no variation according to age, and similar to those seen in adults. Innate immunity was similarly altered in children with Septic Shock than in adult patients. Adaptive immunity seemed to be less impaired by the shock than in adults. Further analyses will be conducted to complete these findings as functional tests on T cells. As secondary infections considerably increase the length of stay at the hospital, this report paves the way for a multicenter therapeutic trial, in order to evaluate immunostimulatory treatment in children with Septic Shock.

Competing interests None.

References
  1. 1.

    Hotchkiss RS, Monneret G, Payen D. Sepsis-induced immunosuppression: from cellular dysfunctions to immunotherapy. Nat Rev Immunol. 2013;862–74.

     
  2. 2.

    Hall MW, Knatz NL, Vetterly C, Tomarello S, Wewers MD, Volk HD, Carcillo JA. Immunoparalysis and nosocomial infection in children with multiple organ dysfunction syndrome. Intensive Care Med. 2011;37:525–32.

     

O29 Ventilator associated pneumonia and ventilator associated events in pediatric intensive care

Maryline Chomton1, David Brossier1, Michaël Sauthier1, Emilie Vallieres2, Philippe Jouvet1
1Soins intensifs pédiatriques, CHU Sainte-Justine, Montréal, Canada; 2Microbiology department, CHU Sainte-Justine, Montréal, Canada
Correspondence: Maryline Chomton - chomton.m@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):O29

Introduction Ventilator associated pneumonia (VAP) is the second cause of nosocomial infection in pediatric intensive care. Recent modifications of the CDC criteria for VAP diagnosis included VAP diagnostic criteria for children [1] and criteria to identify ventilator associated events (VAE) in adults [2] that are not validated for children. The purposes of this study were to determine retrospectively the incidence, risk factors and management of VAP using the new CDC definition and to study the validity of adult VAE diagnostic criteria in critically ill children.

Patients and methods We conducted a single center retrospective study in the pediatric intensive care unit (PICU) of Sainte-Justine Hospital, a medical and surgical PICU including cardiac surgery patients. All patients invasively mechanically ventilated (IMV) >48 h between November 2013 and November 2015 were included. Patient records were analyzed for VAP diagnosis, risk factors, management and VAE. Statistical analysis included median and range calculation for descriptive data and children with and without VAP were compared using a Mann–Whitney test with a significant level: p < 0.05.

Results Of 688 invasively ventilated patients, 287 were included in our study (IMV > 48 h). Thirty patients met radiologic and clinical VAP CDC criteria. VAP rate was 10.4% and VAP incidence was 7/1000 invasive ventilation days. Mortality rate was higher in the VAP group but in the VAP group was not statistically significant [16.0 vs 9.7% respectively, (p = 0.23)]. VAP occurred early in IMV course (4 days). The main technique to identify the pathogen was tracheal aspiration with semi quantitative culture, the most common VAP organisms identified were Gram Negative bacteria (60%) with predominance of Haemophilus influenza and Pseudomonas aeruginosa with sensitive profile and antibiotherapy used was in accordance with guidelines. Median duration of ventilation (15 vs 6 days, p < 0.001) and PICU stay (19 vs 9 days, p < 0.001) increased significantly in children with VAP versus no VAP. Univariate analysis showed that age, reintubation, ARDS and continuous enteral feeding were risk factors for VAP. Among the thirty patients with VAP, 17 had adult CDC VAE’s criteria (sensitivity = 56%).

Discussion The following points are in agreement with VAP literature. Using VAE criteria could constitute a faster, more objective method to screen VAP. However, sensitivity should be improved by adapting VAE criteria to children.

Conclusion Using the CDC updated VAP definition for children, VAP incidence is similar to adults. Adult VAE cannot be used to screen prospectively VAP in children. Specific pediatric VAE needs to be developed and validated.

Competing interests None.

References
  1. 1.

    CDC. Pneumonia (ventilator associated (VAP) and non ventilator pneumonia (PNEU)) Events;2015.

     
  2. 2.

    CDC. Ventilator associated events;2015.

     

O30 Incidence and risk factors of ventilator associated pneumonia in neonatal intensive care unit

Guillaume Geslain1, Isabelle Guellec2, Jérôme Rambaud2
1Hôpital Robert-Debré (AP-HP), Paris, France; 2Réanimation pédiatrique et néonatale, Hopital pour enfants Trousseau, Paris, France
Correspondence: Guillaume Geslain - guillaumegeslain@hotmail.fr

Annals of Intensive Care 2017, 7(Suppl 1):O30.

Introduction Ventilator associated pneumonia (VAP) is defined as a lung infection occurring after 48 h of mechanical ventilation. Ventilator associated pneumonia incidence, complications and mortality are well known in critically ill adults but probably under diagnosed in critically ill neonates. The main objective of our study was to evaluate the incidence of VAP in neonatal intensive care units, evaluate associated mortality and morbidity and find potential risk factors.

Patients and methods This is a prospective, observational, single-center conducted in neonatal intensive care unit of Armand Trousseau hospital from 01/11/2014 to 31/10/15. All infants aged 28 days or less hospitalized in the service are included.

Results 381 patients were enrolled including 327 intubated patients. 17 of 327 patients intubated presented VAP. The incidence of VAP was 4.05 per 1000 days of hospitalization with an incidence rate of 8.78 per 1 000 days of invasive ventilation. The average age at diagnosis of VAP was 21.47 ± 13.02 days for an average duration of invasive ventilation of 15.23 ± 11.48 days. After VAP, invasive ventilation time is prolonged to 25.71 ± 20.90 days (OR 1.19 [1.12–1.27]). The nosocomial infection rate was significantly higher in the VAP group (p < 0.001) with 9 on 17 patients in VAP group (52.94%) versus 21 on 310 patients (6.77%). The occurrence of VAP was significantly associated with higher mortality (OR 4.46 [1.32–14.94]) and an increase in invasive ventilation times (p < 0.001) and non-invasive (p < 0.001) and hospital stay (p < 0.001). There is a significant difference in the duration of invasive ventilation before VAP [average 15.23 ± 11.48 (1–35)] compared to patients without VAP [mean 4.84 ± 4.92 (1–28), p < 0.001]. Patients with a birth weight less than or equal to 1000 grams are associated with risk of VAP (OR 4.31 [1.38–13.39]) in multivariate analysis contrary to the term. Intubated patients with a balloon are associated with risk of VAP (adjusted OR 4.03 [1.14–14.26]) and a Snappe-II score above 16 also (OR 4.98 [1.40–17.67]).

Conclusion We managed one of the larger neonatal study for VAP in critically ill neonates. These pneumonias remained frequent in critically ill neonate and are associated with a higher mortality and morbidity. Patients with a birth weight less than 1000 g seem to be particularly vulnerable.

Competing interests None.

O31 Extracorporeal life support for acute respiratory failure in immunocompromised patients: an international multicenter retrospective study (The IDEA study)

Matthieu Schmidt1, Peter Schellongowski2, Amandine Dorget1, Nicolo Patroniti3, Fabio Silvio Taccone4, Dinis Reis Miranda5, Jean Reuter6, Hélène Prodanovic7, Romain Sonneville6, Marc Pierrot8, Martin Balik9, Sunghoon Park10, Alain Combes11, REVA, ECMOnet
1Service de réanimation médicale, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; 2Unit 13i2, Department of Medicine I/intensive care, Vienna, Austria; 3Anestesia e raiamizione, Ospedale San Gerardo, Monza, Italy; 4Service de Soins Intensifs, Hôpital Erasme, Bruxelles, Belgium; 5Intensive care, Erasmus University Medical Center, Rotterdam, Netherlands; 6Service de réanimation médicale et infectieuse, Hôpital Bichat-Claude Bernard-APHP, Paris, France; 7Unité de réanimation et de surveillance continue, service de pneumologie et réanimation médicale, Pitié-Salpêtrière Hospital, Paris, France; 8Service de réanimation medicale, Hopital Universitaire d’Angers, Angers, France; 9Dept of anaesthesia and intensive care, General University Hospital in Prague, Prague, Czech Republic; 10Pulmonary, Allergy and Critical Care, Hallym University Sacred Heart Hospital, Seoul, Republic of Korea; 11Service de Réanimation Médicale, Groupe Hospitalier Pitié Salpêtrière, Paris, France
Correspondence: Matthieu Schmidt - matthieuschmidt@yahoo.fr

Annals of Intensive Care 2017, 7(Suppl 1):O31

Introduction The proportion of immunocompromised patients with extracorporeal life support (ECLS)-treated severe ARDS varies from 5 to 31% in recent cohorts. To date, very few data on ECMO use and its associated outcomes are available on this population. Our aims were to (1) describe the clinical features, (2) compare the outcomes between causative immunocompromised status, (3) identify predictive pre-ECLS factors of 6-month mortality, and (4) report the rate of ECLS-related complications.

Patients and methods We performed an international multicenter retrospective study in 10 ICUs from 2008 to 2014. Immunocompromised status was defined by hematologic malignancies, solid tumor, solid organ transplant, human immunodeficiency virus (HIV), or long term or high dose glucosteroids or immunosuppressant use. Inclusion criteria were immunocompromised patient with acute respiratory failure rescued by extracorporeal membrane oxygenation or (ECMO) or extracorporeal CO2 removal (ECCO2R).

Results 1. A total of 225 patients (age 48.6 ± 15.1 years; APACHE II 26.4 ± 9.0) were included in the study (30% hematologic malignancies, 28% long-term corticosteroids or immunosuppressant use, 18% solid tumor, 16% solid organ transplant, and 9% HIV). ECLS was initiated for severe ARDS, moderate ARDS, or chronic end-stage respiratory in 190(84%), 14(6%), and 19(8%) patients, respectively. Main ARDS etiologies were bacterial pneumonia (30%), viral pneumonia (18%), and specific lung involvement (12%). Refractory hypoxemia (73%) was the main indication for ECLS with lowest pre-ECLS PaO2/FiO2 at 63 (51–87) mmHg. Venovenous ECMO and ECCO2R were initiated in 199 (88%) and 15(7%) patients, respectively. Pre-ECLS tidal volume was 5.7(4.7–6.4) mL/kg, with a positive end-expiratory pressure at 10(8–13) cmH2O and a plateau pressure at 32(30–35) cmH2O. Interval between mechanical ventilation onset and cannulation was 2(1–8) days.

2. Six-month mortality of patients with hematologic malignancies, long-term corticosteroids or immunosuppressant use, solid tumor, solid organ transplant, and HIV were 76, 60, 80, 51, and 71%, respectively (log-rank test, p = 0.02). Cumulative survival at 6 months were lower for patients with hematologic malignancies versus others (log-rank test, p = 0.003) whereas those with solid organ transplant exhibited higher cumulative survival at 6 months (log-rank test, p = 0.02).

3. One hundred and three patients (46%) were successfully weaned from ECLS. In-ICU and 6-month post ICU discharge survival were 37% (n = 83/225) and 32% (n = 72/225), respectively. Compared to patients who died within 6 months after ICU admission, 6-month survivors were younger (46 vs. 49 years, p = 0.05), had more frequently a newly diagnosed immunocompromised status (39 vs. 17%, p = 0.0003), were more frequently patients with solid organ transplant (24 vs 12%, p = 0.02, had a higher pre-ECMO hemoglobin (9.4 vs 8.8 g/dL) and platelet counts (160 vs 112 × 103/µL; p = 0.008), and exhibited lower mechanical ventilation-ECMO onset interval (1[0–5] vs 3[1–9] days, p = 0.002). Age (OR 1.02/year, 95% CI [1.002–1.04], p = 0.035), solid organ transplant (0.38 [0.17–0.85], p = 0.019), newly diagnosed immunocompromised status (0.32 [0.16–0.65], p = 0.002), platelet count ≥200,000 × 103/µL (0.33[0.15–0.72], p = 0.005) and delay from mechanical ventilation initiation to ECMO cannulation >7 days (3.23 [1.42–7.34], p = 0.005) were independently associated with 6-month mortality.

4. Eighty-two (36%) patients had at least one ECMO-related major bleeding event (oro-nasal bleeding 10%; hemothorax 7%; cerebral bleeding 7%), which was less frequent with patients alive at 6-months. One hundred and four (46%) and 20 (9%) patients reported ventilator associated pneumonia and cannula infection, respectively, with no impact on 6-month survival.

Conclusion Six-month survival of ECLS-treated severe ARDS in immunocompromised patients appears low, especially for patients with hematologic malignancies and solid tumor. However, young age, solid organ transplant, newly diagnosed immunocompromised status and rapid decision to start ECLS seem associated with a better prognosis.

Competing interests None.

O32 Driving pressure is a significant predictor of mortality in the acurasys and proseva randomized controlled trials in ARDS patients

Claude Guérin1, Laurent Papazian2, Reignier Jean3, Louis Ayzac4, Anderson Loundou5, Jean-Marie Forel6
1Réanimation médicale, Hôpital de la Croix-Rousse, Lyon, France; 2Service de réanimation-détresses respiratoires et infections sévères, Hôpital Nord, Marseille, France; 3Réanimation médicale, CHU Hôtel-Dieu Nantes, Nantes, France; 4C-clin, Hôpital Henry Gabrielle, Saint-Genis-Laval, France; 5Unité de recherche de santé publique, Faculté de Médecine secteur Timone (Aix-Marseille Université), Marseille, France; 6Réanimation médicale, Hospital Nord, Marseille, France
Correspondence: Claude Guérin - claude.guerin@chu-lyon.fr

Annals of Intensive Care 2017, 7(Suppl 1):O32

Introduction Driving pressure (ΔP) across the respiratory system has been suggested as the strongest predictor of hospital mortality in ARDS patients. We wonder whether this result may be due to the wide range of tidal volume (VT) and PEEP used across the trials included and whether a strict control of them would minimize the role of ΔP as predictor. Therefore, we investigated ΔP in two trials in which lung protective mechanical ventilation was applied to ARDS patients. Our working hypothesis was that ΔP was a risk factor just like compliance (Crs) or Plateau pressure (Pplat) of the respiratory system.

Patients and methods ARDS patients included in the Acurasys and Proseva trials previously reported were used. Both had near inclusion criteria (notably PaO2/FIO2 < 150 mm Hg and PEEP ≥ 5 cm H2O) and similar lung protective mechanical ventilation (in particular VT 6 ml/kg predicted body weight and PEEP/FIO2 table). Both found survival benefit in the experimental group. SOFA, continuous neuromuscular blocking agent (NMBA) infusion, prone position, combined use of NMBA and prone position, pH, PaCO2, PaO2/FIO2, lactate, breathing frequency, VT, PEEP, Pplat, Crs and ΔP were recorded at day 1 after inclusion together with gender, age and SAPSII at the time of admission and compared between survivors and nonsurvivors at day 90. Cox proportional hazard models were used with covariates significantly different between survivors and non survivors at the threshold of 0.20 and mortality at day 90 as dependent variable. Due to the obvious colinearity between ΔP, Crs and Pplat we performed the following analyses. First we made a specific Cox model for each of them. Second, we developed three Cox models in which we used the above variables by couples (Pplat-ΔP; Crs-ΔP and Crs-Pplat). We made the following assumptions: if both variables in the couple lacked significance in the second model, the same information was carried by each component of the couple; if one or both variables kept significant correlation each brought significant and distinct information; if significant correlation was kept for one of the variables in the couple and lost for the other the former would be more informative than the latter.

Results Both trials enrolled 805 patients of who 787 had data available at day 1 of who 533 survived and 254 did not. In the univariate analysis, ΔP averaged 13.7 ± 3.7 and 12.8 ± 3.7 cmH2O (P = 0.002) in nonsurvivors and survivors, respectively. In each single Cox model, Hazard ratios (HR) were 1.05 (1.02–1.08) (P = 0.005), 1.04 (1.01–1.08) and 0.985 (0.972–0.999) (P = 0.023) for ΔP, Pplat and Crs, respectively. PEEP and VT were not significant risk factors in any model. In the model with ΔP and Pplat used together, each of them kept significance [HR 1.31 (1.07–1.61) and 1.13 (1.02–1.26)]. In the model with ΔP and Crs both lost significance and the same was true in the model using Pplat and Crs.

Discussion ΔP was a significant predictor with a 5% increase in mortality per each cmH2O increment of ΔP, a result similar to that found by Amato et al. However, Pplat conveys the same information. This is likely due to the fact that VT and PEEP were similar in each group of both trials and not different between survivors and non survivors.

Conclusion When strict lung protective mechanical ventilation is applied to ARDS patients ΔP, Crs and Pplat were risk factors of mortality. ΔP and Pplat bring distinct and significant information.

Competing interests None.

O33 Impact of PEEP and body inclination in the supine and prone positions on esophageal pressure in ARDS patients

Mehdi Mezidi1, Mylène Aublanc1, Sophie Perinel-Ragey1, Floriane Lissonde1, Aurore Louf-Durier1, Romain Tapponnier1, Hodane Yonis1, Zakaria Riad1, Jean-Christophe Richard1, Claude Guérin1
1Réanimation Médicale, Hôpital de la Croix-Rousse, Lyon, France
Correspondence: Mehdi Mezidi - mehdi.mezidi@gmail.com

Annals of Intensive Care 2017, 7(Suppl 1):O33

Introduction Prone positioning (PP) for long sessions in association with use of low tidal volume and cisatracurium infusion have been shown survival benefit in ARDS patients. Little is known about evaluation of PEEP setting based on end-expiratory transpulmonary pressure at zero flow (PEEPtotL) in PP. We hypothesized that esophageal pressure (Pes) was lower in PP than in supine position due the relief of the weight of the mediastinum. Hence, the PEEP level to achieve positive PEEPtotL should be lower in PP. Furthermore, the inclination of the body should also influence the measurements of Pes. The main objective of the study was to evaluate the variation of end-expiratory esophageal pressure at zero flow (PEEPtotes) in PP and in supine position, each at two body inclinations, and the subsequent effects on PEEPtotL and transpulmonary driving pressure (ΔPL).

Materials and methods A prospective interventional physiologic study was performed in patients with severe ARDS (PaO2/FIO2 < 150) and requiring PP. Pes was measured with an esophageal balloon. Transpulmonary pressure (Ptp) was computed as the difference between airway pressure and Pes. DPL was computed as the difference in Ptp at the end of inspiration and at the end of expiration at zero flow. Chest wall elastance (Est,cw) was calculated as the ratio of end-inspiratory Pes minus PEEPtotes divided by tidal volume. End-expiratory lung volume (EELV) was measured by nitrogen wash-out method. Thorax angulation was 30° and 0° in supine position (SP) and 0° and 15° in PP. From PEEP set according to the low PEEP/FIO2 table of the ARMA trial (1), PEEP level was further adjusted to achieve PEEPtotL close to 3 cmH2O. Measurements were done in supine position and after 1 h in PP.

Results Twenty patients were included. PEEPtotes did not vary significantly between SP(30°) and PP(0° or 15°). However, opposite variations were found according to thorax angulation in PP: a rise of 1.9 (SD 1.7) cmH2O in PP(0°), p = 0.005 and a drop in PP(15°) of 2.2 (SD 3.2) cmH2O, p = 0.06. In a complementary analysis, PEEPtotes was studied in four positions [SP(30°), SP(0°), PP(0°) and PP(15°)] and followed an inversed U-shape pattern with mean values of 8.6 (SD 3.2), 12.8 (SD 2.7), 10.2 (SD 3.3) and 2.6 (SD 2.1) cmH2O, respectively. These differences were statistically significant (Holm adjusted p value for multiple comparisons <0.05) except between SP(30°) and PP(15°). As a consequence, PEEPtotL rose of 2.6 cmH2O between SP(0°) and PP(0°). With postural variations, EELV was significantly altered. Hence, PEEPtotL at PP(0°) was computed at the EELV in SP(0°), allowing to eliminate the impact of the change of EELV between postures: 77% of PEEPtotL changes were due to change of posture per se [+3.7 (SD 2.6) cmH2O, p < 0.05]. Between SP(30°) and PP(0°), posture effect on PEEPtotL variation was +2.7 (SD 4.5) cmH2O, p = 0.055. A linear mixed model disclosed that rise of PEEPtotL was explained by PP for an amount of 2.7 (SD 0.44) cmH2O and by thorax angulation for 0.13 (SD 0.02) cmH2O per degree (p < 10−6).

PP was associated with lower ΔPL [−1.0 cmH20 (SD 1.3), P = 0.004]. Chest wall elastance did not change between 30° supine and 0°PP [10.4 (SD 3) vs. 8.5 (SD 3.2) L/cmH2O, P = 0.85].

Discussion Variation of thorax angulation significantly alters Pes and Ptp values. Splitting the variation of Pes into those due to change in either EELV or posture allows a better understanding of the impact of PP on Pes.

Conclusion PP(0°) was associated with Pes rise as compared with SP(30°) and Pes drop when compared with SP(0°). However, when analyzing PEEPtotL variation due only to posture change (and not EELV change), a rise of almost 3 cmH2O of PEEPtotL was seen in PP(0°) compared to SP(0°) or SP(30°). Clinicians might therefore consider lowering PEEP level in PP.

Competing interests None.

Reference
  1. 1.

    The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301–8.

     

O34 Can we consider criteria for acute respiratory distress syndrome (ARDS) in patients breathing spontaneously?

Remi Coudroy1, Jean-Pierre Frat1, Florence Boissier1, Damien Contou2, René Robert1, Arnaud W Thille1
1Réanimation médicale, CHU de Poitiers, Poitiers, France; 2Réanimation Médicale, Hôpital Henri Mondor, Créteil, France
Correspondence: Remi Coudroy - remi.coudroy@chu-poitiers.fr

Annals of Intensive Care 2017, 7(Suppl 1):O34

Introduction According to the Berlin definition for ARDS, the degree of hypoxemia must be assessed under either invasive or noninvasive ventilation (NIV). In a recent large international survey, about 15% of ARDS were diagnosed while treated with NIV. However, NIV is debated in hypoxemic patients with acute respiratory failure. We aimed to assess whether the use of NIV is really needed to diagnose ARDS in patients with spontaneous breathing under oxygen.

Patients and methods We included all ICU patients treated first with standard oxygen and then with NIV for non-hypercapnic acute respiratory failure from 2 prospective studies [1, 2]. PaO2/FiO2 was assessed at ICU admission under oxygen with an easily bedside calculated FiO2, and under NIV after 1 h of initiation and within the first 24 h. Severity of hypoxemia was considered as mild when PaO2/FiO2 ranged from 201 to 300, moderate from 101 to 200 and severe when ≤100 mmHg.

Results Among the 219 patients with acute respiratory failure treated with NIV, 172 (79%) fulfilled ARDS criteria within the first 24 h following ICU admission. ARDS was classified as mild in 14%, moderate in 53%, and severe in 33% of cases. The overall rates of intubation and ICU mortality were 58 and 30% respectively.

When considering the 155 patients with bilateral infiltrates on chest X-ray and PaO2/FiO2 ≤ 300 mmHg under oxygen, 87% (n = 135) had ARDS criteria after 1 h of NIV and 95% (n = 148) within the first 24 h. ICU-mortality according to the severity of hypoxemia did not differ under standard oxygen or NIV: 29 versus 20% in mild (p = 0.55), 22 versus 30% in moderate (p = 0.29), and 45 versus 43% in those with severe hypoxemia (p > 0.99).

Conclusion Almost all patients with bilateral infiltrates and PaO2/FiO2 ≤ 300 mmHg under oxygen standard meet ARDS criteria after NIV initiation. Mechanical ventilation does not seem necessary to diagnose ARDS in patients with spontaneous breathing.

Competing interests None.

References
  1. 1.

    Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–96.

     
  2. 2.

    Thille AW, Contou D, Fragnoli C, Cordoba-Izquierdo A, Boissier F, Brun-Buisson C. Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors. Crit Care. 2013;17(6):R269.

     

O35 Prognosis factors of severe influenza in ICU and introduction delay of oseltamivir

Flore Richard1, Rafael Mahieu2, Hélène Le Gullou-Guillemette3, Nicolas Chudeau4, Jonathan Fahri5, Achille Kouatchet1
1Service de réanimation médicale et médecine hyperbare, Centre Hospitalier Universitaire d’Angers, Angers, France; 2Réanimation médicale, Centre Hospitalier Universitaire d’Angers, Angers, France; 3Département de biologie des agents infectieux et pharmaco-toxicologie, Centre Hospitalier Universitaire d’Angers, Angers, France; 4Réanimation médico-chirurgicale, C.H. - Le Mans, Le Mans, France; 5Service des maladies du sang, Centre Hospitalier Universitaire d’Angers, Angers, France
Correspondence: Achille Kouatchet - ackouatchet@chu-angers.fr

Annals of Intensive Care 2017, 7(Suppl 1):O35

Introduction Influenza infection has a major impact on ICU hospitalizations during epidemic season, mainly affecting the elderly with exacerbation of their comorbidities.

To identify bad prognosis factors in severe influenza and the impact of delayed antiviral therapy among ICU patients infected with influenza.

Patients and methods We conducted a retrospective, observational study in Angers CHU medical ICU, from November 2009 to April 2015. Influenza infection was confirmed by Immunofluorescence. Demographic datas, comorbid conditions, antiviral treatment and time elapsed between ICU admission and treatment, clinical outcome, bacterial infection associated, type of virus, antibiotic, ventilation, renal injury, use of vasopressive drugs were recorded. Risk factors for death were analyzed by backward stepwise logistic regression.

Results The study population consisted of 85 patients whom mean age was 63 years old. 80% had at least one comorbidity. Influenza A infected 71% of our patients and type B 28%. [iz1] Most of them was admitted for respiratory distress and 59% were under invasive ventilation. The rate of death was 25% at day 28. 40% were under vasopressive drug. 84% received NAI among whom 76% received it in the first 2 days after ICU admission. Risk factors for death were, shock at the admission, immunosuppressive conditions and late administration of NAI. patients receiving NAI more than 48 h after ICU admission had a higher risk of death.

A multivariate analysis was performed. Shock at the admission was associated with mortality (OR −2.38: 95% CI 0.03–0.045) and time elapsed from ICU to [RM1] NAI less than 3 days was associated with survival at 28 day (OR 1.68: 95% CI 1.30–22.11).

See Table 6.
Table 6

See text for description

 

Death d28

Alive d28

p

Baseline characteristics

 Age

66.1 ± 12.8

61.9 ± 17.2

0.3

 Sex (M)

12 (54.5)

28 (45.2)

0.45

 BMI

25.5 ± 5.3

28.1 ± 8.6

0.2

 Corticosteroids in 10th days before ICU admission

5 (23.8)

5 (7.9)

0.052

 Charlson score

3.2 ± 3.4

2.1 ± 2.5

0.16

 IGS II

49.1 ± 20.8

36.5 ± 15.5

0.0039

Clinical presentation

 Fever (>38 °C)

18 (85.7)

40 (63.5)

0.056

 Body aches

1 (4.8)

16 (25.4)

0.085

Initial influenza diagnostic test

  

0.77

 Rapid diagnosis

8 (38.1)

26 (41.3)

 

 Immunofluorescence

11 (52.4)

28 (44.4)

 

 PCR

2 (9.5)

9 (14.3)

 

Clinical complications

   

 Shock

18 (85.7)

16 (25.4)

<0.0001

 ARDS

11 (52.4)

18 (28.6)

0.047

 Acute renal failure

12 (57.1)

13 (20.6)

0.0015

 Secondary bacterial infection

13 (61.9)

22 (34.9)

0.03

Details of antiviral treatment

   

 ICU to Neuraminh delay <3 days

9 (42.9)

45 (71.4)

0.018

Conclusion Cases of severely ill suspected influenza infections in epidemic period may benefit as soon as they are admitted in ICU from antiviral therapy. Our results add to the existing observational datas on the effectiveness of starting antiviral treatment with Neuraminidase Inhibitors as soon as Influenza is clinically suspected, even if suspicion appears at ICU admission and with delay from symptoms onset.

Competing interests None.

O36 Salbutamol nebulization during non-invasive ventilation in exacerbated COPD patient

Laetitia Bodet-Contentin1, Antoine Guillon1, Thierry Boulain2, Jean-Pierre Frat3, Denis Garot1, Déborah Le Pennec4, Laurent Vecellio4, Elsa Tavernier5, Pierre François Dequin1
1Réanimation polyvalente, CHRU Hôpitaux de Tours, Tours, France; 2Réanimation médicale polyvalente, Hôpital de La Source, CHR Orléans, Orléans, France; 3Réanimation Médicale, CHU de Poitiers, Poitiers, France; 4Cepr (inserm u1100/ea 6305), aérosolthérapie et biomédicaments à visée respiratoire, Université François Rabelais, Tours, France; 5Inserm cic 1415, CHRU Hôpitaux de Tours, Tours, France
Correspondence: Laetitia Bodet-Contentin - laetitia.contentin@univ-tours.fr

Annals of Intensive Care 2017, 7(Suppl 1):O36

Introduction Non invasive ventilation (NIV) is a widely used technique to treat hypercapnic acute respiratory failure (ARF) in Chronic Obstructive Pulmonary Disease (COPD) patients. Nebulization of beta 2 agonists is recommended to treat COPD exacerbations. Nebulizing beta 2 agonist on NIV circuits could be potentially helpful but had been studied only in stable COPD patients. Our aim was to compare effectiveness of salbutamol and placebo nebulized in NIV circuit in patients admitted to the intensive care unit (ICU) for exacerbation of COPD. Aerosols were generated by a vibrating mesh nebulizer, whose optimal place in the circuit (just after the Y-piece) was determined by a preliminary bench study.

Patients and methods We conducted a double-blinded trial comparing salbutamol and placebo delivered in a random order as two aerosols separated by 60 min, during NIV, in 43 patients admitted to the ICU for ARF. A spirometry was obtained at several points before and after nebulizations, as were clinical and biological safety parameters.

Results Forced expiratory volume in one second (FEV1) increased significantly from baseline to 40 min after the end of salbutamol nebulization, when compared to placebo (+5.6 vs. −8.9%, p = 0.04). At the same time, potassium level decreased slightly in the placebo arm (p < 0.01), when glucose and lactate levels increased (NS). Symmetric changes were observed in the salbutamol arm after the second nebulization (+13.7 vs. −8.9%, p < 0.01). Nebulization was well tolerated in all patients.

Conclusion Placing the nebulizer immediately after the Y-piece is appropriate to deliver aerosols in NIV circuit and compatible with crimped circuit. Salbutamol nebulization is well tolerated during NIV and increase significantly FEV1 when compared to placebo. If this physiological effect is associated with clinical benefit remains to demonstrate.

Competing interests I, the undersigned, certify that the BANNISTER clinical trial «Beta Agonist Nebulization in Non Invasively ventilated Chronic Obstructive Pulmonary Disease (COPD) patients: Safety and Therapeutic Efficacy Range» , was funded by Association pour la Promotion à Tours de la Réanimation Médicale and the bench study by Inserm. The nebulizers were provided by Aerogen; the company was not involved in study design, data exploitation or drafting of the manuscript.

References
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    Calvert LD, Jackson JM, White JA, Barry PW, Kinnear WJ, O’Callaghan C. Enhanced delivery of nebulised salbutamol during non-invasive ventilation. J Pharm Pharmacol. 2006;58(11):1553–7.

     
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    Nava S, Karakurt S, Rampulla C, Braschi A, Fanfulla F. Salbutamol delivery during non-invasive mechanical ventilation in patients with chronic obstructive pulmonary disease: a randomized, controlled study. Intensive Care Med. 2001;27(10):1627–35.

     

O37 Effect of a musical intervention on tolerance and efficacy of non-invasive ventilation: the “MUSique pour l’Insuffisance Respiratoire Aigue—MUS-IRA” randomized controlled trial

Jonathan Messika1, Yolaine Martin2, Natacha Maquigneau3, Matthieu Henry-Laguarrigue4, Christelle Puechberty5, Annabelle Stoclin5, Serge Villard2, Aline Dechanet6, Didier Dreyfuss2, David Hajage7, Jean-Damien Ricard8
1Service de réanimation médico-chirurgicale, CHU Louis Mourier, Colombes, Colombes, France; 2Réanimation médico-chirurgicale, Hôpital Louis-Mourier - APHP, Colombes, France; 3Réanimation, Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon, France, La Roche-sur-Yon, France; 4Réanimation, Centre Hospitalier Départemental - site de La Roche-sur-Yon, La Roche-sur-Yon, France; 5Réanimation-uscm, Gustave Roussy, Villejuif, France; 6Unité de recherche clinique, Hôpital Bichat-Claude Bernard (AP-HP), Paris, France; 7Département d’épidémiologie et de recherche clinique, Hôpital Louis-Mourier - APHP, Colombes, France; 8Service de Réanimation Médico-Chirurgicale, CHU Louis Mourier, Colombes, France
Correspondence: Jonathan Messika - jonathan.messika@aphp.fr

Annals of Intensive Care 2017, 7(Suppl 1):O37

Introduction One of major determinants of non-invasive ventilation (NIV) success is its tolerance. Numerous strategies have been assessed to improve this tolerance, such as pharmacological sedation or sophrology. Music therapy has been showed to be effective in healthcare settings, in particular in ICU invasively ventilated subjects [1]. We therefore investigated the effect of a musical session provided by a trained caregiver on NIV tolerance and efficacy in ICU patients with acute respiratory failure.

Patients and methods MUS-IRA is a randomized 3-centers, 3-arm open-label trial (PHRIP 2013). Subjects included were adult acute respiratory failure patients for whom the physician in charge considers NIV as indicated with a level of consciousness allowing a benefit from the musical intervention (Glasgow Coma Scale >11). Non inclusion criteria were contra-indication to NIV; severe hearing impairment; withdrawal of life sustaining therapies with expected survival of less than 48 h; subjects included in another trial dealing with acute respiratory failure. NIV was conducted in the same fashion in the three arms of randomization. The “musical intervention” subjects received a 30-min L-type music session with the MUSIC CARE© software (2), with a sleeping mask concealing the eyes. The “sensory deprivation” group had the sleeping mask and the insulating around-ear headphone, during a 30-min period. The “NIV alone” group had their NIV conducted as it is usually in our ICUs.

The main objective was to determine if a musical intervention improved NIV tolerance, measured by respiratory comfort, and ventilation parameters at 30 min of NIV in comparison to conventional care. The respiratory comfort was assessed by a nurse or nurse assistant blinded to the treatment arm with a numeric visual scale (from 0 to 10) at the initiation (T0), after 30 min (T30), and at different time points of each NIV session. The primary endpoint was the change in respiratory comfort at initiation and after 30 min of the first NIV session. The secondary endpoints were NIV failure and the percentage of patients requiring anxiolytics or sedative during NIV sessions. The comparison performed in a pre-specified fashion was between “musical intervention” group and “NIV-only” group. A total of 99 subjects had to be randomized in order to show a 2-unit difference in respiratory comfort between two groups. This number was extended to 114 because of missing data on the primary endpoint.

Results Among the 114 subjects randomized (May 2015 to May 2016—“musical intervention” group n = 37; “sensory deprivation” group n = 38, “NIV-only” group n = 39), median age was 67 years (60–74), and 63 were men (55.3%). Mean baseline respiratory comfort for “musical intervention”, “sensory deprivation” and “NIV-only” was 4.34 ± 3.01, 4.24 ± 2.59, 3.89 ± 3.03 respectively for the first NIV session (p = 0.74). Mean change in respiratory comfort between T0 and T30 for “musical intervention”, “sensory deprivation” and “NIV-only” was respectively 0.54 ± 3.57; 0.55 ± 2.33; 0.66 ± 2.9. The comparison between “musical intervention” and NIV-alone group yielded a p-value of 0.91. NIV failure during ICU stay was evidenced in 16.2%, 10.5%, 12.8% (“musical intervention”, “sensory deprivation” and “NIV-only”, respectively, p = 0.74). No subjects required the administration of anxiolytics or sedatives to cope with the first NIV session in all groups.

Discussion Our study failed to evidence a significant effect of a musical intervention on the reduction of respiratory discomfort during the first NIV session of acute respiratory failure ICU patients. One may hypothesize that the improvement provided by NIV (which patients received in all three groups) was such that it outweighed and/or masked a potential effect of the musical intervention. Further analysis are planned to investigate the respiratory comfort and the evolution of physiological parameters during the subsequent sessions.

Conclusion Applying a musical intervention early in the course of a treatment by NIV during acute respiratory failure did not modify respiratory comfort. Further research is warranted.

Competing interests None.

References
  1. 1.

    Chlan LL, Weinert CR, Heiderscheit A, Tracy MF, Skaar DJ, Guttormson JL, et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial. JAMA. 2013;309(22):2335–44.

     
  2. 2.

    Guetin S GP Blayac JP, Eledjam JJ. Une nouvelle technique contrôlée de musicothérapie dans la prise en charge des douleurs viscérales aiguës et chroniques. Doul Analg. 2005;(1):19–25.

     

O38 Apnoeic oxygenation via high-flow nasal oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in intensive care unit