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Proceedings of Réanimation 2018, the French Intensive Care Society International Congress
Annals of Intensive Care volume 8, Article number: 13 (2018)
CO-01 Respiratory viral infection in ICU patients with respiratory failure: a snapshot during multiplex PCR era
Epaillard Nicolas1, Bige Naike1, Dumas Guillaume1, Ait Oufella Hafid1, Maury Eric1
1Hôpital Saint-Antoine, Paris, France
Correspondence: Epaillard Nicolas - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-01
Introduction: The role and incidence of viral infections in respiratory failure occurring in ICU patients is more and more investigated. The availability of multiplex PCR assay is actually frequently performed. The aim of this retrospective study was to assess presence of viral species using a multiplex PCR assay in adult patients admitted to ICU for respiratory failure during the November–April period.
Patients and methods: All adult patients admitted to ICU during the November–April period for respiratory failure were eligible. A respiratory sampling was performed according to patient severity—sputum, tracheal aspiration, or per fibroscopic broncho alveolar lavage (LBA) and was analyzed for conventional bacterial strain. In all the patients, a multiplex vial PCR assay was performed on pharyngeal aspirate or LBA fluid.
Results: During the study period 123 patients were analyzed (male 76, SAPS II: 49 ± 17 + age 69 ± 18). 70 of them had at least one respiratory comorbidity. Forty-nine patients required invasive mechanical ventilation. Shock defined by requirement of vasoconstrictor was recorded in 31 patients (23%). In ICU mortality was 23%. Multiplex PCR assay was positive in 23 patients (17%). Co infection by bacteria and virus was noted in 4 patients. Influenzae virus was found in 10 patients and VRS in nine. Four patients with a positive viral sample had a fatal outcome (Influenza virus was found in all these). Mechanical ventilation was required in 45% of patients who were VRS positive but all had a favourable outcome.
Conclusion: Positive viral sample is not infrequent in ICU patients with respiratory failure. VRS is in this study as frequently found than influenzae.
CO-02 Low plasma citrulline concentration is associated with sepsis among critically ill patients
Piton Gaël1, Chaignat Claire1, Renaud Loïc1, Benoit Cypriani1, Hadrien Winiszewski1, Gilles Capellier1
1CHU Besançon, Besançon, France
Correspondence: Piton Gaël - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-02
Introduction: Plasma citrulline concentration, a biomarker of enterocyte function, is frequently low among critically ill patients. Plasma citrulline concentration might be decreased among critically ill patients presenting with sepsis, reflecting an alteration of small bowel function. We aimed to study the link between plasma citrulline concentration measured at ICU admission and variables related to the sepsis in critically ill patients.
Patients and methods: This was a prospective observationnal study performed in a University Hospital. Critically ill patients admitted to the ICU, aged 18 years or more, with ICU duration expected > = 48 h, without chronic renal failure or small bowel disease, were included. Plasma citrulline concentration, plasma I-FABP (biomarker of enterocyte damage), search for sepsis, results of bacterial sample, and usual clinical and biological variables were collected. We compared patients presenting with low plasma citrulline concentration (< = 10 µmol L), suspected of presenting enterocyte dysfunction, and patients with plasma citrulline concentration > 10 µmol L.
Results: Between July and December 2016, 109 patients, aged 64 years, 61% males, SOFA score 8 (6–12), were included in the study. Sepsis was found in 43 patients (40%), mainly of pulmonary (58%) and digestive (21%) origins. A plasma citrulline concentration ≤ 10 µmol L at ICU admission was associated with presence of Gram Negative or Candida infection, and higher plasma concentration of CRP and PCT (all p < 0.05). Plasma citrulline concentration was lower among septic patients than among patients without sepsis (12.0 µmol L [8.6–17.1] vs 20.5 µmol L (11.2–27.1) respectively, p = 0.004). Plasma citrulline concentration was not different among patients presenting with a sepsis of digestive origin and extra-digestive origin (7.8 [7.2–25.2] and 13.4 [9.8–16.3] respectively, p = 0.29). Plasma I-FABP was significantly higher among non-survivors (p = 0.005). Other factors associated with 28-day mortality were the age, plasma creatinine and lactate concentrations, and SOFA score.
Conclusion: This study confirms the link between sepsis and low plasma citrulline concentration in critically ill patients. The gut might be both the culprit, responsible for bacterial translocation, and the victim of sepsis. Indeed, the fact that plasma citrulline was also reduced during extra-digestive sepsis suggests the existence of septic enteropathy. I-FABP confirms its prognostic value among critically ill patients. The prognostic value of plasma citrulline in the critically ill requires further evaluation.
CO-03 Point of care use of the multiplex PCR Unyvero Curetis for the rapid diagnosis of low respiratory infections: performances and practical consequences
Guerpillon Brice1, Negre Jean1, Bohe Julien1, Muszynska Monika1, Thiery Guillaume1, Allaouchiche Bernard1
1Hospices civils de Lyon, Lyon, France
Correspondence: Guerpillon Brice - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-03
Introduction: Lower respiratory tract infections are very common in intensive care units and require rapid microbiological diagnosis in order to optimize the clinical progression and minimize the ecological impact. It currently takes 2–3 days to obtain an antibiogram using conventional microbiological techniques, compared with just a few hours for some multiplex PCR methods.
This prospective observational study focuses on a technique currently available, the multiplex PCR (MxPCR) Unyvero® system that targets the 20 bacteria most commonly implicated in these infections as well as 17 of the most widespread antibiotic resistance genes. Results can be obtained within 5 h.
The primary objective of this study was to demonstrate the diagnostic performance of this technique, and the secondary objective was to assess its practical impact.
Patients and methods: Between December 2016 and September 2017, point-of-care testing using MxPCR and conventional microbiological techniques were performed on respiratory specimens from patients with pulmonary infection in 2 intensive care units. Results, delay to obtain it, clinical and therapeutic datas were recorded.
Results: The main test results are presented in Table 1.
A total of 86 out of 103 samples collected were fully analyzed. The results obtained for 17 samples could not be interpreted due to a handling error (1), technical failures (14) and the absence of conventional antibiograms (2). Samples collected were mostly tracheal aspirates (45). Pathogenic bacteria were detected more often using MxPCR than conventional bacteriology techniques (43 samples compared to 36). Concordance ratio between those two technics is described in Table 1. Antibiotic therapy initiated in the 48 h preceding sample did not increase the mismatching (p = 0.42). Antimicrobial agents administered before microbiological sampling did not alter the concordance between culture and PCRMx (p = 0.42). Despite some inconsistencies, particularly regarding the detection of nonpathogenic saprophytic resistance, clinical and or ecological benefits were observed in 42% of cases with this technique. The benefits were mainly ecological with de-escalation in 24 cases and weaning off antibiotics in 11 cases. The clinical benefits (adjustment of therapy for bacteria not targeted empirically) were more limited as only 7 patients were affected and adjustment was delayed by 2.4 days on average.
Conclusion: Thanks to this technique, the treatment of respiratory infections could have been optimized in 42% (39/86) of cases with a modest clinical gain (7/86) but a significant ecological gain (35/86).
CO-04 Biomarkers to discriminate between infeted and non-infected patients at the time of sepsis criteria: the CAPTAIN multicenter cohort study
Misset Benoît1, Philippart François2, Parlato Mariana3, Rouquette Alexandra4, Moucadel Virginie5, Puchois Virginie6, Bedos Jean-Pierre7, Diehl Jean-Luc8, Hamzaoui Olfa9, Annane Djillali10, Journois Didier8, Ben Boutieb11, Myriam, Esteve Laurent6, Fitting Catherine6, Treluyer Jean-Marc12, Pachot Alexandre13, Adib-Conquy Minou6
1CGU de Rouen, France; 2Hôpital Saint Joseph, Paris, France; 3Hôpital Pitié Salpêtrière, Paris, France; 4CHU de Montpellier, France; 5Biomérieux, Grenoble, France; 6Institut Pasteur, Paris, France; 7CH de Versailles, France; 8Hôpital Européen Georges Pompidou, Paris, France; 9CHU Paris-Sud, Paris, France; 10Hôpital Raymond Poincaré, Garches, France; 11Hôpital Cochin, Paris, France; 12Hôpital Necker, Paris, France; 13Biomerieux, Lyon, France
Correspondence: Misset Benoît - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-04
Introduction: Sepsis and non-septic Systemic Inflammatory Response Syndrome (SIRS) are two similar syndromes, which differ by their cause, sepsis being secondary to microbial infection. Microbiological tests are not enough to early affirm the bacterial or fungal origin of the syndrome. More than fifty biomarkers have been proposed for this purpose but none have been repeatedly validated in external populations. Our goal was to address the accuracy of the biomarkers already reported as being able to efficiently discriminate between sepsis and non-septic SIRS.
Patients and methods: Prospective observational multicenter cohort of 363 consecutive patients with criteria of SIRS who were included when the attending physician considered they required antimicrobial therapy. We collected blood at inclusion to measure 53 biomarkers, including 29 plasma compounds, 10 whole blood RNA and 14 leukocyte surface markers. Patients were classified as sepsis or non-septic SIRS a posteriori, blindly to the biomarker results. Performance of each marker was assessed by AU-ROC curve. Multivariate analysis used a lasso regression (Tibshirani 1996; Musoro 2014), including multiple imputation for missing values and bootstrap validations, adapted for high numbers of variables (biomarkers).
Results: Eighty-four patients had exclusion criteria. Ninety-one patients had non-septic SIRS and 188 had sepsis. Median [IQ] SAPS 2 score was 55 [50–61] in both groups (p = 0.81). Time from ICU admission to inclusion was 1 [0–1] day. 69.8% of infections were pulmonary, most frequent strains were E. coli (23%), S. aureus (15%) and P. aeruginosa (13%). Causes of non septic SIRS were circulatory (37%), inflammatory (25%), hypoxemia (22%) and neurological (16%). Only 8 biomarkers had a ROC-AUC over 0.6 with a 95%IC over 0.5. In multivariate lasso analyses, only CRP and HLA-DRA circulating RNA were repeatedly associated with sepsis, and no model performed better than CRP alone (ROC-AUC 0.76 [0.68–0.84]).
Discussion: Strengths of this series are (1) the similar severity of SIRS and sepsis groups, (2) a multicenter design and (3) the use of a multivariate method adapted to the high number of independent variables.
Conclusion: In this prospective cohort, among 53 previously published biomarkers, CRP was found to better discriminate between sepsis and non septic SIRS than the other biomarkers. However, its performance was insufficient to be useful for routine use. HLA-DR circulating RNA was the only independent marker predicting infection. Multivariate models did not improve the performance of CRP alone.
CO-05 Procalcitonin in necrotizing soft tissue infection: an interesting prognostic marker and a potentially useful marker to guide the antimicrobial therapy duration
Pouly Olivier1, Parmentier-Decrucq Erika1, Duburcq Thibault1, Thieffry Camille1, Mathieu Daniel1, Poissy Julien1
1CHRU Lille, France
Correspondence: Pouly Olivier - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-05
Introduction: Procalcitonine (PCT) is a useful biomarker to reduce antibiotic exposure in intensive care units (ICU), especially in respiratory tract infections. Nevertheless, its usefulness for necrotizing soft tissue infections (NSTI) has not yet been reported. We aimed to assess PCT as a prognostic biomarker and a marker to guide duration of antimicrobial therapy in NSTI.
Patients and methods: We retrospectively included all the patients hospitalised for NSTI between January 1st 2013 and 31 December 2015 in an ICU department of a teaching hospital. Initial PCT value and kinetics, demographic and clinical data were reported. We compared the duration of the antibiotic course with: 1) the IDSA guidelines that recommend to use the decrease of fever and the need for surgical debridement and, 2) a theoretical duration if a PCT-based algorithm has been applied.
Results: We included 196 patients. Median LRINEC score was 6 [5–8.5] and median SOFA score was 6 [4–10]. At D28, mortality was 19.4%, significantly linked with initial PCT value (28.6 ng mL [3.5–58.7] in dead patients versus 3.1 ng mL [0.7–11.8] in survival ones (p = 10–4). There was no decrease in PCT kinetic for 12.2% of the patients who survived versus 62.5% among those who died at D28 (p < 10–5). The duration of the antimicrobial therapy was 12.5 days [10–17]. Stopping antimicrobial therapy if PCT levels was inferior to 0.5 ng mL or decreased of more than 80% from the initial value would have reduced the antibiotic treatment by 6.5 days [5–8] (p = 10–5). It would have been possible wherever the localisation of the infection. But 17.9% of patients could not have had a PCT guided antibiotic duration because of an initial PCT value < 0.5 ng mL, especially in the cervical cellulitis group. Antimicrobial therapy would have been reduced by 4 days if IDSA guidelines had been applied [5–13] (p = 10–5). The reduction of the antibiotic therapy was superior with the PCT algorithm compared to IDSA guidelines (p = 5.10–4).
Conclusion: Procalcitonin could be a good prognostic marker as well as a relevant tool to reduce the antibiotic therapy duration in the severe NSTI. We will nevertheless have to prospectively determine the impact of such a practice on patient prognosis, including mortality and need for reintervention.
CO-06 Health related quality of life trajectories of patients after acute illness
Benammi Sarah1, A. El Khattate1, M. Bizrane1, N. Madani1, Belayachi Jihane1, R. Abouqal1
1Ibn Sina University Hospital, Rabat, Morocco
Correspondence: Benammi Sarah - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-06
Introduction: This study aimed to identify and describe a set of longitudinal HRQoL trajectories then determine factors associated with trajectory class membership of patients after acute illness.
Patients and methods: This was a prospective cohort study conducted in an acute medical unit of University Hospital, between June–September 2014. Patients aged ≥ 17 years admitted to AMU were included. Demographic, medical history, clinical and paraclinical characteristics were recorded at admission. EQ5D index, EQ-VAS and survival status of patients were collected at admission, 3, 6 and 18 months of follow-up. Latent class growth analysis (LCGA) was applied to identify classes of HRQoL trajectories, while association between baseline covariate and class membership were identified using polynominals logistic regression. Statistical analysis was carried out in STATA version 14.
Results: Two hundred fifty-one patients were included. The mean age was 55.6 ± 18.9 years, women were 54.6%. In-hospital and 540 days follow-up mortality were respectively 11.6 and 34.3%. For 229 patients included in LCGA, three trajectory classes where identified for EQ5D Index + stably low (16.2%), stably moderate (30.6%), and high initially increasing (53.2%). The three trajectory classes of EQ-VAS were low increasing, moderate initially increasing and high initially increasing with, respectively, 29.7, 48.5 and 21.8% of the patients. Concerning EQ5D index, comparing to high initially increasing trajectory, factors associated to—(a) stably low trajectory membership were-age ≥ 70 years (OR 9.3; CI 1.7–49; p = 0.008), intensive care unit transit (OR 5.1; CI 0.01–10; p = 0.01) and low hemoglobinemia (OR 0.8; CI 0.05–1.1; p = 0.05) + (b) stably moderate trajectory membership were—comorbidity (OR 2.8 + CI 0.01–6.4 + p = 0.01) and low hemoglobinemia (OR 0.8; CI 0.001–0.9; p = 0.001). Concerning EQ-VAS, comparing to high initially increasing trajectory, factors associated to—(a) low increasing trajectory membership were—female gender (OR 5; CI 1.7–10; p = 0.006), Km hospital-residence (OR 0.9; CI 0.9–0.9; p = 0.01) and comorbidity (OR 9.6; CI 3.1–29; p < 0.001), (b) moderate initially increasing trajectory membership was comorbidity (OR 9.5; CI 3.7–24; p < 0.001).
Conclusion: Three HRQoL trajectories were identified. Aged patients with low hemoglobinemia and who transited through ICU had the worst EQ5D index. Females, with comorbidities, living far from hospital perceived an amelioration of their, previously low, EQ-VAS.
CO-07 Post-traumatic stress disorder after intensive care unit discharge: prevalence and impact on quality of life
1Hôpital de la Côte de Nacre, Caen, France
Correspondence: Pottier Véronique - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-07
Introduction: Hospitalization in ICU is a period of severe stress that can be experienced as a real trauma leading to post traumatic stress disorder (PTSD) after hospital discharge. The objective of this study is to determine the prevalence of PTSD and its impact on the quality of life at 3 months, 6 months and 1 year after ICU discharge.
Patients and methods: A before and after prospective, observational, non-interventional study assessing the impact of a nurse implemented sedation and analgesia algorithm on complications of critical illness and on outcome of patients after their ICU stay, was conducted in surgical ICU, between November 2014 and April 2017. During the “Before” period, sedation and analgesia was managed by the physician, while during the “After” period, it was managed by the nurses. Survivors were followed up by a phone survey at 3 months, 6 months and 1 year after ICU discharge.
Results: 1156 intubated and mechanically ventilated patients were admitted during the study period. Among the 145 included patients, 47 died and 35 were lost or disapproved the follow-up before the 3rd month. Only 62 patients accepted follow-up at 3 months (42.8%), 55 at 6 months (37.9%) and 42 at 1 year (29%). The presence of a new hospitalization after ICU discharge varies from 24.2 to 29.1%, between 3 months and 1 year, and the use of psychotropic drugs from 25.5 to 29%. The prevalence of PTSD (PTSS-10 score ≥ 35) was 12.9% at 3 months, 10.9% at 6 months and 16.7% at 1 year. ICU Stay has a moderate impact on quality of life at 3 months, 6 months and 1 year (62 < WHOQOL-BREF score < 96). Approximately 10% of patients have a severe impact on their quality of life (WHOQOL-BREF > 61) at ICU discharge, up to 1 year. The PTSS-10 score at 3 months is significantly higher in the “Before” period. There is no difference at 6 months and 1 year, nor significant difference on quality of life between the 2 periods.
Conclusion: Improving the quality of care in ICU should also take into account the possible deleterious consequences of ICU stay. Follow-up is paramount in patients at risk, and increased efforts to improve quality of life after ICU discharge are needed.
CO-08 An eye tracking adaptation of the Montreal-Toulouse aphasia test (MT-86) for intensive care patients to evaluate comprehension
Charuel Tessa1, Papazian Antoine1, Persico Lucille1, Aubrey Aurelie1, Barougier Anouck1, Ehrmann Stephan1, Bodet-Contentin Laetitia1
1CHU de Tours, France
Correspondence: Charuel Tessa - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-08
Introduction: In intensive-care units, intubated patients, who can’t speak and patients unable to designate because of physical weakness are strongly limited for communicating with relatives and caregivers, despite cognitive function which may be preserved. There is a lack of validated tools to assess oral comprehension, adapted to those patients. Outside of the critical care setting the Montreal-Toulouse aphasia test (MT-86) is a validated tool to assess language and communication capabilities. It includes an evaluation of the lexical and syntaxic comprehension. This preliminary study aimed to adapt the oral MT-86 to overcome physical limitations of intensive-care unit patients using eye-tracking technology.
Patients and methods: A simplified version of the comprehension tasks from the MT-86, assessing the receptive lexicon and syntax was used. 47 item slides (2 or 4 pictures) were digitalized and integrated into an 8 min automated protocol, presented on a computer screen. The patient’s ocular fixation on pictures, when instructed to do so (human voice), was recorded by an eye-tracking device (see Fig. 1, patient instructed to “look at the button”). For patients regaining capability, the MT-86 paper version was performed.
Results: 11 control subjects (21–70 years old, 2 men 9 women) were used for device development which enabled to defining the response validation criterion after 3.5 s of fixation on the instructed picture. 19 non-intubated patients (12 women 7 men, 24–84 years old) were tested with both versions, and 4 intubated patients with the eye-tracking version. No side effect was noted. 4 types of responses were observed: response validation, sporadic fixation time (no choice), shortened fixation time (low awareness), no fixation. Two patients interrupted the test in both versions, at the same point, demonstrating the same resource cost from both modalities. The Fig. 1 presents 2 patients’ ocular fixation (each color corresponds to one patient). Green patient answered successfully and the total fixation duration was the most important for the area of interest “button”. Pink patient ocular fixation answered not successfully (phonological distractor).
Conclusion: This study shows feasibility of passing the MT-86 using eyetracking technology among critically ill patients. The tool appeared easy to use thanks to its brevity and automation. Further development may provide intensive care unit healthcare workers with a new device to assess comprehension and attention capacities of patients. This study may provide a new evaluation tool for patients among whom classical tests cannot be conducted.
CO-09 Impact of obstructive sleep apnea syndrome on ICU patient prognosis: analysis of a French ICU cohort
Bailly Sebastien1, Seiller Alexandre2, Ruckly Stéphane3, Galerneau Louis Marie1, Terzi Nicolas1, Schwebel Carole1, Neuville Mathilde4, Tamisier Renaud1, Mourvillier Bruno4, Pépin Jean Louis1, Timsit Jean-François4
1CHU de Grenoble, Grenoble, France; 2INSERM, Paris, France; 3INSERM, Paris, France; 4CHU Bichat, Paris, France
Correspondence: Bailly Sebastien - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-09
Introduction: Patients admitted in ICU have frequently several chronic diseases, including obstructive sleep apnea syndrome (OSAS). To date, OSAS was not robustly considered as a determinant of ICU patient prognosis. The objective of the study was to assess the impact of OSAS (known at admission) in patient prognosis of ICU patients.
Patients and methods: Data were retrospectively collected between 2006 and 2013 from two centers of a French national prospective database. A nested exposed-unexposed design was used. The OSAS status was checked for exposed patients using the hospitalization files. Adult patients without therapeutic limitation and staying alive in ICU at least one day were included. OSAS patients were matched (1 − n, n > 2) with non-exposed patients on body mass index, age and presence of chronic obstructive pulmonary disease (COPD). The sample size was computed to reach a power upper than 90% to show a one-day increase of ICU stay (± 4 days). The quality of matching was assessed using the standardized mean differences. The following outcomes were considered: length of stay alive in ICU, ICU mortality, in-hospital mortality, ventilator-associated pneumonia (VAP).
Results: From 5146 patients admitted in both ICUs and included in the study, 288 had a OSAS at ICU admission (5.6%). OSAS patients were mainly male (71 vs 60%), were older (64 years ± 12 vs 59 ± 17), had a higher BMI (29 ± 11 kg m−2 vs 22 ± 4 kg m−2), have a more frequent COPD status (19.4 vs 8.2% p < 0.01) and cardiovascular diseases (35.7 vs 20.5%), had a higher SOFA score at ICU admission (6.6 ± 4 vs 5.2 ± 4.4). After matching (289 OSAS exposed vs. 571 OSAS non-exposed patients), there was no significant impact of OSAS on the length of stay alive in ICU (adjusted RR: 1.09–95% confidence interval: [0.88; 1.36], p = 0.42). Sensitivity analyses showed no differences in the results. Using logistic conditional regression models, the impact of OSAS on ICU mortality, in-hospital mortality and VAP were not different between OSAS and unexposed patients. Limitation—under-diagnosed OSAS for non-exposed patients and the presence of unmeasured confounders in the matching process are major limitations of the study.
Conclusion: In a large cohort of ICU patients, obstructive sleep apnea syndrome do not impact patient’s prognosis and outcome.
CO-10 Crush induction traceability in an ICU dedicated Patient Data Management System (PDMS), 1 year 21 ICU retrospective analysis
Goutorbe Philippe1, Cungi Pierrejulien1, Dupont Herve2, Payen Jean-François3, Radjou Aguila4, Choukroun Gerald5, Charpentier Julien6, Crova Philippe7, Schwebel Carole3, Lanceleur Anthony8, Slama Michel2, Luyt9, Charles-Edouard, Cordier Pierre-Yves10, Boutonnet Matthieu11, Pessey François12, Tran-Van David13, Patrigeon René-Gilles14, Ben Salah Adel15
1Hôpital Sainte Anne, Toulon, France; 2CHU Amiens, Amiens, France; 3CHU Grenoble, Grenoble, France; 4CH René Dubos, Cergy Pontoise, France; 5CH Corbeil, Corbeil-Essonnes, France; 6CHU Cochin, Paris, France; 7CH Bourgoin-Jallieu, Bourgoin-Jallieu, France; 8Hopital Foch, Paris, France; 9CHU Pitié Salpetrière, Paris, France; 10HIA Laveran, Marseille, France; 11HIA Percy, Clamart, France; 12HIA Clermont Tonnerre, Brest, France; 13HIA Robert Picqué, Bordeaux, France; 14CH Auxerre, Auxerre, France; 15CH Chartres, Chartres, France
Correspondence: Goutorbe Philippe - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-10
Introduction: Physicians in charge of critically ill patients deal with very high amount of data. Sources of data are as various as biology, bacteriology, monitoring, therapeutic or clinical inputs. ICU dedicated PDMS provides a quick scalable synthesis of this information. Besides computerized physician order entry (CPOE) seems to reduce medications errors in intensive care unit. It enhances traceability of continuous infusion, planed drugs or any items part of the care plan. But in some emergency cases, orally given orders may not be captured in the Medical file. We studied crush induction traceability in Centricity Critical Care (CCC), ICU dedicated solution, from GE Healthcare.
Patients and methods: We performed a retrospective anonymous database analyze of 2016 in 21 French ICU using CCC. We checked: the number of endotracheal intubations done in ICU (intubation 20 min or later after admission), the number of induction doses of rapid onset neuromuscular blockade agents (rocuronium or suxamethonium) at the same time (sampling only non-continuous perfusion). For each ICU, we asked if nurses were allowed to capture medications on behalf of physicians in the CPOE.
Results: During 2016, 19,736 patients were admitted, mean age was 60.68 mean SAPS II was 40.64 and length of stay was 6.69 days. We identified 5516 ICU intubations and found 909 rocuronium and 829 suxamethonium induction doses. The overall traceability ratio of induction was 31.51%. The traceability greatly varies between different ICU: individual ratio range from 1.32 to 83%. Third quartile was 51.55%. Traceability was better in ICU’s where nurses can capture medications in CPOE 48.7 versus 22.49% p < 0.02 (Fig. 1).
Conclusion: Our study may suffer from 2 opposites bias: replacement of tracheal tube without anesthesia or use of bolus of rocuronium for another reason than intubation. Nevertheless, induction drugs seem to be greatly under written in the PDMS. Where nurses support, traceability is better. CCC allowed such database analyzes. Physician in charge of ICU should periodically, among others, check this indicator. Collaborative work with PDMS providers should keep enhancing traceability and safety. In our case, GE agreed in future software releases to add on top of “prescription” a “nurse note option” and when a nurse is adding a device such as endotracheal tube, tracheostomy or gastrostomy to insert a question: did you perform an anesthesia? Clinical PDMS databases should be great sources of knowledge and improvement areas only in the case of serious data collection.
CO-11 Acute Respiratory Failure of patients with small-vessel vasculitis admitted to intensive care units: a multicenter retrospective study
Gibelin Aude1, Dumas Guillaume2, Valade Sandrine3, Pineton de Chambrun Marc4, Bagate François5, Neuville Mathilde6, Schneider Francis7, Baboi Loredana8, Groh Matthieu2, Raphalen Jean Herlé9, Guerin Claude8, Maury10, Eric, Timsit Jean François6, De Prost Nicolas5, Luyt Charles-Edouard4, Chiche Jean-Daniel3, Hertig Alexandre1, Parrot Antoine1, Azoulay Elie2, Fartoukh Muriel1
1Hôpital Tenon, Paris, France; 2Hôpital Saint Louis, Paris, France; 3Hôpital Cochin, Paris, France; 4Hôpital Pitié Salpêtrière, Paris, France; 5Hôpital Henri Mondor, Paris, France; 6Hôpital Bichat, Paris, France; 7CHU de Strasbourg, France; 8Hôpital de la Croix Rousse, Lyon, France; 9Hôpital Necker, Paris, France; 10Hôpital Saint Antoine, Paris, France
Correspondence: Gibelin Aude - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-11
Introduction: The acute respiratory failure (ARF) of patients with known or de novo small-vessel vasculitis (SVV) admitted to the intensive care unit (ICU) may be due to immune or non-immune causes. The prognosis is poor. Early identification of an underlying immune disorder is essential to initiate appropriate treatment. The aim of the study was to determine the incidence, describe the clinical presentation and assess the prognosis of immune ARF related to SVV.
Patients and methods: This retrospective multicenter study was conducted from January 2007 to June 2017 in 10 ICUs in France. Patients were identified from computerized registers using either keys words research or the International Classification of Diseases, Tenth Revision (CIM10). Inclusion criteria were (1) admission to the ICU for ARF, and (2) known or de novo granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, or anti-glomerular basement membrane antibody disease. Demographics, characteristics of ICU admission, treatments and outcomes were extracted from medical records.
Results: During the study period, 130 patients (64 [51–75.5] years old + 63% male) were eligible. The SAPSII and SOFA scores were 39 [28–54] and 6 [4–8], respectively. A mixed cause of ARF was diagnosed in 22 patients (16.9%), which was secondary classified as a primary immune cause in 16 patients, and a primary non immune cause in 6 patients. Altogether, 67 patients (51.5%) had an immune ARF (n = 67), and 63 (48.5%) a non-immune ARF. Five etiologies accounted for the immune ARF group—diffuse alveolar hemorrhage (n = 47), pulmonary or bronchial granulomatosis (n = 13), acute exacerbation of interstitial lung disease (n = 11), asthma (n = 7), myocarditis (n = 4) and others (n = 2). In univariable analysis, the most relevant factors associated with immune ARF, as compared with non-immune ARF were: absence of chronic renal insufficiency (6 vs 40%; p < 0.0002) and dialysis (1 vs 25%; p < 0.0003), a short time between SVV diagnosis and ARF (0 [0–0] vs 48 months [5–132]; p < 0.0001) and the presence of specific extra respiratory symptoms (72 vs 27%; p < 0.0001). There was no major difference in prognosis between immune and non immune ARF patients (Table 1).
Conclusion: Half of the patients with a known or de novo SVV admitted to the ICU for ARF have an immune cause of ARF. Readily identified predictive factors of an immune cause could allow the introduction of an early and targeted treatment.
CO-12 Anxiety in patients receiving non-invasive ventilation for acute respiratory failure: prevalence, risk factors and prognostic impact
Dangers Laurence1, Laforêt Jean Pierre1, Kouatchet Achille1, Jaber Samir2, Meziani Ferhat3, Perbet Sébastien4, Azoulay Elie5, Demoule Alexandre5
1Hôpital Pitié-Salpêtrière, Paris, France; 2CHU de Montpellier, France; 3CHU de Strasbourg, France; 4CHU de Clermont-Ferrand, France; 5Hôpital Saint Louis, Paris, France
Correspondence: Dangers Laurence - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-12
Introduction: Non-invasive ventilation (NIV) is a cornerstone therapy of acute respiratory failure (ARF) and is increasingly used in the intensive care unit (ICU). A recent survey suggests that up to 37% of patients report a certain level of anxiety related to NIV sessions. However, few is known on the actual prevalence, severity, risk factor and prognosis impact of anxiety in patients receiving NIV for an ARF. Objectives—to determine the prevalence and intensity of anxiety in patients receiving NIV for ARF, to identify the factors associated with anxiety, to assess the impact of anxiety on the risk of NIV failure, outcome, quality of life and post—ICU burden.
Patients and methods: Second analysis of a prospective observational cohort study in patients receiving NIV for ARF in 54 ICUs in France and Belgium, in 2010–2011. Anxiety was quantified using a graded ordinal scale from 0 (no anxiety) to 4 (very strong anxiety). A level of anxiety of 0 or 1 defined “mild or no anxiety” and a level of anxiety of 2, 3 or 4 defined a “moderate to severe anxiety”.
Results: Of the 419 patients included, 280 (67%) had mild or no anxiety and 139 (33%) had moderate to severe anxiety. Moderate to severe anxiety was independently associated with de novo ARF (OR 2.14; 95% CI 1.31–3.49; p = 0.002), male gender (OR 1.60; 95% CI 1.01–2.53; p = 0.047), dyspnea (OR 2.03; IC 95% 1.29–3.20; p = 0.002) and NIV intolerance (OR 4.9; 95% CI 3.03–7.93; p < 0.001). Factors of NIV failure were moderate to severe anxiety (OR 1.78; 95% CI 1.07–2.95; p = 0.027), SAPS 2 (OR 1.07; IC 95% 1.05–1.09) and de novo ARF (OR 3.30; IC 95% 1.97–5.55). In patients with moderate to severe anxiety, there was a trend toward a higher in-hospital (24 vs. 16%; p = 0.052) and day-90 mortality (29 vs. 20%; p = 0.05). Anxiety was not associated with higher length of stay, higher post ICU burden and altered quality of life.
Conclusion: Among patients receiving NIV for ARF, anxiety is frequent and potentially severe. Moderate to severe anxiety is associated with NIV failure and a trend toward higher mortality. Future studies should evaluate the benefit strategy aiming at improving anxiety management in ICU patients.
CO-13 Initial ECCO2R experience in the great Paris area: rate of utilization and safety preliminary data
Augy Jean-Loup1, Aissaoui Nadia1, Richard Christian2, Maury Eric3, Fartoukh Muriel4, Mekontso-Dessap Armand5, Paulet Rémi6, Anguel Nadia2, Blayau Clarisse4, Cohen Yves7, Chiche Jean-Daniel8, Gaudry9, Stephane, Voicu Sebastian10, Demoule Alexandre2, Combes Alain2, Charpentier Emannuel11, Haghighat Suzanne12, Panczer Manuelle12, Diehl Jean-Luc1, Megarbane Bruno10
1Hôpital Européen Georges-Pompidou, Paris, France; 2Hôpital de Bicêtre, Paris, France; 3Hôpital Saint Antoine, Paris, France; 4Hôpital Tenon, APHP, Paris, France; 5Hôpitaux Universitaires Henri Mondor, Paris, France; 6Centre Hospitalier Longjumeau, Paris, France; 7Hôpital Avicenne, Paris, France; 8Hôpital Cochin, Paris, France; 9Hôpital Louis Mourier, Paris, France; 10Hôpital Lariboisière, Paris, France; 11Office du Transfert de Technologie et des Partenariats Industriels, Paris, France; 12Agence Générale des Equipements et Produits de Santé, Paris, France
Correspondence: Augy Jean-Loup - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-13
Introduction: Veno-venous extracorporeal CO2 removal (ECCO2R) is a promising new therapeutic option in the critical care setting. We conducted a prospective observational study of the use of ECCO2R in selected voluntary centers during 2 years aiming to assess the prevalence of the ECCO2R use mainly among COPD and ARDS patients.
Patients and methods: Two medical devices: Hemolung (Alung Technologies, Pittsburgh, USA) and iLA Activve (Xenios Novalung, Heilbronn, Germany) were selected after literature and medico-economic evaluations. A specific medical and nurses training was provided in each center. Data were collected on a dedicated form and were centralized by the coordinating center. Primary outcome was the number of patients treated per month and per center during the 2-years study period. Secondary outcomes were ICU and hospital-mortality and adverse events complications related to device use.
Results: We present preliminary results from 47 patients recruited in 6 centers (29 men, 18 women, mean age 66.9 yrs ± 11.3 yrs). The utilization rate was of 0.33 ± 0.32 patient month center. Thirty-nine patients were under invasive and 8 under noninvasive mechanical ventilation. Hemolung was used in 40 patients (65% in jugular site, cannula size: 15.5 F) and iLA Activve in 7 (71% in femoral site, cannula size: 24 F). Main indications were COPD AE (n = 22) and ARDS (n = 18). Eighteen patients were treated as a part of a clinical trial and 29 were treated as decided by the physician in charge according to current practice. Mean duration of ECCO2R was 5.4 ± 3.0 days. Twenty-five ECCO2R treatments were discontinued because of clinical condition improvement, 10 because of complications, 7 because of death and 5 for futility. Twenty hemolysis (either biological-free Hb > 100 µmol L or clinical), 15 hemorrhagic complications, 4 thrombosis, 1 cannula disinsertion, and 1 local hematoma occurred. Results according to the used medical devices are presented in Table 1. Twenty-one deaths occurred during ICU stay, 27 during the hospitalization, 3 of which in relation with ECCO2R.
Conclusion: Our data indicate a preferential use of veno-venous ECCO2R devices in very severe (as illustrated by the overall high mortality) COPD and ARDS patients; with a lower than expected rate of utilization. Safety remains a major concern, indicating the need for further technological improvements as well of for optimization of anticoagulation regimen. Ultimately, RCTs will help to delineate clinical indications in these 2 main settings (COPD and ARDS).
CO-14 Impact of an electronic monitoring device on maintaining a semirecumbent position in mechanically ventilated patients
Bouadma Lila1, Guillaume Sit1, Couffignal Camille1, Toni Alfaiate1, Arnaud Foucrier1, Mathilde Neuville1, Romain Sonneville1, Mourvillier Bruno1, Timsit Jean-François1
1Hôpital Bichat, Paris, France
Correspondence: Bouadma Lila - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-14
Introduction: Maintaining a semirecumbent position (SRP) with a backrest elevation (BE) of 45° is not feasible for patients on mechanical ventilation (MV). Therefore, the effect of a SRP on the development of ventilator-associated pneumonia is uncertain. Our objective was to determine the efficacy of a simple electronic monitoring device to maintain a SRP during MV.
Patients and methods: We conducted a prospective, randomized, crossover study in two ICUs. BE of the patients were continuously assessed during a sequence of two consecutive 24 h-periods. Each period was either a control day = CD or a prototype day = PD. During the two periods, the targeted BE was between 40° and 45°. During the CD, BE was managed according to an internal procedure published previously. During the PD, an electronic device developed by our institution was added to the bed. The device was able to monitor continuously the BE and to alarm if the patient is not in the proper position. Adults patient were eligible if they were intubated with an expected duration of MV > 48 h and not eligible if they had a contraindication to SRP or a SAPS II score > 65. The time spent in a SRP defined by a BE between 40° and 50° was compared first in each crossover period by a Wilcoxon Rank-Sum test and then by a linear mixed effect model.
Results: One-hundred-five patients were randomized and a complete set of data were available for 103 patients: 72 men + age 59 ± 16 years, SAPS II score 48 ± 14 + acute respiratory failure in 28% and coma in 27%. BE was recorded for 833 ± 435 min during the CD and 1211 ± 333 min during the PD. During the two periods, patients had a median proportion of time spent in SRP about 30% higher in PD than in CD (IQR [25–75%]). In period 1 and period 2, patients had a higher median proportion of time spent in SRP in a PD than in a CD (93% [86–96%] vs 59% [34–79%], p < 0.0001) and (95% [78–97%] vs 62% [31–92%], p < 0.005) respectively. No period effect was identified. No adjustment covariate was significantly associated with the proportion of time spent in the SRP.
Conclusion: In ICUs with a high proportion of patients in a SRP (about 60%), a simple removable, washable, easily sanitized electronic monitoring device is able to raise this proportion at about 95%. Prospective studies are required to assess its clinical impact.
CO-15 Assessment of proportional assist ventilation in patients exhibiting refractory ineffective triggering during pressure support ventilation
Haudebourg Anne-Fleur1, Maraffi Tommaso1, De Prost Nicolas, Razazi Keyvan, Mekontso Dessap Armand1, Carteaux Guillaume1
1Hôpital Henri Mondor, Paris, France
Correspondence: Haudebourg Anne-Fleur - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-15
Introduction: Ineffective triggering is frequent during pressure support ventilation (PSV). Its occurrence is favored by dynamic hyperinflation that may arise when increasing the pressure support level (PSL). Decreasing the PSL however fails to suppress ineffective triggering in a subgroup of patients that are therefore exposed to refractory ineffective triggering. Proportional assist ventilation with load-adjustable gain factors (PAV +) decreases the incidence of ineffective triggering in unselected patients but its effect on refractory asynchrony during PSV is unknown. The main aim of our study was to assess the effect of PAV + in patients exhibiting refractory ineffective triggering during PSV.
Patients and methods: Refractory ineffective triggering was defined as persisting ineffective triggering at the lowest tolerated PSL. Patients with refractory ineffective triggering during PSV were included. Flow, airway and esophageal pressures were continuously recorded during 10 min under PSV with the minimal tolerated PSL, and then under PAV + with the gain adjusted to target a muscle pressure between 5 and 10 cm H2O. Primary endpoint was the comparison of asynchrony index between PSV and PAV + . Continuous data are reported as median [25th–75th percentiles].
Results: Seven patients with refractory ineffective triggering were included so far. The median lowest tolerated PSL was 16 cm H2O [12–18], with a PEEP level of 8 cm H2O [5.5–8] and a PaO2 FiO2 ratio of 209 mmHg [178–225]. The median gain during PAV + was 70% [63–73]. The asynchrony index was significantly lower with PAV + than PSV (3% [2–8] vs. 24% [13–48] respectively, p = 0.02). Moreover, the asynchrony index decreased in every patient with PAV + (Fig. 1). Noticeably, the tidal volume was already protective in PSV and decreased even more during PAV + (5.71 mL kg [4.6–9.3] vs. 5.71 mL [1.8–7.1] respectively, p = 0.03); and the neural respiratory rate was high in both modes (41 cycles min [26–51] in PSV vs. 40[28–44] in PAV + , p = 0.61). Total esophageal Pressure–Time Product (PTPes) did not significantly differ between the two modes but the PTPes proportion that was wasted in ineffective efforts decreased with PAV + (1% [1–2] vs. 18% [7–37], p = 0.03).
Conclusion: Our preliminary data suggest that: (1) PAV + reduces the incidence of refractory ineffective triggering; (2) patients exposed to refractory ineffective triggering during PSV seem characterized by rapid shallow breathing despite high ventilatory support, questioning the tolerance of both ventilatory modes. Results with further inclusions will be presented.
CO-16 Should we perform an immediate coronary angiogram in all patients after cardiac arrest?
Bougouin Wulfran1, Dumas Florence1, Karam Nicole1, Maupain Carole1, Marijon Eloi1, Lamhaut Lionel, Jost Daniel1, Geri Guillaume1, Beganton Frankie1, Varenne Olivier1, Spaulding Christian1, Jouven1, Xavier, Cariou Alain1
1Hôpital Cochin, Paris, France
Correspondence: Bougouin Wulfran - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-16
Introduction: An immediate coronary angiogram (CAG) may be associated with better outcome after out-of-hospital cardiac arrest (OHCA) in neurologically preserved patients but could be futile in other cases. We aimed to assess the relationship between an immediate invasive strategy and survival after an out-of-hospital cardiac arrest (OHCA) of presumed cardiac cause, according to prognosis evaluated on hospital arrival.
Patients and methods: From May 2011 to May 2015, we collected data for all patients admitted in hospital after OHCA in Paris and suburbs (France). Risk of in-hospital death was retrospectively calculated using the validated Cardiac Arrest Hospital Prognosis (CAHP) score. Independent predictors of survival at discharge (including immediate CAG) were assessed in multivariate logistic regression in each of the 3 pre-defined subgroups of CAHP score: low (< 150 points), medium (150–200 points) and high (> 200 points) risk for in-hospital death.
Results: 1410 patients were included and overall survival rate at hospital discharge was 32%. Distribution in the low, medium and high-risk CAHP subgroups was 667 (47%), 469 (33%) and 274 patients (20%) respectively. The rate of early CAG was 86, 66 and 47% in the low, medium and high-risk subgroups, respectively (p < 0.001). Early invasive strategy was independently associated with better survival in low-risk patients (OR 2.3, 95% CI 1.4–3.9, p = 0.001), but not in medium (p = 0.55) and high-risk (p = 0.43) patients. Sensitivity analysis found consistent results.
Conclusion: In cardiac arrest patients, our results suggest that the potential benefit of an early coronary angiogram (and subsequent revascularization) is restricted to those with a preserved neurological prognosis at hospital arrival.
CO-17 Unexpected cardiac arrest in the ICU: intermediate results of an ongoing multicenter study (ACIR)
Leloup Maxime1, Langlois Alice1, Briatte Isabelle1, Faucher Eric1, Bedoussac Emilie1, Lesieur Olivier1, Acir Study Group1
1Groupe hospitalier La Rochelle Ré Aunis, La Rochelle, France
Correspondence: Leloup Maxime - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-17
Introduction: To our knowledge, no study mapped the epidemiology of unexpected cardiac arrest (i.e. with resuscitation attempt) in French ICUs. The current research primarily aims at describing the demographics, management, and prognosis of patients concerned.
Patients and methods: “ACIR” (in French: Arrêt Cardiaque Inattendu en Réanimation) is a prospective multicenter study that started on January 1st 2017, and is expected to last 1 year. All victims of cardiac arrest during ICU stay are included, whereas patients presenting with cardiac arrest at the time of admission are not. By convention, any resuscitation attempt (chest compression, adrenaline and or electric shock) defines the “unexpected cardiac arrest”. The data collected comprise medical history, circumstances of happening, ongoing treatments, resuscitation maneuvers, and outcome). A 6-month follow up period is planned for survivors.
Results: Forty-four centers (17 University and 27 general hospitals) are participating in the study, including 8 medical, 7 surgical and 29 medical surgical ICUs. Among those, nearly one-third have implemented a specific protocol regarding the management of cardiac arrest. Around half undergo regular resuscitation trainings, and among them 80% do so at least annually. Following unexpected cardiac arrest, most of ICU staffs set up post hoc debriefings (always 32%, often 20%, sometimes 41% or never 7%). On two-thirds of the investigation period, 2842 patients were victim of cardiac arrest in the participating units. Of those, 2426 did not endure any resuscitation attempt: 1687 were previously attributed a “do-not-resuscitate” order, 589 were unresponsive to maximal therapy and 150 for other reasons. Four hundred and sixteen patients (69% men, 68 ± 13 years, mean SAPS2 72 ± 25) were included in the “unexpected cardiac arrest” chart. Half of the events occurred within the first 24 h from admission. Return of spontaneous circulation was achieved in 271 (66%) patients (67% men, 68 ± 13 years, mean SAPS2 70 ± 25), and among them 69 (25%) were discharged alive from hospital (62% men, 64 ± 15 years, mean SAPS2 64 ± 24).
Conclusion: According to the Utstein style, our intermediate data are within the range reported in relevant literature. Although initial resuscitation was successful in two-thirds of cases, only 16.5% of victims of unexpected cardiac arrest in the ICU were discharged alive from the hospital. Among other concerns, this study aims at determining among participating centers what specific interventions are likely to enhance prognosis and quality of life for cardiac arrest patients in the ICU.
CO-18 Venous-to-arterial carbon dioxide difference (cv-art CO2 gap): prognosis factor of septic shock patients according to central venous oxygen saturation (ScvO2)
Ronflé Romain1, Lefebvre Laurent2, Garrigues Bernard2 Lehingue Samuel1, Duclos Gary1, Papazian Laurent1, Leone Marc1
1Hôpital de La Timone, Marseille, France; 2CH d’Aix En Provence, France
Correspondence: Ronflé Romain - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-18
Introduction: Venous-to-arterial carbon dioxide difference (cv-art CO2 gap) is a marker of tissue perfusion. Despite being in the security zone, high central venous oxygen saturation (ScvO2) is associated with poor outcome in patients with septic shock. The aim of this study is to assess the ability of the cv-art CO2 gap to predict clinical worsening in patients with septic shock, according to ScvO2.
Patients and methods: We performed a multicentric prospective study in 3 ICUs. All consecutive patients with septic shock were included during the study period. Patients were assigned into three groups according to ScvO2. Clinical worsening was defined as an increase of SOFA score ≥ 1 two days after admission ∆SOFA ≥ 1). Patients characteristics and severity scores were collected during the first 3 days of stay. To assess the ability of the cv-art CO2 gap to predict a clinical worsening, a ROC curve was produced for the event ∆SOFA ≥ 1. Associations between cv-art CO2 gap and 28-day mortality along with length-of-stay (LOS) were explored using linear regression and correlations.
Results: Fifty-six patients were included. 28-day mortality was 23% with an admission mean SOFA score of 9 ± 3. On admission, mean ScvO2, blood lactate and cv-art CO2 gap were 74 ± 13%, 3.4 ± 2.8 mmol L and 6 ± 4.5 mmHg, respectively. Considering all patients, cv-art CO2 gap failed to predict ≥ 5.7 in the [70–80%] ScvO2 group could predict clinical worsening (Se = 67%, Sp = 75%, PPV = 57%, NPV = 82%, AUC = 0.7). In addition, every increase of 1 mmHg in cv-art CO2 gap might extend the LOS by 1.8 day (95% CI [0.2–3.4], p = 0.025). Finally, 28-day mortality of patients with mean cv-art CO2 gap > 6 mmHg within 72 h was 39% compared with 16% for patients with cv-art CO2 gap > 6 mmHg (p = 0.056).
Table Hermodynamic and biological characteristics of studied patients according to ΔSOFA
|Variable||Cohort (n = 52)||ΔSOFA ≥ 1 (n = 13)||ΔSOFA < 1 (n = 39)||p|
|IGS2 score||54 ± 18||64 ± 14||53 ± 17||0.06|
|Admission SOFA score||9 ± 3||9 ± 4||9 ± 2||0.54|
|28 days mortality n (%)||12 (23)||8 (67)||4 (33)||0.001|
|Mean MAP 72 h (mmHg)||77 ± 9||72 ± 8||80 ± 9||0.016|
|Mean Lactate 72 h (mmol/l)||3.2 ± 2.3||4.5 ± 3.1||2.5 ± 1.7||0.008|
|Mean ScvO2 72 h (%)||74 ± 8||74 ± 8||73 ± 7||0.5|
|Mean cv-art CO2 gap 72 h (mmHg)||5.6 ± 2.1||5.9 ± 1.3||5.5 ± 2.3||0.23|
|∆ Lactate H0–H6 (mmol/l)||0.15 ± 1.2||− 0.07 ± 1.1||− 0.17 ± 1.2||0.87|
|Mean diuresis 24 h (ml)||1600 ± 1400||1111 ± 1647||1800 ± 1273||0.01|
|Mean fluid 24 h (ml)||3935 ± 3237||4091 ± 4176||3880 ± 2915||0.85|
|Mean fluid balance 24 h (ml)||3566 ± 2860||5498 ± 4237||3039 ± 2157||0.04|
|Mean ICC 24 h (l/min/m2)||3.34 ± 0.94||3.4 ± 0.8||3.4 ± 1||0.9|
|Mean admission EVLW (ml/Kg)||11 ± 4||10.9 ± 3.4||11.5 ± 4.6||0.84|
|Mean PaO2 72 h (mmHg)||96 ± 20||98 ± 23||94 ± 19||0.72|
|Mean PaCO2 72 h (mmHg)||41 ± 10||42 ± 5||40 ± 11||0.07|
|Mean PaO2/FiO2 24 h (mmHg)||191 ± 73||181 ± 67||195 ± 75||0.54|
|PaO2/FiO2 < 150 (mmHg) n (%)||14 (29)||3 (22%)||11 (78%)||0.73|
|Mean noradrenaline 72 h (μg/kg/min)||0.44 ± 0.56||0.85 ± 0.95||0.28 ± 0.20||0.0001|
|Precharge dependance n (%)||35 (71)||7 (20)||28 (80)||0.28|
Conclusion: cv-art CO2 gap is a parameter to assess the inadequacy of circulating blood flow in response to metabolic demand. cv-art CO2 gap could help clinicians to identify septic shock patients with organ dysfunction despite normalization of ScvO2.
CO-19 Reversible microvascular endothelial dysfunction during correction of ketoacidosis diabetes
Joffre Jérémie1, Bourcier Simon1, Hariri Geoffroy1, Miaihle Arnaud Felix1, Bige Naike1, Dumas Guillaume1, Guidet Bertrand1, Maury Eric1, Ait Oufella Hafid1
1Hopital Saint Antoine, Paris, France
Correspondence: Joffre Jérémie - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-19
Introduction: Context—Metabolic acidosis is commonly observed in critically ill patients. Experimental studies suggested that acidosis by itself could impair vascular function but such hemodynamic effect has been poorly investigated in human. Objectives: To assess the relationship between metabolic acidosis severity and endothelial microvascular function.
Patients and methods: Design, settings and patients: Prospective monocenter study. All adult diabetes patients admitted in our medical ICU for ketoacidosis (pH < 7.35) were included. Endothelial microvascular response to acetylcholine iontophoresis was measured at admission (H0) and after correction of metabolic acidosis (H24).
Results: Thirty-nine patients with diabetes ketoacidosis were included, 68% (n = 18) were male, with a median age of 43 [31–57] years. At admission, endothelial function significantly correlated with acidosis severity, the deeper acidosis was the worst endothelial activity (R = 0.53, p < 0.001). Endothelial response was strongly depressed below a pH at 7.20 (AUC 1779 [740–3079] versus 12,944 [4874–21,596], p < 0.0001). At H24, after rehydration and insulin infusion, clinical and biological disorders were fully corrected. After acidosis correction, endothelial response improved more in patients with baseline deep acidosis (pH < 7.20) when compared to patients with mild acidosis (AUC + 453 [213–1470] versus + 121 [79–312] %, p < 0.01).
Conclusion: We documented an endothelial dysfunction during metabolic acidosis in critically ill patients with diabetic ketoacidosis. Endothelial dysfunction recovered after acidosis correction.
CO-20 Intra-abdominal hypertension is responsible to false negatives to the passive leg raising test
Beurton Alexandra1, Teboul Jean-Louis1, Girotto Valentina1, Galarza Laura1, Richard Christian1, Monnet Xavier1
1Le Kremlin-Bicêtre, Paris, France
Correspondence: Beurton Alexandra - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-20
Introduction: The passive leg raising (PLR) test mimics a volume challenge and is based on the passive transfer of some venous blood from the legs toward the cardiac cavities when moving a patient from the semi-recumbent to a passive leg raised position. Nevertheless, intra-abdominal hypertension (IAH) may increase the resistance to venous return through the inferior vena cava and may impede the PLR-induced increase in cardiac preload. We tested the accuracy of the PLR test to predict fluid responsiveness in case of IAH.
Patients and methods: In patients with an intra-abdominal pressure (IAP) > 12 mmHg, we measured the changes in cardiac index (PiCCO2 device) induced by a PLR test and by a 500-mL saline volume expansion. The IAP (bladder pressure) was measured at different study steps.
Results: Twenty-nine patients were included, 20 being fluid responders (fluid-induced increase in cardiac index 15%) and 9 fluid non-responders. The IAP at baseline was 20 ± 6 mmHg. It significantly decreased during the PLR test in fluid responders (by 34 ± 13%) and in fluid non-responders (by 30 ± 16%). In fluid responders, cardiac index increased by 7 ± 9% during PLR and by 22 ± 6% during volume expansion. The PLR test was negative (PLR-induced increase in cardiac index < 10%) in 15 patients (false negatives) and positive in 5 patients (true positives). In fluid non-responders, cardiac index increased by 6 ± 6% during PLR and 6 ± 3% during VE. The PLR test was negative in all but one of them was positive (false positive). The sensitivity and specificity of the PLR test to detect fluid responsiveness were 40% (95% confidence interval 19–64) and 89% (52–100), respectively. The area under the receiver operating characteristic curve was 0.58 ± 0.11.
Conclusion: Intra-abdominal hypertension is responsible for false negatives to the PLR test. The PLR test significantly reduces IAP.
CO-21 A prospective observational study reporting for acute mesenteric ischemia the results of the first 18 months of a dedicated intestinal stroke center for acute mesenteric ischemia
Nuzzo Alexandre1, Huguet Audrey1, Weiss Emmanuel1, Tran Dinh Alexy2, Maggiori Léon1, Iserentant Jules1, Pellenc Quentin2, Roussel Arnaud2, Sibert Annie1, De Blic Romain2, Billiauws Lore1, Ronot1, Maxime, Montravers Philippe1, Panis Yves1, Vilgrain Valerie1, Bouhnik Yoram1, Castier Yves Herve2, Paugam Burtz Catherine1, Corcos Olivier1
1Hôpital de Beaujon, Clichy, France; 2Hôpital Bichat, Paris, France
Correspondence: Nuzzo Alexandre - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-21
Introduction: Acute mesenteric ischemia (AMI) has high mortality and intestinal resection rates. An intestinal stroke center based on a multimodal and multidisciplinary management focusing on intestinal viability was created in our center in January 2016. We aimed to study AMI patients and outcomes.
Patients and methods: Single-center, observational and prospective study was carried out in our intestinal stroke center. AMI was defined as an acute intestinal injury related to a splanchno-mesenteric insufficiency and without alternative diagnosis. All AMI patients underwent a computed tomography angiography. AMI were classified in occlusive (atheroma, thrombosis, embolisms etc.) and non-occlusive (splanchnomesenteric hypoperfusion, vasoconstrictive medications), arterial and venous. Patients with post-AMI short bowel syndrome (SBS), chronic mesenteric ischemia, aorta dissection anevrism and left ischemic colitis were not included. Outcomes studied were mortality at 3 months and at the end of follow-up, intestinal resection, SBS and parenteral nutrition requirement. Predictive factors of intestinal resection and mortality were studied in uni- and multivariate analyses. Quantitative data were reported as medians (range). A p value < 0.05 was considered to be significant.
Results: In 124 included patients (female 38%, 66.1 (26.3–95.6) yo) AMI was occlusive, non-occlusive, arterial, venous in 89, 11, 81 and 18.5%, respectively. Main etiologies of occlusive AMI were atheroma (39.5%), thrombosis (35%), embolism (9.7%). Occlusion concerned one, two or three of the digestive arteries in 54, 23 or 13%, respectively and superior mesenteric artery in 89.1% of arterial AMI. Chronic mesenteric ischemia preceded AMI in 22%. A surgical (n = 23) and or radiological (n = 36) revascularization was performed in 56.4% of arterial AMI. Intestinal resection was necessary in 31.4%. At end of follow-up of 290 (0–614) days, 22 (18%) patients had a SBS and 16 (13%) required parenteral nutrition. Mortality at 3 months and at the end of follow-up were 11.3 and 16.9%, respectively (Figure). In multivariate analysis a stay in ICU was the only factor associated with resection (p < 0.001, OR 7.9 (2.9–21.4)) and mortality (p = 0.02, OR 4.4 (1.2–15.4)).
Conclusion: AMI patients treated in the intestinal stroke center have a survival and small bowel preservation rates of more than 80 and 70%, respectively. Such structure could serve as a model for multicentric studies and to improve at a large territorial scale the prognosis and the knowledge of AMI.
CO-22 Incidence of intravascular catheter-related infections among patients undergoing prone positioning for Acute Respiratory Distress Syndrome: an exposed non-exposed study
Jacquot Audrey1, Novy Emmanuel1, Louis Guillaume3
1CHU Nancy, France; 2CHR Metz Thionville, Ars-Laquenexy, France
Correspondence: Jacquot Audrey - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-22
Introduction: The use of prone positioning (PP) for patients presenting moderate to severe Acute Respiratory Distress Syndrome (ARDS) has increased since the PROSEVA trial. Adverse events associated with PP have been well described such as pressure sores. But although patients with moderate to severe ARDS had high mortality, had prolonged length of stay and were particularly exposed to central venous catheters (CVC), there were no data reporting intravascular catheter-related infections (ICRI). In this study, we evaluated the incidence of CVC colonization in patients exposed to PP for ARDS.
Patients and methods: In this retrospective bicentric observational study we compared two groups of adults, assigned 1:1. The “exposed” group was composed of patients treated with PP for moderate to severe ARDS. The “non-exposed” group was composed of non-ARDS patients matched with: centre, year, sex, age, APACHE II score and length of ICU stay. ICRI incidence rate (1/1000 catheter-days) and preventive bundles were similar between the two centres, as well as the practice for PP session. The primary outcome was the incidence of catheter-related colonization in each group. The secondary outcome was the incidence of a composite criterion which evaluated an overall infectious risk associating colonization and/or bloodstream catheter-related infection and/or ICRI.
Results: Between January 1st, 2014 and December 31st, 2015, 173 patients were eligible for the “exposed” group: we matched 101 patients with 101 non-exposed patients. ARDS patients were mainly composed of direct ARDS (Pneumonia), median length of mechanical ventilation was 20 days, the average number of PP session was 2 and its mortality rate was 30%. “Non-exposed” group included a majority of cardiogenic shock. The number and length of catheter did not differ significantly between groups. The incidence of CVC colonization was 23.8% in the exposed group and 8.91% in the non-exposed group (p = 0.007) (Fig. 1). The odds ratio for PP was 3.8 (p = 0.01). The incidence of composite criterion was significantly higher in the exposed than in the non-exposed group (34% versus 19% p = 0.02).
Conclusion: This is the first study to assess the incidence of ICRI in ARDS patients undergoing prone positioning. In our study, PP was associated with a higher rate of colonization. The overall catheter-related infectious risk was affected by the PP. We probably identified a population at high risk of ICRI who may benefit from additional preventive measures.
CO-23 Low versus standard-blood-flow reperfusion strategy in experimental ischemic refractory cardiac arrest treated with Extra Corporeal Life Support
Levy Bruno1, Luo Yun1, Fritz Caroline1, Hammache Nefissa1, Kimmoun Antoine1, Grandmougin Daniel1, Orlowski Sophie1, Albuisson Eliane1, Tran N’Guyen1
1CHRU NANCY, Vandoeuvre-Les-Nancy, France
Correspondence: Levy Bruno - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-23
Introduction: This study was designed to assess the effect of two extracorporeal life support (ECLS) blood-flow strategy in an experimental model of E-CPR in the first six hours of resuscitation on macrocirculatory and microcirculatory parameters, lactate clearance and cytokine storm.
Patients and methods: Cardiac arrest was induced in 18 pigs by surgical ligature of the left coronary artery. ECLS was initiated after 40 min of cardiopulmonary resuscitation and the ECLS blood flow was set on 30–35 ml kg−1 min−1 (low-blood-flow group, LBF) versus 65–70 ml kg−1 min−1 (standard-blood-flow group, SBF) according to the randomized group. Continuous systemic blood pressure and carotid blood flow were continuously monitored. Blood gas analysis and lactate were measured at baseline H0, H3 and H6. Sublingual microcirculatory was assessed by sidestream dark field (SDF) technology and the following parameters were assessed: total and perfused vessels density (TVD, PVD), the proportion of perfused vessels (PPV) and microvascular flow index (MFI). Leg tissue oxygenation (StiO2) was monitored by a Near-Infrared Spectrometer (NIRS) device. Cytokine inflammatory was measured by enzyme-linked immunosorbent assay (ELISA).
Results: There was no differences between groups at baseline and at ECLS initiation (H0). Lactate and sublingual microvascular parameters were significantly impaired after the low-flow period. MAP target (65 mmHg) was reach in each randomized group. Total infused norepinephrine and total infused fluid were similar between the two groups. A significant difference was observed in the six hours evolution concerning carotid blood flow (LBF vs SBF at H6–19 [5–34.45] vs 67.81 [43.5–82] %, p < 0.05). Lactate clearance at H6 was inferior in the LBF compared with the SBF (6.67 [− 10.46 to 18.78] vs 44.72 [19.54–69.07] %, p < 0.05). Concerning the microvascular parameters, the LBF had lower PVD, PPV and MFI at H3 compared with the SBF but no significant difference observed at H6. TNF: was lower (361 [73–778] vs 1164 [177–1848] ng ml−1, p < 0.05) in the LBF at the end of the experiment.
Conclusion: In an experimental porcine model of refractory cardiac arrest treated by ECLS, a low-blood-flow strategy during the first six hours of resuscitation was associated with a decreased cerebral blood flow, lactate clearance and microcirculatory parameters despite a lower inflammatory response.
CO-24 Hemodynamic efficacy of high permeability hemodialysis in post-cardiac arrest shock: results of the HYPERDIA randomized control trial
Geri Guillaume1, Grimaldi David1, Seguin Thierry1, Lamhaut Lionel1, Marin Nathalie1, Chiche Jean-Daniel1, Pène Frédéric1, Bouglé Adrien1, Daviaud Fabrice1, Morichau-Beauchant Tristan1, Arnaout Michel1, Champigneulle1, Benoit, Bougouin Wulfran1, Zafrani Lara1, Bourcier Simon1, Nguyen Yen-Lan1, Charpentier Julien1, Mira Jean-Paul1, Coste Joel1, Cariou Alain1
1Hôpital Cochin, Paris, France
Correspondence: Geri Guillaume - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-24
Introduction: After resuscitation of cardiac arrest (CA), an acute circulatory failure occurs in about 50% of cases, which shares many characteristics with septic shock. Most frequently, supportive treatments are unable to control this shock that may provoke multiple organ failure and death. We evaluated whether an early plasma removal of inflammatory mediators using high permeability hemodialysis (HPHD) in addition to conventional treatments could improve hemodynamic status of this patients.
Patients and methods: We performed a randomized open-label trial. Successfully resuscitated comatose CA patients who had a post-resuscitation shock (defined as requirement of norepinephrine or epinephrine infusion > 1 mg h) were included. The experimental group received 2 separated sessions of HPHD during the first 48 h following ICU admission. The control group received continuous veno-venous hemofiltration (CVVH) if needed. Non-parametric tests were used to compare the two groups. The primary outcome was the duration of the shock expressed by the length of catecholamine infusion. Number of vasopressors-free days, 6-h repeated measures of blood pressure, daily fluid balance and mortality (ICU and day-28) have been evaluated as well.
Results: 35 patients were included: 17 (median age 68.4, 59% male) in the HDHP group and 18 (median age 66.3, 83% male) in the control group. Baseline characteristics did not differ between the two groups. Ventricular fibrillation was the first recorded rhythm in 23.5 and 44.4% in the HDHP and control group, respectively (p = 0.289). Day-28 mortality rate was 64.7 and 72.2% in the HDHP and control group, respectively (p = 0.72). Probability of vasopressors discontinuation over time was similar in the two groups (Figure, p for logrank test = 0.67). Number of catecholamine-free days was 25.1 [0, 26.5] and 24.5 [0, 26.2] in the HDHP and control group, respectively (p = 0.65). No difference was observed regarding the daily-dose of vasopressors and the 6-h recorded systolic mean diastolic arterial pressure. No difference in terms of fluid balance was observed either.
Conclusion: In post-cardiac patients with acute circulatory failure, HPHD did not reduced the duration of shock and had no effect on hemodynamic status. Registration: NCT00780299 the study was completely funded by the French Ministry of Health. Baxter provided the Septex membranes that were used in the HPHD group.
CO-25 Usefulness of the Unyvero system to decrease broad-spectrum antibiotics consumption in patients with ventilator-associated pneumonia
Luyt Charles-Edouard1, Nicolas Bréchot1, Hékimian Guillaume1, Aubry Alexandra1, Lafeuille Emilie1, Schmidt Matthieu1, Franchineau Guillaume1, Besset Sébastien1, Nieszkowska Ania1, Bourcier Simon1, Coutrot Maxime1, Combes1, Alain
1Hôpital de la Pitié-Salpêtrière, Paris, France
Correspondence: Luyt Charles-Edouard - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-25
Introduction: Reducing the use of broad-spectrum antibiotics in the ICU is a key issue. The P55 pneumonia cartridge of the multiplex-PCR Unyvero (Curetis) system allows identification of 19 bacteria and 1 fungi among the most frequently responsible for ventilator-associated pneumonia (VAP), and 19 of their resistance markers directly in clinical specimens. We aimed to evaluate the concordance between this technique and the conventional microbiological methods (CMM) for the diagnosis of VAP, assuming that it could support a decrease in broad-spectrum antibiotics consumption.
Patients and methods: Prospective, observational, single centre study. All consecutive patients with suspected VAP and a positive direct examination of broncho-alveolar lavage fluid (i.e. intracellular bacteria on direct examination) were included. Fresh BAL fluid was submitted to CMM and tested with the Unyvero system. We compared the results given by the 2 techniques, CMM being considered as the reference.
Results: Forty-four patients (median age 55 [43–63] yrs, median SAPS II score 54 [36–68]) were included. Microorganisms responsible for VAP were predominantly P. aeruginosa (Pa, n = 19) and Enterobacteriaceae (n = 21). 13 (30%) patients had polymicrobial VAP. The Unyvero system correctly identified pathogens in 35 (80%) patients + whereas no bacteria were detected for 4 patients, and a bacteria different that the one identified by CMM for 5 patients (Table 1). The Unyvero system failed to identify the resistance mechanism in 19 (43%) patients, either by default (n = 12) or excess (n = 7). These failures were mainly observed for Pa (n = 14, 74% of failures). In non-Pa VAP, the system failed to detect penicillinase in 2 patients with Enterobacteriaceae, and ESBL in 2 patients with E. coli VAP. Excluding Pa VAP, and assuming that the Unyvero system had been used for choosing initial empirical treatment, it could have saved a median of 2 [2–3] days of broad-spectrum antibiotics in 24 patients, but with a potential inappropriate initial antimicrobial treatment in 2 patients (2 with ESBL not detected).
Conclusion: A strategy based on direct examination of BAL fluid followed by the P55 cartridge when the former is positive allows rapid identification of pathogen in 80% of patients with VAP. Excluding Pa VAP, mechanism of resistance could be correctly detected in 83% of VAP patients. Interventional studies are warranted to test the usefulness of this technique in an antimicrobial stewardship program. Acknowledgment: Curetis GmbH provided the P55 cartridges.
CO-26 Hemophagocytic lymphohistiocytosis in adult ICU patients: an epidemiological and clinical study
Sellami Walid1, Rafrafi Emel2, Ben Mrad Ines2, Hajjej Zied2, Bousselmi Radhouene2, Yengui Olfa2, Sammoud Walid2, Gharssallah Hedi2, Labbene Iheb2, Ferjani Mustapha2
1Montefleury, Tunis, Tunisia; 2Hôpital Militaire de Tunis, Tunis, Tunisia
Correspondence: Sellami Walid - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-26
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare yet life-threatening condition characterized by an inappropriate activation of lymphocytes and or histyocytes leading to an abnormal phagocytosis of blood cells. Prognosis and outcomes mainly depend on the precocity of diagnosis and specific treatment implementation. A few studies were interested in HLH occuring in ICU patients. The Purpose of the study was to describe epidemiological, clinical, paraclinical and therapeutic characteristics of HLH in ICU patients.
Patients and methods: It was a retrospective, descriptive and longitudinal study including 30 cases of HLH, assessed during a 5 years period in the intensive care unit. We included all patients who had evidence of hemophagocytosis in bone marrow smears (realized when HLH was suspected) and a H-score superior to 169.
Results: The mean age of our patients was 48.9 ± 17.6 years [17–80] with a female preavalence. Hypertension and diabetes were the most frequent comorbidities. Immunodepression was present in 5 patients. Shock and neurological disorders were the main causes of admission in ICU. Mean APACHE II and SOFA (admission) scores were respectively 22.6 and 8.2. Fever was the most common clinical presentation in SAM. The most common biological disorder was bicytopenia (anemia and thrombopenia). The mean H-score was 209.7 p. Hemodynamic and respiratory distress were the prevalent organ failures. Corticoïds and immunoglobuline were given respectively to 14 and 13 patients. Etoposid was taken by one patient. Infections were the largely predominant etiology of HLH with a clear prevalence of multidrug resistant bacterial infections. Mortality at day 28 was 40%. Septic shock was the leading cause of death. SOFA and APACHE II scores were the only predictive factors of mortality (p = 0.015 and p = 0.042).
Conclusion: Management a patient with HLH is challenging because of its rarity, its variable presentation and its association with a panel of disorders. A multidisciplinary approach is mandatory to determine the best therapeutic option for the patient.
CO-27 Effects of red blood cell transfusion on global oxygenation in anemic critically ill patients
Themelin Nicolas1 Biston Patrick1, Massart Jacqueline1, Piagnerelli Michael1
1CHU de Charleroi, Belgium
Correspondence: Themelin Nicolas - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-27
Introduction: Anemia and RBC transfusion as treatment are common in ICU patients. Neverthless, RBC transfusions are associated with increased morbidity and mortality. Restrictive strategy policy, based on a haemoglobin [Hb] level of 7 g dL, is the guideline to transfuse most of ICU patients. The aim of RBC transfusion is to avoid tissue hypoxia by improving oxygen delivery (DO2) and therefore oxygen consumption (VO2). This could suggest to combine [Hb] and some parameters reflecting the sytemic DO2 VO2 balance to decide to transfuse. This study aims to analyse the effects of RBC transfusion on the systemic oxygenation assessed by the (central) venous oxygen saturation (S(c)VO2), the lactate level, the venous-to-arterial carbon dioxyde pressure gradient (Pv-aCO2) and the ratio between cardiac index and O2 extraction (IC EO2), and to assess their usefulness in the transfusion decision.
Patients and methods: During 9 months, all adult patients transfused in the ICU of CHU-Charleroi Marie Curie were included except patients with active bleeding or without jugular or subclavicular catheter. The systemic oxygenation parameters have been measured before and after transfusion. Patients a priori have been grouped according to their initial S(c)VO2 (< or > 70%), to their cardiac (< or > 50% of a left ventricular ejection fraction) and septic status. The results are expressed in median and interquartile ranges. Comparisons were made by a Wilcoxon test.
Results: 86 RBC transfusions were made on 53 patients. For all patients, mean arterial pressure, [Hb] and S(c)VO2 increased significantly after transfusion ([Hb]: 7.4 [7–7.8] to 8.3 [7.7–8.8] g dL; MAP: 79 [69–90] to 82 [74–92] mmHg and S(c)VO2: 66 [60–73] to 69 [63–75] %; for all p < 0.001). Only patients with an initial S(c)VO2 < 70% improved it after transfusion (62 [58–65] to 66 [62–71] %; p < 0.001). The Pv-aCO2 was significantly higher in patients with an initial S(c)VO2 < 70% (8 [5–10] mmHg) but did not change after transfusion as [lactate] and IC EO2. These results are maintained whatever the cardiac or septic status.
Conclusion: A S(c)VO2 < 70% in anemic ICU patients compared to other systemic oxygenation parameters, seems to be useful to assess the transfusion requirement as indicator of a DO2 VO2 imbalance. It should be interesting to combine it with the [Hb] in the decision to transfuse anemic critically ill patient.
CO-28 Elderly patients with cancer in the ICU
Sirjacques Camille1, Ameye Lieveke1, Berghmans Thierry1, Paesmans Marianne1, Sculier Jean-Paul1, Meert Anne-Pascale1
1Institut Jules Bordet, Bruxelles, Belgium
Correspondence: Sirjacques Camille - Camille.Sirjacques@ulb.ac.be
Annals of Intensive Care 2018, 8(Suppl 1):CO-28
Introduction: There is very little data on the survival of elderly patients with cancer requiring admission to intensive care unit (ICU). The aim of the study is to evaluate in our department prognostic factors for hospital mortality and survival after hospital discharge for patients aged more than 65 years.
Patients and methods: This is a retrospective study including all patients aged more than 65 with a solid or hematological tumor admitted for acute complication in an oncological ICU over a 3 years period. In case of multiple admissions only the 1st admission was used for the statistical analyses.
Results: We recorded 311 admissions for 270 patients over the 3 years period. The main reasons for admission were cardiovascular (22%), respiratory (17%) and hemodynamic (13%). ICU and in-hospital mortality rates were respectively 10% (95% CI 6–13%) and 22% (95% CI 17–27%). Median survival after discharge from hospital was 7.8 months (95% CI 5.7–11.3). The identified prognostic factors for higher hospital mortality were non invasive ventilation use (OR 9.8, 95% CI 3.3–28.5), invasive mechanical ventilation use (OR 8.6, 95% CI 3.4–21.9) and the existence of a therapeutic limitation in the first 24 h (OR 3.1, 95% CI 1.5–6.6) (assessment of all covariates was restricted to the period of 24 h following ICU admission). After hospital discharge, prognostic factors for higher risk of death were Charlson’s score bigger than 8 (HR 2.73, 95% CI 1.93–3.86), SAPS II score bigger than 37 (HR 1.50, 95% CI 1.08–2.09), administration of amines in the first 24 h (HR 2.13, 95% CI 1.03–4.38) and the existence of a life-sustaining therapeutic limitation in the first 24 h (HR 2.35, 95% CI 48–3.73). A total of 77% of patients were able to benefit from an antineoplastic treatment after hospital discharge.
Conclusion: 78% of oncologic patients aged more than 65 years were discharged alive from hospitalization after an ICU stay and the large majority were still able to benefit from cancer treatment. Life-sustaining therapeutic limitation is directly related to hospital mortality and post-discharge survival.
CO-29 Clinical features and outcomes of central nervous system (CNS) infections in critically ill immunocompromised patients
Kerhuel Lionel1, Mariotte Eric1, Zafrani Lara1, Ghrenassia Etienne1, Ardisson Fanny1, Ekpe Kenneth1, Darmon Mickael1, Azoulay Elie1
1Hôpital Avicenne, Paris, France
Correspondence: Kerhuel Lionel - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-29
Introduction: Studies assessing outcomes of CNS infections in critically ill immunocompromised patients are scarce. We sought to describe clinical features and outcomes in this population.
Patients and methods: We conducted a retrospective observational study over a 13-year period (01, 2004–08, 2017). All patients admitted to the ICU, presenting with meningitis, encephalitis or brain abscess were included. All patients with the following diseases were considered: hematologic malignancy, solid tumor, solid organ transplantation, autoimmune disease and splenectomy. HIV patients were not included. Baseline characteristics and variables related to ICU admission, treatments, ICU outcomes and neurological status (Rankin scale 6 months after ICU discharge) were collected.
Results: Among the 182 patients admitted to our ICU for CNS infection, 64 were included. HIV patients (N = 45) and non-immunocompromised patients (N = 73) were not included. Among the 64 patients, 40 (63%) had hematological malignancies (in whom 6 received an allogeneic stem cell transplant), 8 (13%) solid tumors, 9 (14%) autoimmune diseases, 7 (11%) renal transplantations and 3 (5%) splenectomies. Thirty-four (53%) were male, with a median age of 55 [47; 64] years and a Performance Status of 1 [0; 2]. The main reason for ICU admission was mental confusion or coma (77%). Lumbar puncture was performed in 57 (89%) patients. CNS CT was performed in 51 patients and was abnormal in 14 (27%). Brain MRI was performed in 40 patients and was abnormal in 34 (85%). Meningitis accounted for 48% (n = 31), in whom 74% were microbiologically documented (Streptococcus pneumonia, Streptococcus spp. and Gram negative bacilli in 8, 3 and 3 cases, respectively). Encephalitis accounted for 31% (n = 20) of diagnoses, in whom 80% were microbiologically documented (tuberculosis, Herpes Simplex Virus and Human Herpes Virus 6 in 5, 3 and 3 cases, respectively). Brain abscess accounted for 20% (n = 13) of diagnoses, in whom 69% were microbiologically documented (Aspergillus and Nocardia in 4 and 3 cases, respectively). Median ICU length of stay was 7 [3; 18] days. Mechanical ventilation was performed in 35 (56%) patients. Vasopressors and renal replacement therapy were implemented in 25 (40%) and 2 (11%) patients respectively. ICU mortality was 32% (n = 20), and 25 (48%) patients were alive 6 months after ICU discharge with a good neurological status (Rankin < 4).
Conclusion: This study sheds light on clinical features and outcomes in immuncompromised patients with CNS infections. Determinants of mortality and comparative data across the main groups of CNS infections are being prepared.
CO-30 Cardiac involvement in patients with severe thrombotic thrombocytopenic purpura (TTP)
Fourmont Aude-Marie1, Zafrani Lara2, Mariotte Eric3, Galicier Lionel3, Merceron Sybille4, Bertinchamp Remi4, Lemiale Virginie3, Darmon Michael3, Veyradier Agnes3, Azoulay Elie3
110, Paris, France; 2HU Est-Parisien, 10, Paris, France; 3Hôpital Saint Louis, 10, Paris, France; 4CH de Versailles, 10, Paris, France
Correspondence: Fourmont Aude-Marie - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-30
Introduction: Cardiac involvement in patients with TTP is associated with high mortality. It might be undermined by the lack of operational definition and established diagnostic workup for cardiac TTP. The objectives of this study were to describe cardiac involvement in TTP patients and to assess prognostic value of each clinical sign.
Patients and methods: In a single center study, all adult patients admitted to our ICU between 2007 and 2017 with confirmed TTP (ADAMTS13 < 10%) were included and standardized diagnostic workup was performed. Cardiac signs included chest pain, changes in electrocardiogram, increase troponin level, new-onset changes in cardiac echography, cardiogenic shock, cardiac arrest.
Results: Among the 98 TTP patients (67 women, 65% non-Caucasian, age 43(32–53)), 28 had a cardiovascular comorbidity and 12 were HIV-infected. Half the TTP were idiopathic, 25 autoimmune, 5 drug-related and 4 surrounded pregnancies. At initial clinical evaluation organ involvement was present in all patients, including neurological (N = 77), cardiac (N = 76), renal (N = 50), or digestive (N = 32). All patients received urgent plasma therapy with a median number of plasma exchanges of 11(8–18) and all but 3 received steroids, including 28 who received bolus. 52 patients required a rescue therapy (49 rituximab, 21 vincristine, 4 cyclophopshamide, and 6 splenectomy). 68 patients required antihypertensive therapy, 24 mechanical ventilation, 18 vasopressors and 15 renal-replacement therapy. Cardiac involvement was observed in 89 (91%) patients. Namely, 23 patients exerted chest pain, 57 electrocardiogram changes, 70 (71%) increased troponin, and 6 cardiac arrest. Troponin was the only feature of cardiac involvement in 24 patients. In 13 patients, echocardiography identified focal or global hypokinesia. Anticoagulants were prescribed in 86 patients (58 prophylactic and 28 curative) and 88 patients received low dose aspirin. Hospital mortality was 9.4%. All the 9 patients without cardiac involvement survived. Cardiac involvement was associated with prolonged ICU stay (6 (4–7) vs. 8 (6–14), p = 0.04). By univariable analysis, factors associated with mortality included age, platelet count, status epilepticus, troponin level, cardiac arrest. Of striking finding, cardiac involvement of TTP was not associated with mortality or with adverse TTP outcome.
Conclusion: In patients with severe TTP, cardiac involvement is present in 90% of patients. In this cohort of patients receiving a second-line TTP therapy in half the cases, aspirin in 90% and anticoagulants in 88%, cardiac involvement was not associated with mortality suggesting that aggressive TTP management translates into improved outcomes.
CO-42 Use of alternatives to carbapenems for the treatment of EBSL Gram-negative bacilli severe infections in the ICU
Besset Sébastien1, Hékimian Guillaume1, Bréchot Nicolas1, Franchineau Guillaume1, Coutrot Maxime1, Bourcier Simon1, Nieszkowska Ania1, Schmidt Matthieu1, Combes Alain1, Luyt Charles-Edouard1
Hôpital Pitié-Salpêtrière, Paris, France
Correspondence: Besset Sébastien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-42
Introduction: The use of alternatives to carbapenems to treat patients with extended-spectrum beta lactamase-producing Gram negative bacilli (ESBL-GNB) infections remains controversial. Their use in patients with severe infections in the ICU has been poorly studied. The aim of this study was to compare the outcome of ICU patients having received carbapenems to those having received a carbapenem-sparing agent (CSA).
Patients and methods: The charts of patients with ESBL-GNB infection hospitalized in our ICU between 2015 and 2017 were retrospectively reviewed. Patients treated with betalactam betalactam inhibitor (BL BLI), cefepime or quinolones were considered has having received an alternative to carbapenems (CSA). Patients having received such a CSA were compared to those having received a carbapenems. Primary outcome was treatment failure at day 28, defined as ESBL-GNB infection recurrence (relapse with same pathogen) or death, whichever first occurred.
Results: 66 patients with ESBL–GNB infection were included. Source of infection was the lung for most of them. Characteristics of patients are displayed on Table 1. Their median SAPS II and SOFA scores were 59 [44–71] and 12 [7–15], respectively, and 38 (58%) were on septic shock. 40 patients received a carbapenem empirically, among whom 18 were switched to a CSA agent when antibiogram was available (CSA-definite group), whereas carbapenems were pursued in the 22 others (carbapenem-only group), mainly because pathogens were resistant to others antibiotics. Among the 26 patients having received a non-carbapenem agent as empirical treatment, pathogen was susceptible to this agent in 9 and they pursued the same treatment (CSA-only group), whereas 17 were switched to a carbapenem (pathogens resistant to empirical treatment, carbapenem-definite group). Treatment failure were not different among these 4 groups (Table 1). Globally, 27 patients received a CSA as their definite treatment (CSA-definite and CSA-only groups), whereas 39 received a carbapenems (carbapenems-only and carbapenems-definite groups). Whereas duration of antimicrobial treatment was similar (8 [6–10] days vs. 9 [7–10] days, respectively, p = NS), treatment failure rate was not higher in the former, as compared to those having received a carbapenems (29 vs. 71%, respectively, p = 0.049).
Conclusion: Treatment of patients with ESBL-GNB severe infection in the ICU with a CSA seems to be safe when the pathogen is susceptible to this CSA. However, MIC should be first determined before de-escalating to a CSA. Larger studies are needed.
CO-43 Is augmented renal clearance responsible for subtherapeutic ß-lactam antibiotic concentrations and therapeutic failure in critically ill patients? A prospective observational study
Petit Laurent1, Carrié Cédric1, Cottenceau Vincent1, Lafitte Mélanie1, D’Houdain Nicolas1, Breilh Dominique1, Sztark François1
1CHU PELLEGRIN, Bordeaux, France
Correspondence: Petit Laurent - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-43
Introduction: This study aimed to assess whether augmented renal clearance (ARC) impacts negatively on beta-lactam antibiotic unbound concentrations and clinical outcome in critically ill patients.
Patients and methods: Over a 9-month period, all critically ill patients treated by beta-lactam antibiotics for a microbiologically documented infection without renal impairment were eligible. During the first 3 days of antimicrobial therapy, every patient underwent 24-h creatinine clearance (CrCL) measurements and therapeutic drug monitoring. The main outcome investigated in this study was the rate of therapeutic failure, defined as an impaired clinical response with a need for escalating antibiotics during treatment and or within 15 days after end-of-treatment. The secondary outcome was the rate of pharmacokinetic pharmacodynamics (PK PD) target non-attainment defined by at least one sample under four times MIC of the known pathogen (subexposure < 4.MIC).
Results: Over the study period, 96 patients were included. The rate of therapeutic failure was 16%. Mean CrCL values over the first three days of antimicrobial therapy were significantly higher in patients with therapeutic failure (203 ± 63 vs. 163 ± 68 ml min, p = 0.04). Subexposure < 4.MIC was independently associated with therapeutic failure with an OR at 5.8 (1.3–25.4), p = 0.02. Patients with mean CrCL > 200 ml min presented higher risk of subexposure < 4.MIC with an OR at 5.1 (1.8–14.4), p = 0.002. The percentages of samplings which attained the PK PD targets for various CrCL are presented Fig. 1.
Conclusion: Our results suggested that (1) mean CrCL values > 200 ml min were associated with higher rates of sub-exposure < 4.MIC and (2) sub-exposure < 4.MIC was associated with higher rates of therapeutic failure. This study emphasizes the need of therapeutic drug monitoring in patients with ARC, especially when targeting less susceptible pathogens or surgical infections with limited penetration of antimicrobial agents. Whether those patients should benefit for increased dosing regimens should be evaluated by randomized controlled studies.
CO-44 Impact of renal replacement therapy strategies on beta-lactamine plasma concentrations: the BETAKIKI study: an ancillary study of a randomized controlled trial
Roux Damien1, Benichou Nicolas1, Hajage David1, Martin-Lefèvre Laurent2, De Prost Nicolas3, Lerolle Nicolas4, Maizel Julien5, Boulet Eric6, Mayaux Julien7, Mégarbane Bruno8, Mahjoub Khaoula9, Carpentier10, Dorothée, Nseir Saad11, Tubach Florence1, Ricard Jean-Damien11, Dreyfuss Didier7, Gaudry Stéphane1
1Hôpital Louis Mourier, Colombes, France; 2CHU de La Roche-sur-Yon, France; 3Hôpital Henri Mondor, Créteil, France; 4CHU d’Angers, Angers, France; 5CHU Amiens, Amiens, France; 6Hôpital René Dubos, Pontoise, France; 7Hôpital Pitié-Salpêtrière, Paris, France; 8Hôpital Lariboisière, Paris, France; 9Hôpital Delafontaine, Saint-Denis, France; 10CHU de Rouen, Rouen, France; 11CHU de Lille, France
Correspondence: Roux Damien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-44
Introduction: Critically-ill patients often receive antimicrobials. Early adequate antibiotic administration, usually including beta-lactams, improves prognosis of septic patients. However, beta-lactam pharmacokinetic as well as effect of renal replacement therapy (RRT) on beta-lactam concentrations have been hardly explored in ICU patients with acute kidney injury (AKI). We aimed to determine factors associated with potential suboptimal beta-lactam concentration in critically-ill patients with AKI treated either with an early or a delayed RRT strategy.
Patients and methods: Ancillary study in a subset of patients with severe AKI (KDIGO3), receiving a beta-lactam antibiotic, in a trial comparing two RRT initiation strategies. In this trial, patients from 31 intensive care units were randomly assigned to either an early (immediate RRT) or a delayed (late or no RRT) RRT initiation strategy. Beta-lactam residual concentrations were sampled at 24 and 48 h after inclusion. The appropriate concentration was defined as a trough of at least 4 times the minimal inhibitory concentration (clinical breakpoint of EUCAST). The primary outcome was an adequate plasma concentration of the beta-lactam during the first 2 days.
Results: Among the 233 patients included in the 11 centers participating to this ancillary study, a beta-lactam trough concentration was evaluated in 112 subjects, 53 in the early and 59 in the delayed groups. Ninety patients (80.4%) had an adequate beta-lactam dosage. RRT initiation strategy had no impact on beta-lactam concentration (p = 0.78). Among the 83 septic shock patients (74% of the sampled patients), 73 (88%) had a correct antibiotic concentration. In contrast, only 10 of the 16 patients without definite sepsis (62.5%) had a correct dosage. Factors associated with an adequate beta-lactam trough concentration in univariate analysis were admission for a septic shock (p = 0.002), a higher plasma creatinine level (p = 0.024), a higher mean arterial pressure (p = 0.018) and a lower serum bicarbonate level (p = 0.045) at randomization. A higher SOFA score was associated with an adequate beta-lactam concentration near to statistical significance (p = 0.053). Multivariate analysis will be presented.
Conclusion: In the context of severe AKI, beta-lactam concentration reached a sufficient level in 88% of septic shock patients. Interestingly, RRT initiation strategy was not associated with beta-lactam trough concentration. Early RRT did not affect trough concentration of beta-lactam. We may hypothesize that physicians were highly vigilant and adapted antibiotic administration adequately in these patients.
CO-45 Predictors of insufficient Amikacin peak concentration in critically ill patients on extracorporeal membrane oxygenation
Touchard Cyril1, Aubry Alexandra2, Bréchot Nicolas1, Lebreton Guillaume2, Besset Sebastien2, Franchineau Guillaume2, Hekimian Guillaume2, Nieszkowska Ania2, Leprince Pascal2, Luyt Charles-Edouard2, Combes Alain2, Schmidt2, Matthieu2
1Clinique du Parc, Aix-en-Provence, France; 2Hôpital Pitié-Salpêtrière, Paris, France; 3Clinique Saint George, Paris, France
Correspondence: Touchard Cyril - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-45
Introduction: Amikacin infusion requires to target a peak serum concentration (Cmax) 8–10 times the minimal inhibitory concentration, corresponding to a Cmax at 60–80 mg L−1 for the least susceptible bacteria. Recent study reported that 33% of critically ill patients do not attain this target with a 25 mg kg dose (1). Membrane sequestration, alteration of the volume of distribution and lack of data in this population make drugs pharmacokinetics (PK) on ECMO challenging. Our study aimed to assess the prevalence of insufficient Amikacin Cmax in critically ill patients on ECMO and to identify relative risk factors.
Patients and methods: Prospective, observational, monocentric study of adult patients on venoarterial (VA) or venovenous (VV) ECMO receiving a loading dose of Amikacin for suspected Gram-negative infections. Intravenous Amikacin was administered with a loading dose of 25 mg kg of total body weight and Cmax was measured 30 min after the end of the infusion. Independent predicators of Cmax < 60 mg L−1 after the first Amikacin infusion were identified by mixed model multivariate analysis.
Results: From January 2015 to February 2016, 106 patients (median SAPS 2 (interquartile range) 68(47–81); age 55(45–62) years) under VA-ECMO (68%) or VV-ECMO (32%) were included. At inclusion, the SOFA score was 15 (12–18) and 54 (51%) patients were on renal replacement therapy. Overall ICU mortality was 54%. Cmax was < 60 mg L−1 in 41 (39%) of the patients. Independent risk factors of amikacin under-dosing were body mass index (BMI) < 22 kg m−2 (Odds Ratio (OR) 6.38, 95% confidence interval 95%CI 1.8–22.8, p = 0.043) and a positive 24 h fluid balance (OR per 500 mL increment: 1.28, 95%CI 1.05–1.65, p = 0.041) (Fig. 1). Our results were comparable to those observed in patients treated with Amikacin without ECMO (1).
Conclusion: This large prospective study suggests that the prevalence and associated risk factors of Amikacin under-dosing are similar in critically-ill patients with or without ECMO. The use of a 30 mg kg dose in low BMI patients and in those with a positive 24-h fluid balance on ECMO is strongly encouraged to obtain adequate therapeutic targets and prevent therapeutic failure.
de Montmollin E, Bouadma L, Gault N, Chemam S, et al. Predictors of insufficient amikacin peak concentration in critically ill patients receiving a 25 mg kg−1 total body weight regimen. Intensive Care Med. 2014.
CO-46 BLInD: Beta-Lactams Induced Delirium? A pilot feasibility study
Van Grunderbeeck Nicolas1, Klapka-Petit Elisa1, Alexandrzak Perrine1, Temime Johanna1, Pouly Olivier1, Bignon Anne2, Boulo Marie2, Mallat Jihad1, Hennart Benjamin2, Thevenin Didier1
1CHU de Lens, France; 2CHRU Lille, Lille, France
Correspondence: Van Grunderbeeck Nicolas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-46
Introduction: Delirium is frequent in the ICU and has impact on morbidity and mortality. Broad-spectrum beta-lactams (BL) are daily used and may have neurological side effects, notably in cases of overdosing. We aimed to assess impact of BL overdosing on confusion through a validated method, the CAM ICU (Confusion Assessment Method for the ICU) as a primary endpoint, and to look for pharmacokinetic factors associated with respect of the BL therapeutic index as a secondary objective.
Patients and methods: Prospective observational study–pilot study in two centers. Patients treated with broad spectrum BL for more than 48 h to treat sepsis or septic shock in the ICU could be included. Delirium was assessed through CAM-ICU, and determined group of inclusion: delirium patients or control group. Exclusion citeria were RASS inferior or equal to: 3, imipenem, and other obvious causes of neurologic failure (stroke, poisoning, previous neurological disorders). BL concentrations were measured at peak and trough for intermittent and extended perfusion, and at plateau for continuous perfusion, by high performance chromatography coupled with mass spectrometry. Data were expressed as median [25–75%, interquartile range]. Statistical were performed by Mann–Whitney U test and Pearson test. Analysis referred to delirium factors and betalactams’ concentrations, and PK factors (obesity, renal failure, hypoalbuminemia) and overdosing.
Results: Fifty patients were included (29 with delirium, 21 controls), at day 4 for controls and day 5 for patients with confusion. Delirium patients were more severely ill SOFA 5 [3; 9] versus 3[1; 5] (p = 0.05); with higher RASS 1[0; 2] versus 0[0; 0] (p = 0.05). They presented with 41% BL overdosing versus 19% in controls (p = 0.09); with 41% of BL in therapeutic index: 71% in controls (p = 0.04). Obesity and renal failure were not associated with BL overdosing but there was a trend with hypoalbuminemia (p = 0.09).
Discussion: Trend in association of BL overdosing with delirium corresponds to previous studies, and would need a larger scale study to be confirmed. Severity differences in groups would need changes in inclusion criteria to obtain homogeneous groups. A possible association of BL underdosing with poor evolution of infection and organ failures would need more precise evaluation. Hypoalbuminemia could have an impact on BL overdosing.
Conclusion: Delirium was not associated with BL overdosing but with therapeutic index. A high variability of BL concentrations warrants therapeutic drug monitoring. A larger scale study should include changes in design.
CO-47 Feasibility and safety of low-flow extracorporeal CO2 removal with a renal replacement platform to enhance lung protective ventilation in patients with mild to moderate ARDS
Schmidt Matthieu1, Jaber Samir1, Constantin Jean-Michel1, Capellier Gilles1, Zogheib Elie1, Combes Alain1
1Hopital Pitié Salpetrière, Paris, France
Correspondence: Schmidt Matthieu - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-47
Introduction: Extracorporeal carbon dioxide removal (ECCO2R) might allow ultraprotective mechanical ventilation with lower tidal volume (VT) (< 6 mL kg ideal body weight), plateau pressure (Pplat) (< 30 cm H2O), driving pressure, and respiratory rate (RR) to reduce ventilator induced lung injury (VILI). The aim of this study was to assess the feasibility and safety of ECCO2R with a renal replacement platform (RRT) to permit ultra-protective ventilation in patients with mild to moderate acute respiratory distress syndrome (ARDS).
Patients and methods: Twenty patients with mild (n = 8) or moderate ARDS were included. VT was gradually reduced from 6 to 5, 4.5 and 4 mL kg−1 and PEEP adjusted to reach 23 > Pplat > 25 cm H2O. Stand-alone ECCO2R (no hemofilter associated on the RRT platform) was initiated when arterial PaCO2 increased by more than 20%. Ventilation parameters (VT, RR, PEEP), respiratory compliance, driving pressure, arterial blood gases, and ECCO2R system operational characteristics (blood flow, sweep gas flow, and CO2 removal rate) were collected during a minimum of 24 h of ultra-protective ventilation. Complications, mortality at day 28, need for adjuvant therapies and data on weaning from both mechanical ventilation and ECCO2R were also collected.
Results: While VT was reduced from 6 to 4 mL kg−1 and Pplat kept below 25 cm H2O, PEEP was significantly increased from 13.4 ± 3.6 at baseline to 15.0 ± 3.4 cm H2O at VT = 4 mL kg−1. As a result, the driving pressure was significantly reduced to 7.9 ± 3.2 cm H2O at VT = 4 mL kg−1 (p < 0.05) (Fig. 1). No significant differences in RR, PaO2 FiO2 ratio, respiratory system compliance were observed after Vt reduction. Mean extracorporeal blood, sweep gas flow and CO2 removal were 421 ± 40 mL min−1, 10 ± 0.3 L min−1 and 51 mL min−1, respectively. Mean treatment duration was 31 ± 22 h. Main side effects related to ECCO2R were membrane clotting which occurred in 7 patients after 19 ± 9 h.
Conclusion: A low-flow ECCO2R device driven by a RRT platform efficiently removed CO2 while allowing ultra-protective mechanical ventilation settings in patients with mild to moderate ARDS (ClinicalTrials.gov identifier: NCT02606240).
CO-48 Afterload burden on the right ventricle is enhanced when ARDS is associated with hypercapnic acidosis
Morimont Philippe1, Habran Simon1, Desaive Thomas1, Janssen Nathalie1, Amand Theophile1, Blaffart Francine1, Dauby Pierre1, Kolh Philippe1, Defraigne Jean-Olivier1, Lambermont Bernard1
1CHU de Liège, Liège, Belgium
Correspondence: Morimont Philippe - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-48
Introduction: Protective lung ventilation (PLV) is recommended in patients with acute respiratory distress syndrome (ARDS) to minimize additional injuries to the lung. However, increased right ventricular (RV) afterload resulting from ARDS could be enhanced by hypercapnic acidosis resulting from ventilation at lower tidal volume. Relative contribution of these factors (ARDS and PLV) in RV afterload is not clearly established. The aim of this study was to compare RV afterload in ARDS combined with PLV to RV afterload in PLV alone.
Patients and methods: This study was performed in an experimental model of severe hypercapnic acidosis performed in 2 series of 6 pigs. In both groups, respiratory tidal volume was decreased by 60%. In the first group (ARDS group), an ARDS (obtained by repeated bronchoalveolar lavage) was performed before reducing ventilation, while in the second group (control group), hypercapnic acidosis was resulting from low tidal volume ventilation alone.
Results: In both groups, systolic pulmonary artery pressure (PAPs) significantly increased during PLV. This increase was significantly higher in ARDS group than in control group (Fig. 1). Severe hypercapnic acidosis occurred in both groups: PaCO2 increased from 41.7 ± 3.6 to 78.6 ± 8.1 (p < 0.01) and arterial pH decreased from 7.44 ± 0.05 to 7.13 ± 0.04 (p < 0.01) in ARDS group while PaCO2 increased from 37.7 ± 9.4 to 93.6 ± 6.4 (p < 0.01) and arterial pH decreased from 7.48 ± 0.05 to 7.11 ± 0.04 (p < 0.01) in control group. PaO2 significantly decreased in ARDS group (178 ± 42 to 54 ± 12.3 mmHg, p < 0.01) but did not significantly changed in control group.
Conclusion: Isolated hypercapnic acidosis resulting from PLV was clearly responsible for increased RV afterload and this effect was significantly enhanced in ARDS. Pulmonary vasoconstriction resulting from hypercapnic acidosis is strongly enhanced by factors like hypoxia, endothelial injuries or inflammatory mediators in ARDS. Extracorporeal CO2 removal could be the solution to limit afterload burden on the right ventricle when PLV is achieved during ARDS.
CO-49 Effect of prone positioning on transpulmonary driving-pressure in ARDS patients: a pilot study
Persichini Romain1, Jozwiak Mathieu2, Teboul Jean Louis2, Richard Christian2, Monnet Xavier2
1CHU de La Réunion, Saint Denis, France; 2Le Kremlin-Bicêtre, Saint Denis, France
Correspondence: Persichini Romain - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-49
Introduction: Prone positioning has been shown to improve mortality in acute respiratory distress syndrome (ARDS) patients. The respiratory system driving-pressure (DPRS) and the transpulmonary driving-pressure (DPL), measured with esophageal manometry, have been shown to be strongly correlated with mortality. The aim of this study was to investigate the evolution of the DPL during prone positioning and its relationship with evolution of oxygenation in ARDS patients.
Patients and methods: Ten patients with ARDS equipped with esophageal manometry were enrolled. DPRS, DPL and chest wall driving-pressure (DPCW) were measured before and 1 h after prone positioning. Respiratory system, pulmonary and chest wall elastance (ERS, EL, ECW) were calculated at the same time. Finally, we studied the correlation between these respiratory variables and oxygenation indicators. Patients were classified as responders to prone positioning if the change in the ratio of arterial oxygen partial pressure oxygen inspired fraction (Delta.PaO2/FiO2) induced by the manoeuvre was larger than the median value observed in the group.
Results: In the whole population, median value of Delta.PaO2/FiO2 was 53.5 mmHg, and 5 patients were classified as responders and 5 as non-responders. In responders, DPL significantly decreased from 8.8 ± 4.1 cm H2O to 5.9 ± 5.4 cm H2O (p = 0.02) and EL decreased from 21.9 ± 5.1 cm H2O L to 14.9 ± 6.5 cm H2O L (p = 0.02) after prone positioning. Other respiratory variables did not change. In non-responders, respiratory variables did not change. Between responders and non-responders, there was no significant difference between baseline respiratory variables. After prone positioning, Delta.PaO2/FiO2 was not related to baseline respiratory parameters. On the contrary Delta.PaO2/FiO2 induced by prone positioning was strongly correlated with changes in DPL (r = − 0.70, p = 0.02) and changes in EL (r = − 0.69, p = 0.03). We did not find any correlation between Delta.PaO2/FiO2 and changes in DPCW or changes in ECW. The correlation between Delta.PaO2/FiO2 and changes in DPRS (r = − 0.56, p = 0.09) and changes in ERS (r = − 0.55, p = 0.10) did not reach significance.
Conclusion: In patients who respond to prone positioning by the highest improvement in oxygenation, DPL significantly decrease after prone positioning. The changes in DPL and the changes in EL play a major role in the improvement in oxygenation induced by prone positioning whereas the changes in DPCW and ECW do not.
CO-50 A prospective international observational prevalence study on prone positioning ARDS patients: the APRONET (Ards PROne position NETwork) study
Guerin Claude1, Beuret Pascal2, Constantin Jean-Michel3, Bellani Giacomo4, Baboi Loredana5, Mercat Alain6, Chretien Jean Marie6, François Guy8, Ayzac Louis9
1Hôpital de la Croix Rousse, Lyon, France; 2CH Roanne, France; 3CHU Clermont-Ferrand, France; 4Monza, Italie; 5Hôpital de la Croix Rousse, Lyon, France; 6CHU Angers, France; 8Bruxelles, Belgique; 9CHU de Lyon, France
Correspondence: Guerin Claude - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-50
Introduction: Whereas prone positioning (PP) has been shown to improve patient survival in moderate to severe ARDS patients, its rate of use was 7.4% in Lung Safe study. However, Lung Safe study was not specifically focused on PP. Therefore, present study aimed to determine prevalence of use of PP in ARDS patients (primary end-point), physiologic effects of and reasons for not using PP (secondary end-points).
Patients and methods: The APRONET study was a prospective international one-day prevalence study performed 4 times in April, July, October 2016 and January 2017. At each study day, investigators had to screen every patient staying in ICU from 0 to 24 h and to fill electronic CRF. For patients with ARDS (defined from the Berlin definition criteria) at each study day oxygenation and ventilator settings were recorded. For those receiving PP these variables were recorded before and at the end of PP session. The reasons for not proning were also collected. Values are presented as median (1st–3rd quartiles). Prevalence rates of PP were compared by using Chi square for trend and groups were compared with nonparametric tests.
Results: In the study period 6723 patients were screened in 141 ICUs from 21 countries, of who 735 with ARDS were analyzed. Over the four study days, one-hundred and two ARDS patients received at least one proning session (13.2%). The prevalence of prone positioning in ARDS patients was not significantly different between study days: 13.8% (33 240), 12.6% (18 143), 15.3% (24 157) and 13.8% (27 195) (p = 0.83, Chi square for trend). Over the four study days merged, the rate of PP use was 5.9% (11 187), 10.3% (41 399), 32.9% (49 149) in mild, moderate and severe ARDS, respectively (p = 0.0001). The duration of the first PP session was 18 [16–23] hours. Between supine before PP and end PP, PaO2 FIO2 ratio significantly increased from 101 [76–136] to 171 [118–220] mmHg (p = 0.0001), driving pressure significantly decreased from 14 [11–17] to 13 [10–16] cm H2O (p = 0.001). The main reason for not proning was not severe enough hypoxemia (472 734 reasons for not proning 633 ARDS patients, 64.3%).
Conclusion: Present study found a higher rate of PP use in severe ARDS patients than in the Lung Safe study, which could reflect change in practice or ICU selection bias.
CO-51 Treatments and outcomes of severe hypoxemic patients in French speaking ICUs: a subgroup analysis from the SPECTRUM study
Hraiech Sami1, Grimaldi David2, Boissier Florence3, Barbar Saber4, Brouard Florence5, Da Silva Daniel5, Ehrmann Stéphane7, Hamzaoui Olfa7, Kimoune Antoine7, Lacherade Jean-Claude9, Lascarrou Jean-Baptiste10, Michel11, Philippe, Piton Gaël12, Youssoufa Atika13, Muller Grégoire13, Aissaoui Nadia14, Cerc Cerc15
1Hôpital Nord, Marseille, France; 2Bruxelles, Belgique; 3CHU de Poitiers, France; 4CHU de Nîmes, France; 5CHU de Perigueux, France; 6CHU de Tours, France; 7CHU Paris-Sud, Paris, France; 9CHU de La Roche-Sur-Yon, France; 10CHU de Nantes, France; 11CHU de Pontoise, France; 12CHU de Besançon, France; 13CHU de Marseille, France; 14Hôpital Européen Georges Pompidou, Paris, France; 15(on Behalf Of The Srlf Trial Group), France
Correspondence: Hraiech Sami - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-51
Introduction: Although acute respiratory distress syndrome (ARDS) has been largely focused on, few data are available concerning hypoxemia independently of its cause in intensive care unit (ICU) patients. A recent prevalence-point-day (PPD) evaluated the patterns and outcomes of hypoxemia in French speaking ICUs. Here, we describe the main etiologies, management and outcomes of the patients of this cohort presenting with severe hypoxemia.
Patients and methods: A PPD was conducted among 117 French speaking ICUs during spring 2016. Hypoxemia was defined by a PaO2 FiO2 ratio below 300. We analyzed the data from patients with severe hypoxemia (i.e. with a PaO2 FiO2 ratio < 100) and compared their characteristics (causes of hypoxemia, ventilatory and non-ventilatory management) and outcomes to the patients with mild or moderate hypoxemia.
Results: Among the 859 hypoxemic patients the day of the study, 74 (9%) had severe hypoxemia. The main cause of hypoxemia was pneumonia and this diagnosis was more frequent than in mild and moderate hypoxemia. Whereas bilateral radiologic infiltrates were present in 56 (84.9%) patients, ARDS was diagnosed by physicians in only 30 (40.5%) of them. Invasive mechanical ventilation (MV) was used in 55 (74.3%) patients. High flow oxygen was administered in 11 (14.9%) of them and 8 (10.8%) were under non-invasive ventilation (NIV) the day of the study. Median Vt was 6.1 (4.8–6.6) ml kg of IBW. Positive end-expiratory pressure (PEEP) was higher than in mild and moderate hypoxemic patients (10 (8–12) vs. 5 (5–8) and 7 (5–10) cm H2O respectively, p < 0.001). Median plateau pressure was 25.5 (23–29.5) and was higher than in mild and moderate groups. Median driving pressure was 13 (10–19) cm H2O with no difference when compared to other groups. Neuromuscular blocking agents were administered in 28 (51.9%) patients, inhaled nitric oxide (iNO) in 7 (13%) patients and only 6 patients (11.1%) were on prone positioning. Fourteen (18.9%) patients were under extracorporeal membrane oxygenation (ECMO). ICU mortality was higher in severe hypoxemic patients as compared to mild and moderate (50.7 vs. 21.3 and 28.5% respectively, p < 0.001). ICU length of stay in ICU survivors was not statistically different between groups.
Conclusion: Severe hypoxemia, independently from ARDS, worsens the prognosis of ICU patients. Even though ARDS might be underdiagnosed, a protective ventilation was respected in severe hypoxemic patients.
CO-57 Determinants of ICU-acquired infections in septic shock in the current era
Llitjos Jean-François1, Gassama Aïcha1, Jamme Matthieu1, Charpentier Julien1, Cariou Alain1, Chiche Jean-Daniel1, Mira Jean-Paul1, Pene Frederic1
1Hôpital Cochin, Paris, France
Correspondence: Llitjos Jean-François - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-57
Introduction: Major changes in septic shock management raise the questions of the relevance of the classical risk factors of nosocomial infections in the current era and the link with the primary infectious insult. We herein investigated the risk factors and the outcomes of ICU-acquired infections in a recent cohort of septic shock patients.
Patients and methods: This was a 9-year (2008–2016) monocenter retrospective study. All adult patients diagnosed for septic shock within the first 48 h were included. Septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. Patients who survived the first three days were eligible for assessment of the risk of the first ICU-acquired infections. The diagnosis of nosocomial infections were based on current international guidelines. Patients were classified according to the development of pulmonary or non-pulmonary ICU-acquired infections. The determinants of ICU-acquired infections were addressed in a multivariate logistic regression analysis.
Results: 938 patients were admitted for septic shock. 788 patients remained alive in the ICU after the first three days and could then be evaluated for the risk of ICU-acquired infections. Hence, 554 patients remained free of secondary infections, 138 patients first developed an episode of nosocomial pneumonia and 96 patients first developed an episode of non-pulmonary infection. The mortality rates of patients with ICU-acquired pneumonia, non-pulmonary ICU-acquired infections and without secondary infections were 49, 49 and 14%, respectively (p = 0.0001). In multivariate analysis, the development of ICU-acquired pneumonia was independently associated with male gender (OR 2.23, CI 95% [1.28–3.48], p = 0.003), renal replacement therapy (OR 2.15, CI 95% [1.35–3.42], p = 0.001), platelet transfusion (OR 2.38, CI 95% [1.4–4.04], p = 0.001) and a primary pulmonary infection (OR 8.06, CI 95% [2.69–24.12], p < 0.001). The development of non-pulmonary infections was independently associated with renal replacement therapy (OR 4.6, CI 95% [2.7–7.85], p < 0.001), fresh frozen plasma transfusion (OR 2.49, CI 95% [1.42–4.37], p = 0.001), healthcare-associated septic shock (OR 1.8, CI 95% [1.1–2.91], p = 0.01).
Conclusion: ICU-acquired pneumonia occurs preferentially in patients with septic shock of pulmonary origin. In addition, we identified the transfusion of blood products as a risk factor for pulmonary and non-pulmonary nosocomial infections.
CO-58 Albumin infusion had protective endothelial effects in septic shock patients
Hariri Geoffroy1, Joffre Jérémie1, Mialhe Arnaud-Felix1, Bigé Naïke1, Dumas Guillaume1, Deryckere Stéphanie1, Baudel Jean-Luc1, Maury Eric1, Guidet Bertrand1, Aït-Oufella Hafid1
1Hôpital Saint-Antoine, Paris, France
Correspondence: Hariri Geoffroy -email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-58
Introduction: Human serum albumin is used for the restoration of blood volume, emergency treatment of septic shock patients. Several experimental studies suggested that albumin could have additional protective effects on the vascular wall and more specifically on endothelial functions. However, the in vivo effect of albumin in human endothelium remains unknown. The aim of this study is to assess the effect of albumin or saline infusion on skin endothelial function in septic shock patients requiring volume expansion.
Patients and methods: We performed a prospective randomized monocentric study in an 18-bed medical intensive care unit. All patients with septic shock who required fluid administration were included between H6 and H24 after vasopressor starting. Patients were randomized to receive either 500 ml of saline solution 0.9% or 100 ml of albumin 20%. Norepinephrine dose was not modified 1 h before and during the procedure. Endothelium-dependant vasodilatation in the skin circulation was assessed by iontophoresis of acetylcholine before and after fluid administration. The improvement of skin blood flow in response to acetylcholine after fluid administration was compared between groups. For each patient, age, sex, SAPS II, site of infection, global hemodynamic parameters and clinical microcirculatory parameters were recorded. Results are expressed as mean ± SD. Qualitative data were compared using Chi-2 or Fisher’s exact test while quantitative data comparisons used Student t Test or Mann–Whitney as appropriate.
Results: Twenty-two patients were included (12 women, age: 79 ± 17, SAPS II: 42 ± 12). Twelve patients received saline and 10 received albumin. Apart from age, no statistical difference was found between groups regarding demographic characteristics and baseline hemodynamic parameters. Norepinephrine dose and mean volume of infused fluid before inclusion was not different between groups (Table 1). Before fluid replacement, endothelial response to acetylcholine iontophoresis was not different between groups (AUC 3514 vs 3378; p = 0.16). Volume expansion induced a slight increase of systolic arterial pressure, significantly higher in the albumin group (7 vs 2%; p = 0.02) with no difference regarding cardiac output variations between groups. Next, we compared the variations of endothelium response to iontophoresis before and after fluid infusion. The improvement of endothelial response after acetylcholine challenge was significantly higher in the albumin group (196 vs 44%, p = 0.01).
Conclusion: In the early stage of septic shock resuscitation, we showed that albumin infusion had protective endothelial effects. This result has to be confirmed in a larger cohort.
CO-59 Early identification of sepsis-associated encephalopathy with EEG is not associated with short-term cognitive dysfunction
Maenhout Christelle1, Ferlini Lorenzo1, Crippa Ilaria Alice1, Taccone Fabio1, Créteur Jacques1, Peigneux Philippe1, Gaspard Nicolas1
1ULB - Hôpital Erasme, Bruxelles, Belgium
Correspondence: Maenhout Christelle - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-59
Introduction: Encephalopathy occurs in 75% of patients with sepsis and is associated with short-term mortality and long-term cognitive disability among survivors. It is currently unclear what is the gold standard to detect SAE, how it can be prevented, and how evolution to long-term disability can be prevented. The aims of this study were to determine which clinical scales are altered after sepsis and if acute encephalopathy is associated with short-term cognitive impairment.
Patients and methods: We prospectively included adult patients with sepsis between January 2016 and September 2017. Exclusion criteria were encephalopathy from another etiology, psychiatric disorder, recent sepsis or cardiac surgery. We assessed consciousness twice daily (with the Confusion Assessment Method for the ICU [CAM-ICU], Glasgow Coma Scale [GCS], Full Outline of UnResponsiveness [FOUR], Coma Recovery Scale-Revised [CRS-R], and Reaction Level Scale 85 [RLS85]). All patients received continuous EEG monitoring for up to 7 days after admission. We assessed encephalopathy using a modified Synek scale. After discharge from ICU, we assessed cognitive functions (with the Montreal Cognitive Assessment [MOCA], the Frontal Assessment Battery [FAB], and the Language Screening Test [LAST]). A healthy control group of 18 adults was used for comparison.
Results: We enrolled 38 patients, all with EEG demonstrated encephalopathy. Clinical tools identified encephalopathy in 57 (42% + positive CAM-ICU), 147 (72% + GCS < 15) + 113 (55% + FOUR < 16) + 140 (69% + CRS-R < ) and 139 assessments (68% + RLS85 > 1). We found significant correlations between clinical and EEG assessment (GCS-Eye [R2 = .35], GCS-Verbal [R2 = .43], GCS-Motor [R2 = .375], FOUR-Eye [R2 = .363], FOUR-Motor [R2 = .344], FOUR-Brainstem [R2 = .183], FOUR-Respiration [R2 = .38], CRS-R [R2 = .432], and RLS85 [R2 = .418] + all p < .001). We found no correlation between cognitive scores at hospital discharge and the severity of EEG-defined encephalopathy during the 7 days of ICU or during the first 48 h after admission. However, sepsis survivors’ scores were lower than controls’ (p < .001) (Table 1).
Conclusion: In this study, EEG was more sensitive than clinical tools to detect SAE but clinical scales correlated with the EEG grade. Encephalopathy was not associated with short-term cognitive function. Further study and a larger cohort are needed to determine which early EEG features can identify patients who will develop short-term and long-term cognitive dysfunction.
CO-60 Cerebral autoregulation during septic shock
Crippa Ilaria Alice1, Vincent Jean-Louis1, Creteur Jacques1, Subirà Carles2, Taccone Fabio1
1Université Libre de Bruxelles, Belgium; 2Althaia Xarxa Assistencial Universitària, Manresa, Spain
Correspondence: Crippa Ilaria Alice - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-60
Introduction: Sepsis associated encephalopathy (SAE) is associated with increased morbidity and mortality. Its pathophysiology is incompletely elucidated but a possible impairment of cerebral autoregulation (CAR) could result in brain hypoperfusion and neuronal damage (1, 2). We studied CAR in septic patients to test the hypothesis that its alteration is associated with SAE.
Patients and methods: We studied 96 adult patients with sepsis (July 2015–August 2017). Exclusion criteria were—intracranial disease; arrhythmias; extracorporeal membrane oxygenation; and any supra-aortic arteriopathy. Transcranial Doppler (DWL, Germany) was performed, insonating the left middle cerebral artery (LMCA) with a 2 MHz probe. LMCA blood flow velocity (FV) and arterial blood pressure (BP) signals were simultaneously recorded; Pearson´s correlation coefficient between BP and FV (Mxa) was calculated using MATLAB (MathWorks, USA). Impaired CAR was defined as Mxa > 0.3 (3). All data are reported as median [IQR], n (%).
Results: Age was 62 [52–71] years + APACHE II score was 21 [15–26] + 70 96 patients were treated with norepinephrine (0.15 [0–0.5] mcg min). Site of infection was mainly abdominal (45%) or pulmonary (28%). ICU length of stay was 7[4–12] days. Seventy-two patients (75%) were alive at ICU discharge. Mxa was 0.27 [0.02–0.62]. CAR was impaired in 46 patients (48%) overall. SAE was diagnosed in 54 patients (56%). CAR was altered in 31 54 (57%) patients with SAE and 15 41 (36%) patients without SAE (p = 0.06). In univariate analysis (Table 1), Mxa and history of arteriopathy were different in patients with and without SAE + the differences persisted in a multivariate analysis (p < 0.05).
Conclusion: CAR was altered in nearly half of the patients with sepsis. Mxa was higher in patients with than without SAE.
CO-61 Bedside assessment of resistance to corticotherapy in adults with sepsis
Sivanandamoorthy Sivanthiny1, Heming Nicholas1, Meng Paris1, Maxime Virginie1, Chevret Sylvie2, Annane Djillali1
1Hôpital Raymond Poincare, Garches, France; 2Hôpital Saint-Louis, Paris, France
Correspondence: Sivanandamoorthy Sivanthiny - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-61
Introduction: There is growing evidence that corticotherapy improves survival from septic shock. This observational study aimed at evaluating at bedside resistance to corticosteroids in adults with sepsis.
Patients and methods: Participants—ICU adults with septic shock or without sepsis admitted to the Raymond Poincaré university hospital. We also evaluated 10 healthy controls. Intervention—resistance to corticosteroids was assessed using a skin test. 10 µl of dermocorticoid cream (class III, Betamethasone) was applied on a 3 cm2 surface of the skin. At 24 h, two independent physicians scored the blanching of the skin from 0 to 4—0- no blanching + 1- < 50% of surface + 2- 50 to 75% of surface + 3- 75 to 100% of surface, and 4- blanching beyond application area. Cohen’s kappa was used to measure concordance. A mean score of < 2 indicated corticoresistance and a score of 4 indicating normal sensitivity to corticosteroids. We also performed a 250 µg ACTH test.
Results: We enrolled 110 patients, 47 patients with septic shock (22 males, SAPSII 34 [6–114]) and 63 patients without sepsis (28 males, SAPSII 30 [6–100]). Overall, 81 95 (85%) with two measurements patients had concordant evaluation of score by the two physicians + while 14 had a difference of 1-point in scores, resulting in a kappa of 0.78 (95% CI 0.65–0.91). In patients with septic shock, 32 (78%) have corticoresistance, i.e. a mean score < 2, 8 (20%) a score of 2 or 3, and 1 (2%) has normal sensitivity to corticosteroids. In non-septic critically ill, 30 (56%) have corticoresistance, 20 (37%) a mean score of 2–3, and 4 (7%) have normal sensitivity to corticosteroids. Hence, as compared to non-septic patients, patients with septic shock were more likely to have corticoresistance (p = 0.04).
Discussion: Topic application of corticosteroids on the skin results in activation of glucocorticoid receptors present within the vessels. Subsequently, activation of lipocortin 1 may inhibit the activity of phospholipase A2, regulator of prostaglandins, leucotrienes and platelet activating factor. Then, the coupling of alpha adrenoreceptors to their agonists is potentiated, increasing vessels smooth muscles sensitivity to catecholamines. The subsequent local vasocontriction is reflected by skin blanching. Thus, the observed lack of skin blanching in septic patients may reflect altered coupling between gluocorticoids and glucocorticoids receptors.
Conclusion: Roughly one out of two adults with septic shock may develop a resistance to corticosteroids as assessed by a skin blanching test in response to betamethasone.
CO-62 Short term antibiotics prevents early VAP in patients treated with mild therapeutic hypothermia after cardiac arrest
Daix Thomas1, Cariou Alain2, Clere-Jehl Raphaël3, Dequin Pierre-François4, Guitton Christophe5, Deye Nicolas6, Plantefève Gaëtan7, Quenot Jean-Pierre8, Desachy Arnaud9, Kamel Toufik10, Bedon-Carte Sandrine11, Diehl Jean-Luc12, Nicolas Chudeau13, Karam Elias14, Renon-Caron Françoise1, Vignon Philippe1, Le Gouge Amélie4, François Bruno1
1CHU Dupuytren, Limoges, France; 2HU Paris-Centre, Paris, France; 3Hôpital civil, Strasbourg, France; 4CHU Bretonneau, Tours, France; 5CHU de Nantes, Nantes, France; 6CHU Lariboisière, Paris, France; 7CH Victor Dupouy, Argenteuil, France; 8CHU de Dijon, France; 9CH d’Angoulême, France; 10CHR Orléans, Orléans, France; 11CH de Périgueux, France; 12HU Paris-Ouest, Paris, France; 13CHU Le Mans, France; 14CHU de Brive La Gaillarde, France
Correspondence: Daix Thomas - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-62
Introduction: Mild therapeutic hypothermia, currently recommended in the management of cardiac arrests with shockable rhythm could promote infectious complications and especially ventilator-associated pneumonia (VAP) (Mongardon et al. Crit Care Med 2011). Despite high incidence of VAP and retrospective trials suggesting a benefit of short-term (48 h) antibiotics in this setting (Davies et al. Resuscitation 2013), systematic use of antibiotic prophylaxis is not recommended in patients treated with mild therapeutic hypothermia after cardiac arrest. The primary objective was to demonstrate that systematic short-term antibiotic prophylaxis with amoxicillin-clavulanic acid can reduce incidence of early VAP (< 7 days) in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest. Secondary objectives were its impact on incidence of late VAP and on Day 28 mortality.
Patients and methods: Multicenter two parallel-group double-blinded randomized trial. Adult patients hospitalized in ICU, mechanically ventilated after out-of-hospital resuscitated cardiac arrest related to initial shockable rhythm and treated with mild therapeutic hypothermia were eligible. Exclusion criteria were pregnancy, need for extracorporeal life support, ongoing antibiotic therapy or pneumonia, known chronic colonization with multiresistant bacteria, known allergy to beta-lactam antibiotics and moribund patients. Patients received either intravenous injection of amoxicillin-clavulanic acid (1 g 200 mg) or placebo three times a day for 2 days. The primary endpoint was the onset of early VAP. All suspected pulmonary infections were adjudicated by a blinded independent committee.
Results: Out of 198 patients included, 196 were finally analyzed, 99 in treatment group and 97 in placebo group (mean age 60.5 ± 14.4 years, sex ratio = 4, SOFA score 8.7 ± 3.1). Characteristics of cardiac arrest were similar in both groups (no flow = 3.5 ± 4.8 min vs 3.8 ± 4.0 min, low-flow = 21.8 ± 13.7 min vs 18.2 ± 10.1 min). 51 early VAP were confirmed, 19 in treatment group vs 32 in placebo group, with an incidence of 19.2 vs 33.0%, respectively (HR = 0.546 + IC 95% = [0.315 + 0.946], p = 0.031) (Fig. 1). The procedure did not affect occurrence of late VAP (> 7 days), respectively 4 vs 5. Day 28 mortality was similar in both arms (41.4 vs 37.5%, p = 0.58) and no adverse event was related to study treatment.
Conclusion: Short-term antibiotic prophylaxis with amoxicillin-clavulanic acid significantly decreases incidence of early VAP in patients treated with mild therapeutic hypothermia after out-of-hospital cardiac arrest related to shockable rhythm.
CO-63 Treatments and outcomes of hypoxemia in immunosuppressed patients compare to immunocompetent patients in French speaking ICU: a sub-study from the SPECTRUM study
Grimaldi David1, Hraiech Sami2, Boissier Florence3, Lacherade Jean Claude4, Muller Gregoire5, Michel Philippe6, Lascarrou Jean Baptiste7, Piton Gaël8, Barbar Saber9, Youssoufa Atika8, Brouard Florence11, Ehrmann Stephan12, Aissaoui Nadia13
1Hôpital Erasme, Bruxelles, Belgium; 2Hôpital Nord, Marseille, France; 3CHU de Poitier, France; 4CHU de La Roche-sur-Yon, France; 5Hôpital de la Source, Orléans, France; 6; 7CHU de Nantes, France; 8CHU de Besançon, France; 9CHU de Nîmes, France; 10CH de Périgueux, France; 11CHU de Tours, France; 12Hôpital Européen Georges Pompidou
Correspondence: Grimaldi David - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-63
Introduction: Immunosuppressed (IS) patients are prone to develop respiratory failure and to need ventilatory support. Invasive ventilation shared a grim prognosis in the past and non-invasive ventilation had been recommended in these patients, however NIV efficacy has been recently challenged and the advent of high flow oxygen therapy had brought even more complexity in the management of such patients. Using the data from a recent point-prevalence-day of hypoxemia in ICU, we compare the frequency, management and outcomes of hypoxemia in IS and immuncompetent (IC) patients.
Patients and methods: The SPECTRUM study was conducted in 117 French-speaking ICUs in 7 countries during spring 2016. IS was retained in case of malignant hemopathy, HIV positivity, immunosuppressive drugs, recent chemotherapy, neutrophil count < 0.5 G L. Hypoxemia was defined as a PaO2 FiO2 ratio > 300 and separate into severe (> 100), moderate (> 200) and mild (> 300). We focused on the causes of hypoxemia, the ventilatory management and the outcome.
Results: Among the 1604 patients included, 187 (12%) were IS out of whom 99 (53%) were hypoxemic, proportion similar to the IC patients. Mean age and IGS-2 of hypoxemic patients were similar in IS and IC patients. Hypoxemia was mild in 46 (46%), moderate in 43 (43%) and severe in 10 (10%) IS patients with a similar distribution compared to hypoxemic IC patients. The causes of hypoxemia were also similar pneumonia being the leading cause. 24 (24%) hypoxemic IS patients fulfilled the Berlin criteria for ARDS in a similar proportion to IC patients. Respiratory support used in hypoxemic IS patients was ambient air in 3, low flow oxygen in 24, high flow in 11, NIV in 5 and invasive ventilation in 56 patients, with a different distribution from the IC patients (more patients on high flow therapy and less invasively ventilated). The day of the study, thoracic CT scan and echocardiography were performed in a similar proportion in IS and IC patients whereas broncho-alveolar lavage was more frequently performed in IS patients (14 vs 6%, p < 0.001). Finally, as expected, ICU mortality was higher in hypoxemic IS patients (38 vs 25%, p < 0.01).
Conclusion: Immunosuppression in the ICU seems not to be associated with hypoxemia, severity of hypoxemia or ARDS. Oxygenation management is slightly different from immunocompetent patients with more frequent use of high flow therapy.
CO-64 Can a flow rate of 3 L/kg/min, compared to 2 L/kg/min, reduce the risk of failure during the initial management of acute viral bronchiolitis with high flow nasal cannulae: a randomized controlled trial (TRAMONTANE 2 study)
Milesi Christophe1, Pierre Anne Florence2, Deho Anne3, Pouyau Robin4, Liet Jean-Michel5, Guillot Camille6, Guilbert Anne Sophie7, Rambaud Jerome8, Millet Anne9, Afanetti Mickael10, Guichoux Julie11, Genuini Mathieu12, Mansir Thierry13, Bergounioux Jean14, Michel Fabrice15, Marcoux Marie Odile16, Baleine Julien1, Durand Sabine1, Douillard Aymeric1, Cambonie Gilles1
1CHU de Montpellier, Montpellier, France; 2Hopital Kremlin Bicetre, Paris, France; 3Hopital Robert Debré, Paris, France; 4Hopital de Lyon, Lyon, France; 5Hopital de Nantes, Nantes, France; 6Hopital Jeanne de FLandre, Lilles, France; 7CHU de Strasbourg, France; 8HU Est parisien, Paris, France; 9CHU de Grenoble, Grenoble, France; 10CHU Lenval, Nice, France; 11CHU de Bordeaux, France; 12HU Necker, Paris, France; 13CH de Pau, France; 14Hôpital Raymond Poincaré, Paris, France; 15Hôpital de la Timone, Marseille, France; 16CHU TLSE, Toulouse, France
Correspondence: Milesi Christophe - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-64
Introduction: HFNC is currently proposed as first-line respiratory support in moderate to severe acute viral bronchiolitis (AVB) in infants. However, the flow setting remains empiric, 2 L/kg/min being used by most teams. Considering the failure rate observed with this device, as high as 50% in some studies, we hypothesized that a higher flow rate may improve this issue. The purpose of the present study was to compare the failure rates with two flow regimen-2 L/kg/min versus 3 L/kg/min.
Patients and methods: A randomized controlled study was performed in 16 French Pediatric Intensive Care Units (PICUs). Infants younger than 6 months-old with moderate to severe AVB, defined by Wood-modified Clinical Asthma score (mWCAs) > 3, were randomly allocated to HFNC treatment with a flow rate of 2 L/kg/min or 3 L/kg/min for 48 h. The primary endpoint was the percentage of failure, defined as the occurrence of one or more of the following—increase in mWCAs or RR, increase in discomfort (EDIN score), and severe apnea episodes.
Results: 287 infants with mean (SD) age and weight of 47 (58) days and 4460 (1130) g were included from November 2016 to March 2017. At baseline, RR was 58 (16) rpm, mWCAs 4.5(1), FiO2 32 (13) %, PCO2 59 (13) mmHg, pH 7.26 (0.1). 142 were included in the 2 L/kg/min group and 145 in the 3 L/kg/min group. No difference was observed between groups for baseline characteristics. Failure rate was not different between groups—38.7 vs 39.3% + p = 0.92. No center effect was observed for failure. Discomfort was more frequent in the 3 L kg min group—7 vs 17% + p = 0.006. The length of stay was shorter in the 2 L kg min group—5.3 (2.8) vs 6.4 (5) days + p = 0.048. Intubation occurred in 4 142 patients in the 2 L/kg/min group vs 10 145 patients in the 3 L kg min group (p = 0.12).
Conclusion: HFNC with a flow rate of 3 L/kg/min did not reduce the risk of failure compared to 2 L/kg/min at the initial respiratory management of AVB in young infants.
CO-65 Comparison of epinephrine and norepinephrine for the treatment of cardiogenic shock following acute myocardial infarction. OPTIMA CC study
Levy Bruno1, Meziani Ferhat1, Leone Marc2, Guiot Philippe3, Quenot Jean-Pierre4, Louis Guillaume5, Legras Annick6, Duarte Kevin7, Vignon Philippe8
1CHRU de Strasbourg, France; 2Hôpital Nord, Marseille, France; 3Hôpital Emile Muller, Mulhouse, France; 4CHRU de Dijon, France; 5CHR Metz, France; 6CHRU Bretonneau, Tours, France; 7CHU de Nancy, France; 8CHU de Limoges, France
Correspondence: Levy Bruno - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-65
Introduction: Despite the frequent use of vasopressors which are administered in 90% of patients in cardiogenic shock (CS), there is only limited evidence from randomized trials comparing vasopressor in CS. Hence, the OPTIMA CC study was designed to compare epinephrine and norepinephrine in cardiogenic shock following myocardial infarction.
Patients and methods: Multicenter, double-blind, randomized trial in 8 french ICU. Cardiogenic shock patients due to myocardial infarction treated by PCI were randomized to receive epinephrine or norepinephrine to maintain MAP at 70 mmHg. Dobutamine was introduced at the physician discretion according to a combination of parameters—echocardiographic parameters, cardiac index, lactate clearance, SVO2 and Swan-Ganz derived parameters.
Results: 56/57 patients were ventilated (98%). There were no differences in the duration nor in the maximal dose or cumulated dose of epinephrine or norepinephrine. Dobutamine was used in 18/27 (67%) in the epinephrine group and in 20/30 (67%) in the norepinephrine group. There were no differences in the duration, in the maximal or cumulated dose. Arterial pressure evolution was similar. Heart rate increased significantly in epinephrine group and did not change in norepinephrine group. Cardiac index and cardiac power index increased significantly more in the epinephrine group than in the norepinephrine group. Cardiac double product, a surrogate of myocardial oxygen consumption increased in epinephrine group and did not change in norepinephrine group. Epinephrine use was associated with a lactic acidosis from H2 to H24 while arterial pH increased and lactate level decreased in norepinephrine groupEpinephrine was significantly associated with an higher incidence of refractory shock—10/27 (37%) versus 2/30 (7%) p = 0.008). The incidence of arrhythmia was identical (epinephrine—41% versus norepinephrine—33%, p = 0.59). ECMO was used in 3/27 (11%) in the epinephrine group and in 1 30 (3%) in the norepinephrine group (p = 0.34) Mortality was 11/30 (37%) in the norepinephrine group and 14/27 (52%) in the epinephrine group (p = 0.25) Epinephrine use was associated with a trend to an increased risk of death (p = 0.08) and an increased risk of death plus ECMO (p = 0.031) at 7 days. There was a trend for an increased risk of death plus ECMO at J28 (p = 0.064).
Conclusion: In patients with cardiogenic shock following myocardial infarction, epinephrine use was associated with a lactic acidosis, an higher incidence of refractory shock and an increased risk of death plus ECMO at J7.
CO-67 High dose immunoglobulins in toxic shock syndrome in children: a pilot randomized controlled study (IGHN study)
Javouhey Etienne1, Leteurtre Stéphane2, Tissières Pierre3, Joram Nicolas4, Wroblewski Isabelle5, Ginhoux Tiphanie6, Dauger Stéphane7, Kassai Behrouz8
1Hôpital Mère Enfant, Bron, France; 2Hôpital Jeanne de Flandre, Lille, France; 3Hôpital du Kremlin-Bicêtre, Le Kremlin-Bicêtre, France; 4CHU Nantes, Nantes, France; 5CHU Grenoble, La Tronche, France; 6Hospices Civils de Lyon, Bron, France; 7Hôpital Robert Debré, Paris, France; 8Hospices Civils de Lyon, Bron, France
Correspondence: Javouhey Etienne - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-67
Introduction: Superantigen toxins synthesized by S. aureus or by S. pyogenes are responsible for toxic shock syndromes (TSS) which lethality can reach 28%. High dose intravenous immunoglobulins (IVIG), able to neutralize these toxins, are frequently used even tough evidence of its efficacy is not supported by randomized controlled study (RCT). Moreover, IVIG are expensive and possibly harmful. Before conducting a RCT, a pilot study was first designed to assess the feasibility in the context of pediatric critical care.
Patients and methods: A double blinded RCT was performed comparing 2 g kg of IVIG to isovolumic 4% albumin perfusion within the first 12 h of TSS in children aged between 1 month to 17 years. A priori criteria to determine the feasibility were defined as a rate of inclusion among eligible patients > 50%, a rate of protocol’s deviations < 30% (treatment delivery, non-respect of blinding, premature stop), and by the practical and financial aspects of the protocol. Secondary objectives were to assess the efficacy of IVIG on organ dysfunction (using Pelod-2 score), on mortality at day 60 and their safety. The study was promoted by the Hospices Civils of Lyon, approved by the CPP Sud-Est and registered at clinical trial (NCT02219165). Inform consent from both parents was required before randomization. This study was funded by CSL-Behring company.
Results: During the 30 months study period, 21 patients were included in 9 centers. The inclusion rate was of 71% (5 parent’s refusals, 3 parents were absent at admission). Two patients were wrongly included (pneumococcal shocks), one patient didn’t receive the treatment because he was transferred for ECMO in a non-investigator center, three patients were treated after 12H, and in two patients one bottle of treatment was missing. The blinding was well respected. Missing data on the Pelod2 score and mortality was lower than 10%, and no premature stop was reported. The eCRF completion was judged easy by investigators. The inclusion of children within the first 12 h was judged challenging. The treatment delivery had to be improved, requiring the help of research assistants. Seven serious and one severe adverse events were registered, all patients recovered and no death was reported.
Conclusion: This pilot study suggested that a RCT is feasible. It provides crucial information to improve the recruitment, the respect of the protocol and the correct measure of organ failure. However, inclusion of international centers is necessary to attain the sample size required.
CO-68 Indirect calorimetry as a tool to assess the work of breathing in critically ill children
Mortamet Guillaume1, Nardi Nicolas2, Essouri Sandrine2, Jouvet Philippe2, Emeriaud Guillaume2
1CHU Grenoble, Grenoble, France; 2CHU Sainte-Justine, Montréal, Canada
Correspondence: Mortamet Guillaume - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-68
Introduction: Indirect calorimetry is a non invasive tool to measure oxygen consumption (VO2) and resting energy expenditure at bedside. The aim of the present study was to assess the validity of the indirect calorimetry-based method for the work of breathing assessment when compared to esophageal pressure (Pes) measurement and Electrical Activity of the Diaphragm (EAdi) during a spontaneous breathing trial in continuous positive airway pressure.
Patients and methods: A prospective single center study. All intubated and mechanically ventilated children > 1 months and < 18 years old, hospitalized in the pediatric intensive care unit were eligible. Patients considered as ready to extubate were included. Simultaneous recordings of VO2, Pes and EAdi were performed during 3 steps: before, during and after the spontaneous breathing test in continuous positive airway pressure.
Results: Twenty patients, median 5.5 months, were included. Half of the patients were admitted for a respiratory reason. Predicted resting energy expenditure was overestimated as compared to measured resting energy expenditure (51 [47–55] vs 23 [21–29] kcal kg day, p < 0.001). Spontaneous breathing test was associated with an increase in Esophageal Pressure–Time Product from 23 [5–89] to 83 [24–110] cm H2O s min. The same trend was observed in respiratory drive, assessed by EAdi which increased from 7.5 [3.2–16.3] to 15.9 [5.2–22.1]. Oxygen consumption obtained by IC was higher during spontaneous breathing test as compared to conventional ventilation (3.8 [3.0–5.2] vs 3.6 [3.1–4.6] ml kg min) but non significantly. Changes in work of breathing as assessed by VO2 was poorly correlated with measurements from Pes and EAdi whereas we found a moderate correlation between Pes and EAdi values. Spontaneous breathing test and extubation were successful in 20 (100%) and 18 (90%) patients, respectively.
Conclusion: During weaning from mechanical ventilation, spontaneous breathing test in continuous positive airway pressure induced an increase in work of breathing, both in respiratory drive, as measured by EAdi and in respiratory mechanics, as measured by Pes. Oxygen consumption measured by Indirect Calorimetry does not seem to be a reliable tool to assess work of breathing in mechanically ventilated children.
CO-69 Determinants of continued breastfeeding during hospitalization for bronchiolitis in infants less than 6 months of age (Bronchilact II)
Ben Gheriba Khalil1, Grimaud Marion1, Heilbronner Claire1, Roy Emeline1, Hadchouel Alice1, Renolleau Sylvain1, Rigourd Virginie1
1Hôpital Necker Enfants Malades, Paris, France
Correspondence: Ben Gheriba Khalil - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-69
Introduction: During the winter season 2015–2016 we had evaluated breastfeeding disruption after hospitalization for bronchiolitis in our hospital in infants under 6 month (n = 84). We observed 51% of mothers whose breastfeeding was stopped of modified. Clinical severity had no impact on breastfeeding but 63% of mothers stated that lack of support and advice was the first cause of breastfeeding disturbance. We conducted this second phase to evaluate the potential impact of actions to promote breastfeeding on unwanted weaning during hospitalization for bronchiolitis.
Patients and methods: This is a cross sectional study during two epidemic seasons of bronchiolitis in a tertiary care hospital. All patients aged 6 months or younger hospitalized with acute bronchiolitis and receiving at least partial breastfeeding were eligible for the study. Patients discharged at home whose parents accepted to be contacted by phone were included. A bundle of actions to promote breastfeeding in patients with bronchiolitis was implemented (posters, flyers, staff training, equipment with breast pumps) between the two epidemic seasons. The data was extracted from the charts and from a phone survey two weeks after discharge to evaluate breastfeeding in eligible patients in our hospital. Phase I (before action) had included 84 patients hospitalized between December 2015 and March 2016 in all wards hosting patients with bronchiolitis. Phase II (after action) included 50 patients hospitalized from October 2016 to December 2016. The data from phase II was compared with data from phase I.
Results: Fifty patients could be included during the second step of the study, with a mean age of 37 days. Breastfeeding was exclusive for 78% of mothers (vs 77% in phase I). The median length of stay was 6 days (vs 3 days in phase I). Twenty-one (42%) patients spent time in PICU vs. 32% in phase I, 3 21 needed intubation, 18 21 received non invasive ventilation for a median length of 4 days (vs. 3 days in phase I). The number of patients needing nutritional support was 35 50 (70%) during phase II vs. 44 84(52%) during phase I. After implementation of our actions, 40 50 (81%) mothers kept breastfeeding as before (vs. 49% in the previous epidemic season, p < 0.05), 4 mothers (8%) stopped, 4 (8%) switched to partial breastfeeding and 2 (4%) reduced without stopping.
Conclusion: Bronchiolitis is a high risk event for breastfeeding disruption but staff training and correct advices and support for mothers during hospitalization seems to diminish that risk.
CO-70 Benefits of using a high temporal resolution database in the automatic real-time pediatric ARDS screening
Nardi Nicolas1, Sauthier Michael1, Brossier David2, Eltaani Redha1, Emeriaud Guillaume1, Jouvet Philippe1
1CHU Sainte Justine Montréal, Canada; 2CHU de Caen, France
Correspondence: Nardi Nicolas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-70
Introduction: Pediatric acute respiratory distress syndrome (PARDS) is frequent in pediatric intensive care units (PICU), potentially lethal and the diagnosis is often missed or delayed (PALICC 2015). In PICU, data are usually recorded between 5 to 60 min which leads to only a minority of the arterial partial pressure of oxygen (PaO2) that are usable to calculate a valid oxygenation index (OI). If not available, PaO2 should be replaced by the SpO2 if < 98% to calculate the oxygen saturation index (OSI). Using a high temporal resolution (HTR) database that records data every 5–30 s, we aim to develop a relevant clinical algorithm of mass data aggregation to improve PARDS screening with the automatic OI and OSI calculation.
Patients and methods: All the patients admitted to our Pediatric ICU between May 2015 and August 2017 were included. The HTR and the electronic medical records (EMR) were queried through Structured Query Language (SQL) following these steps—(1) Data selection (2) Extraction to a linear format (3) Date and time synchronization (4) Data pivoting (5) Aggregation through a 10-min moving average (6) Hypoxemia calculation. Statistical analysis included proportions, correlations and Bland–Altman analysis.
Results: Between May 2015 and August 2017, 1793 patients (2210 stays) were admitted to the PICU. Approximately 46 million rows were retrieved from the databases including 19,189 PaO2 values. The algorithm was able to calculate 11,320 (59% of the PaO2) OI and 5204 OSI. The comparison between OI and OSI showed that 97.4% of the results were between the limits of agreements (− 17.2 + 10.6), a bias of − 3.3 and a correlation R2 = 0.643. The comparison between the OIs from the HTR and EMR databases showed that 94.6% of the results were between the limits of agreements (− 5.47 + 5.39), a bias of − 0.04 and R2 = 0.904.
Conclusion: Using a mass data aggregation algorithm on a HTR database allows more PaO2 to be used to calculate an OI than the usual EMR. The OI results differ slightly between the HTR and the EMR. The accuracy is probably in favor of the HTR because of the shorter time-lapse between the OI parameters. The OSI is possibly a biased OI surrogate and should be interpreted with caution. Our next step will be to measure the impact of the algorithm on the PARDS real-time diagnosis and PARDS severity categories.
CO-71 Are beta-lactam concentrations adequate in severe sepsis and septic shock in children?
Chosidow Anaïs1, Benaboud Sihem1, Beranger Agathe1, Zheng Yi1, Moulin Florence1, Dupic Laurent1, Renolleau Sylvain1, Tréluyer Jean-Marc1, Oualha Mehdi1
1Hôpital Necker Enfants-Malades, Paris, France
Correspondence: Chosidow Anaïs - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-71
Introduction: Early administration of appropriate antibiotic therapy with adequate concentration is the cornerstone of the severe sepsis and septic shock’s treatment. Adult studies showed alteration of distribution and elimination which can lead to insufficient drug concentration in septic patients. In children, studies are lacking and antibiotic dosing may be suboptimal. We aim to describe the plasma concentration of the most used beta-lactam in critically ill children, to describe the rate of patients with suboptimal exposure and associating clinical and biological factors.
Patients and methods: This was a prospective, single center, observational study designed in 32 beds Pediatric Intensive Care Unit (PICU) and high dependency care at the Necker Hospital (Paris, France) from January 2016 to May 2017. Were included, children with severe sepsis or septic shock, aged less than 18 years and weighing more than 2.5 kg, and receiving one or more of the following antibiotics—amoxicillin, cefotaxime, cefazolin, ceftazidime, piperacillin-tazobactam, meropenem and imipenem for suspected or proven infection. Beta-lactam plasma concentrations were analysed using High Performance Liquid Chromatography.
Results: We enrolled 37 children (severe sepsis, n = 22 (59.5%) + septic shock, n = 15 (40.5%)) with a median age of 19 months (4–64. Bacteria were identified in 26 patients (70.3%). A total of 132 blood samples were analysed at a median of 2 days (1–12) following the onset of sepsis. Twenty-four patients (64.8%) had insufficient concentration (cefotaxime 7 14 (43%) + piperacillin-tazobactam, 10 13 (77%) + amoxicillin 6 7 (86%) + meropenem 3 6 (50%), cefazoline 1 4 (25%), imipenem 0 2 (0%) + ceftazidime 0 1 (0%)). Insufficient concentrations were associated with early measurements (< 72 h from the sepsis’ onset) (p = 0.035) and creatinine clearance increase (p = 0.01). Adequate concentrations were associated with small age (p = 0.048).
Conclusion: In conclusion, current standard beta-lactam dosing in children with severe sepsis or septic shock could be inadequate to reach the target concentrations. That could lead to the risk of clinical and bacteriological failures as well as the emergence of bacterial resistance. Further pharmacokinetic studies are mandatory to improve antibiotic therapy in this vulnerable population.
CO-72 Predicting intradialytic hemodynamic instability in critically ill patients: derivation and validation of a bedside tissue hypoperfusion score
Bigé Naïke1, Dang Julien1, Attias Philippe1, Deryckere Stéphanie1, Joffre Jérémie1, Dubée Vincent1, Dumas Guillaume1, Preda Gabriel1, Bourcier Simon1, Pichereau Claire1, Guidet Bertrand1, Maury Eric1, Ait-Oufella Hafid1
1Hôpital Saint-Antoine - Service de Réanimation Médicale, Paris, France
Correspondence: Bigé Naïke - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-72
Introduction: Intermittent hemodialysis is a key support therapy in ICU. Despite protocol-based optimization, intradialytic hemodynamic instability (IHI) remains a common complication and could account for mortality and delayed renal recovery. The identification of patients at high risk for IHI is crucial but remains poorly explored. Our objective was to test whether tissue perfusion parameters assessed at the bedside (mottling, index capillary refill time (iCRT), and lactate) predict IHI and to develop and to validate a predictive score of IHI.
Patients and methods: Prospective observational study in a 18-bed medical ICU in a tertiary university hospital including hemodialysis sessions performed for acute kidney injury. Exclusion criteria were patients with dark skin and dialysis performed in extreme emergency. Mean arterial pressure (MAP), mottling score, iCRT, and lactate were recorded just before starting hemodialysis. First episode of IHI requiring therapeutic intervention was recorded 60, 120, and 240 min after hemodialysis starting.
Results: Ninety-six hemodialysis sessions performed in 43 patients were recorded. Half of the patients received vasopressors (n = 43, 45%). IHI occurred in 22 (23%) sessions and was more frequent among patients receiving vasopressors (42 vs 7%, p < 0.0001). Mottling were more frequent (59 vs 26%, p = 0.005), lactate levels higher (2.8 [1.4–6.9] vs 1.1 [0.8–1.5] mmol L, p < 0.0001) and iCRT longer (3.3 [1.6–4.6] vs 1.1 [0.8–2.0] s, p < 0.0001) before sessions with IHI compared to sessions without, independently of MAP (p < 0.0001). The incidence of IHI increased with the number of tissue perfusion alterations (3, 11, 41, and 55% for 0, 1, 2, and 3 alterations, respectively, p < 0.0001). A tissue hypoperfusion score, defined as iCRT (seconds) + lactate level (mmol L) + 1 if mottling presence was predictive of IHI independently of MAP (OR 1.18 [1.05–1.32], p < 0.0001) with an AUROC of 86 [77–94] %. A threshold of 4.1 predicted IHI with a sensitivity of 82 [60–95] %, and a specificity of 82 [72–90] %. The accuracy of this score was validated in a second prospective cohort including 115 hemodialysis sessions performed in 45 patients.
Conclusion: The incidence of IHI increases with the number of tissue perfusion alterations independently of MAP. At the bedside, a combined tissue hypoperfusion score including mottling score, iCRT and lactate level is helpful to identify patients at high risk of IHI.
CO-73 Long term renal recovery in out-of-hospital cardiac arrest survivors
Ait Hamou Zakaria1, Jamme Matthieu1, Ben Hadj Salem Omar1, Dumas Florence1, Guillemet Lucie1, Bougouin Wulfran1, Pène Frédéric1, Mira Jean-Paul1, Cariou Alain1, Geri Guillaume1
1Hôpital Cochin, Paris, France
Correspondence: Ait Hamou Zakaria - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-73
Introduction: Epidemiological data suggest an increased risk of long-term chronic kidney disease after acute kidney injury (AKI). In survivors of out-of-hospital cardiac arrest (OHCA), AKI is frequent and is associated with numerous factors of definitive renal injury. We made the hypothesis that AKI after OHCA was a strong risk factor of long-term chronic kidney disease (CKD). We aimed to evaluate renal outcome of OHCA survivors according the occurrence of AKI in ICU.
Patients and methods: We used the cohort of consecutive OHCA patients admitted between 2007 and 2012 in a tertiary medical ICU previously described (Geri et al. ICM. 2015). AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Long-term creatinine level was the last blood creatinine assessment we were able to retrieve. The main outcome was the occurrence of CKD, defined by an estimated glomerular filtration rate (eGFR) lower than 60 mL min 1.73 m2 according to the MDRD equation. Long-term mortality was evaluated as well. Factors associated with CKD occurrence were evaluated by competing risk survival analysis (Fine Gray and Cox cause specific models providing sub-hazard ratio (sHR) and Cox sub-hazard (CSH)).
Results: Among the 246 OHCA patients who were discharged alive, we were able to retrieve the outcome of 133 patients (median age 55 [iqr 46, 68], 75.2% of male) who were included in the analysis. During a median follow-up time of 1.8 [0.8–2.5] years, CKD occurred in 17 (12.7%) patients and 24 (18%) patients died. A previous history of arterial hypertension (sHR = 3.28[1.15 + 9.39], p = 0.027 + CSH = 4.83 [1.57 + 14.9], p = 0.006), AKI during ICU stay (sHR = 3.72[1.40 + 9.84], p = 0.008 + CSH = 5.41[1.79 + 16.3], p = 0.003) and an age higher than 55 (sHR = 6.13[1.55 + 24.3], p = 0.009 + CSH = 2.16[1.72 + 43.8], p = 0.006) were independently associated with CKD occurrence. AKI was not associated with long-term mortality (sHR = 0.73 [0.27 + 1.99], p = 0.55 + CSH = 0.75 [0.28 + 2.01], p = 0.57).
Conclusion: In OHCA survivors resuscitated from an OHCA, CKD was a frequent long-term complication. AKI during ICU stay was a strong determinant of long-term CKD occurrence.
CO-74 Trends in acute kidney injury requiring dialysis in metropolitan France between 2009 and 2014
Garnier Fanny1, Couchoud Cécile2, Boudemaghe Thierry1, Landais Paul3, Moranne Olivier
1CHU Carémeau, Nîmes, France; 2Agence de la Biomédecine, Saint Denis La Plaine, France; 3Laboratoire de Biostatistique, Montpellier, France
Correspondence: Garnier Fanny - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-74
Introduction: Acute kidney injury requiring dialysis (AKID) is associated with high mortality. In several countries, epidemiology of AKID is lacking. Objectives of the study was to assess changes in standardized incidence, patients’ characteristics and hospital mortality in France.
Patients and methods: The study was conducted using the French database on hospitalizations (Program of Medicalization of Information Systems). It focused on adults hospitalized in metropolitan France between 2009 and 2014 and diagnosed with AKID according to the codes of Common Classification of Medical Procedures. We described and statistically compared crude and standardized incidence of AKID on gender and age, as well as comorbidity and mortality rates, principal diagnosis and dialysis modality. We also analyzed variables associated with mortality using logistic regression.
Results: Crude incidence of AKID increased from 459per million people (pmp) in 2009 (16,500 cases) to 512pmp (25,142 cases) in 2014. Standardized incidence increased from 475[468–482] in 2009 to 524 pmp[517–532] in 2013, an annual increase of 2%. AKID’s incidence was twofold higher for men. Patients’ median age was 68 years. Standardized incidence of AKID increased by 18, 8, 15 and 50% for the 60–69, 70–79, 80–89 and over 90 age groups respectively. The most common comorbidities were cardiocerebrovascular (67.3%), pulmonary (42%), chronic kidney disease (CKD) (32.5%), diabetes (27.9%), all of which increased significantly (excluding CKD). The five most frequent principal diagnoses were heart failure (17.7%), sepsis (13.4%), acute kidney injury (12.7%), digestive diseases (11.6%) and shock (8.7%), with significant increase in heart failure and digestive diseases. Number of stays in intensive care units increased from 80.3 to 83.9%. Continuous dialysis was the most widely used dialysis modality, with a utilization rate up from 56.9 to 61.8%. Intra-hospital mortality was stable at 47%. Factors associated with higher mortality were: advanced age, intensive care admission (OR 3.33), introduction to dialysis exceeding 8 days (OR 1.46), cardiocerebrovascular comorbidities (OR 1.12), pulmonary comorbidities (OR 1.39), cancer (OR 1.33), hepatic comorbidities (OR 1.85). Diagnoses associated with higher mortality, compared with CKD, were: shock (OR 5.99), respiratory diseases (OR 4.81), sepsis (OR 4.44), digestive diseases (OR 4.10) and heart failure (OR 3.33).
Conclusion: It is the first study in France showing a significant increase in AKID’s standardized incidence among adults and a significant change in patients’ characteristics.
CO-75 Prolonged heparin-free hemodialysis sessions with calcium-free citrate-containing dialysate in critically ill patients with a moderate to high risk of bleeding
Faguer Stanislas1, Saint-Cricq Morgane1, Lavayssiere Laurence1, Setbon Nicolas1, Nogier Marie-Béatrice1, Kamar Nassim1, Cointault Olivier1
1Hôpital Rangueil, Toulouse, France
Correspondence: Faguer Stanislas - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-75
Introduction: Many critically ill patients have a moderate to high risk of bleeding but they also require prolonged intermittent dialysis to ensure a negative water balance without hemodynamic adverse events. Thus, a heparin-free easy-to-use anticoagulation within the dialysis circuit is needed but, to date, usual protocols (iterative saline flushes, heparin grafted membranes) lead to 20–50% of premature clotting and sessions that last greater than 240 min are rarely achievable. We assessed the safety and efficiency of heparin-free regional citrate anticoagulation of the dialysis circuit using a calcium-free citrate-containing dialysate, with calcium reinjected according to ionic dialysance (an online measure of the instantaneous clearance of small molecules available in most of dialyzers).
Patients and methods: We prospectively reported the clotting events that occurred during all the heparin-free dialysis sessions that were performed with a regional anticoagulation based on calcium-zero citrate-containing dialysate (Citrasate, Hemotech, France) between January 2016 and August 2017 in a 28-beds ICU.
Results: A total of 186 dialysis sessions were performed in 70 patients (mechanical ventilation n = 93 + norepinephrine n = 20). Median duration of dialysis was 240 min (IQR, 240–300 + maximum 360 min), and median ultrafiltration volume was 2 L (IQR 1.3–2.6). When assessed, urea and Beta2-microglobulin reduction rates were 64.5% ± 0.4% and 48% ± 0.13%, respectively. Postfilter ionized calcium was 0.35 ± 0.17 and 0.38 ± 0.14 mmol L at 1 and 3 h, respectively, within the extracorporeal circuit. A major clotting event that led to premature termination of the session occurred in only 5186 sessions (2.7%). In these five cases, major catheter dysfunction occurred before clotting within the circuit. Prefilter ionized calcium remained within narrow ranges (before after change +0.07 ± 0.006 mmol L), and total-to-ionized calcium ratio, a surrogate marker for citratemia, was unchanged and always below 2.5. In 85 sessions, no ionized calcium measurement was required.
Conclusion: Dialysis anticoagulation with calcium-free citrate containing dialysate is an easy-to-use, efficient, and inexpensive form of heparin-free regional anticoagulation. Calcium reinjection according to ionic dialysance allows prolonged hemodialysis sessions in critically ill patients without the need to systemically monitor ionized calcium. Sessions can be safely extended according to the hemodynamic tolerance to ensure an adequate dose of dialysis and a negative water balance, a major point in patients with severe AKI.
CO-76 Renal replacement therapy initiation strategies for critically ill patients with acute on chronic renal failure: a post hoc analysis of the AKIKI trial
Gaudry Stéphane1, Verney Charles1, Hajage David2, Martin-Lefèvre Laurent3, Pons Bertrand4, Boulet Eric5, Boyer Alexandre6, Chevrel Guillaume7, Lerolle Nicolas8, Carpentier Dorothee9, De Prost Nicolas10, Lautrette Alexandre11, Bretagnol Anne12, Mayaux Julien2, Nseir Saad13, Schortgen Frederique10, Tubach Florence14, Ricard Jean-Damien1, Dreyfuss Didier1
1Hôpital Louis Mourier, Colombes, France; 2Hôpital Pitié-Salpêtrière, Paris, France; 3CHU de la Roche sur Yon, France; 4CHU DE Pointe à Pitre, France; 5CHU de Pontoise, France; 6CHU de Bordeaux, France; 7CHU de Vienne, France; 8CHU d’Angers, France; 9CHU de Rouen, France; 10HU Henri Mondor, Paris, France; 11CHU de Clermont-Ferrand, France; 12CHU d’Orléans, France; 13CHU de Lille, France; 14Hôpital Bichat, Paris, France
Correspondence: Gaudry Stéphane - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-76
Introduction: Acute kidney injury (AKI) is frequent and associated with poor intensive care unit (ICU) outcome in critically ill patients. Superimposed AKI on chronic kidney disease (CKD) is associated with long-term risk of death and end-stage renal disease. We aimed to investigate the effect of an early compared to a delayed RRT initiation strategy in patients with severe AKI on CKD.
Patients and methods: Post-hoc analysis of the AKIKI trial. In this multicenter pragmatic RCT, patients with severe AKI (stage 3 of KDIGO classification) were randomly assigned to either an early or a delayed RRT initiation strategy. The subgroup of patients with CKD was a priori defined as a preexisting creatinine clearance < 60 ml min in stable condition. The primary endpoint was 60-day mortality. Secondary endpoints included—number of patients who actually received RRT, RRT-free days, mechanical ventilation-free days and vasopressor-free days, ICU and hospital length of stay, time to renal function recovery, day-28 and day-60 dependence on RRT.
Results: Of the 619 patients, 60 (10%) had CKD. We found significant treatment effect heterogeneity according to the CKD status (test for interaction p = 0.006). Patients with CKD had an increased risk of death (HR 2.50 (95% CI 1.23–5.00, p = 0.009) with the early strategy (Fig. 1). Delayed strategy allowed avoidance of RRT in 45% of patients with CKD. Mechanical ventilation-free days, ICU and hospital length of stay, dependence on RRT at day-28 and day-60 did not significantly differ between RRT strategies. The number of vasopressor-free days was significantly higher in patients with CKD assigned to the delayed strategy (5.5 [0–20] vs 22.0 [3–26], p = 0.02). We found a trend for an earlier renal function recovery with the delayed RRT strategy but this difference did not reach significance (p = 0.06).
Conclusion: Early renal replacement therapy initiation strategy was associated with a significant increase in 60-day mortality in the subgroup of patients with CKD. Delaying RRT initiation may benefit patients with severe AKI on CKD.
CO-82 Background EEG reactivity and neurologic outcome after cardiac arrest in the Parisian registry
Benghanem Sarah1, Paul Marine1, Charpentier Julien1, Rouhani Said1, Ben Hadj Salem Omar1, Guillemet Lucie1, Llitjos Jean Francois1, Legriel Stephane1, Pene Frederic1, Chiche Jean Daniel1, Mira Jean-Paul1, Dumas Florence1, Cariou Alain1
1Hôpital Cochin, Paris, France
Correspondence: Benghanem Sarah - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-82
Introduction: Brain injury is the first cause of death after cardiac arrest (CA) and multimodal neuroprognostication is a cornerstone of post-resuscitation care. Among the different usable information provide by electroencephalogram (EEG), the aim of this study was to evaluate the predictive value of EEG reactivity regarding neurological outcome at discharge.
Patients and methods: Using our prospective registry of successfully resuscitated patients admitted to a cardiac arrest center between January 2007 and 2016, we studied all consecutive comatose patients still alive at 48 h and in whom at least one EEG was performed during coma. In addition to usual clinical findings, we collected EEG (patterns and reactivity, status epilepticus) and somatosensory evoked potentials characteristics. The EEG reactivity was evaluated by a blinded neurophysiologist and was defined as a reproducible change of the tracing (in amplitude or frequency) provoked by an auditory and a nociceptive standardized stimulation. We evaluated the predictive values of persistent lack EEG reactivity and other indicators regarding their respective ability to predict a favorable or unfavorable outcome. Recovery of a level 1 or 2 on the Cerebral Performance Category (CPC) scale at discharge was considered as a favorable outcome, as opposed to recovery of a CPC level 3–5 (unfavorable outcome).
Results: We included 428 patients who were mostly male (71%), with median age of 63 years. CA occurred in a public place in 32% of cases, and it was witnessed in 89% of cases. Bystander CPR was initiated in 61% patients and the initial cardiac rhythm was shockable in 49% patients. Median time to EEG was 3 days (1–4) and 43% of patients were still sedated during the examination. A favorable neurologic outcome was observed in 85 patients (20%). An EEG reactivity was present in 78 85 patients (92%) with favorable outcome and in 117 343 patients (34%) with unfavorable outcome. The positive predictive value (PPV) of a persistent EEG reactivity for prediction of favorable outcome was 40% (IC 95% 33–47). By contrast, the PPV of lost EEG reactivity for prediction of unfavorable outcome was 97% (IC 95% 94–99) with a false positive rate (FRP) of 2.8% (1.2–4.4).
Prognostic value of clinical and EEG parameters for poor outcome
|Sensitivity (IC 95%)||Specificity (IC 95%)||NPV (IC 95%)||PPV (IC 95%)||FPR (IC 95%)|
|Absent pupillary reflex||40.82 (35.6–46.2)||78.82 (68.6–86.9)||24.81 (19.8–30.4)||88.61 (82.6–93.1)||11.4 (8.4–14.4)|
|Absent motor Glasgow||74.92 (70–79.4)||37.65 (23.4–48.8)||27.12 (19.4–36.1)||82.90 (78.2–86.9)||17.1 (13.5–20.7)|
|Areactive first EEG background||63.66 (58.2–68.9)||92.86 (85.1–97.3)||40 (33.1–47.2)||97.16 (93.9–98.9)||2.8 (1.2–4.4)|
|Bilaterally absent N20 on SSEP||54.21 (46.9–61.4)||100 (79.4–100)||15.53 (9.2–24)||100 (96.5–100)||0 (0–1.8)|
|Burst suppression||7.87 (5.3–11.3)||100 (95.8–100)||21.20 (12.3–25.5)||100 (87.2–100)||0 (0–0.9)|
Conclusion: In this population of post-cardiac arrest patients, the presence of EEG reactivity was poorly predictive of a favorable neurologic outcome. The absence of reactivity was highly predictive of unfavorable outcome. In combination with other indicators, searching for EEG reactivity may have important implications in the neuroprognostication process.
CO-83 Morbidity and mortality of crystalloids vs. colloids in surgery: a subgroup analysis of a randomised trial
Heming Nicholas1, Lamothe Laure1, Jaber Samir2, Trouillet Jean Louis3, Martin Claude3, Chevret Sylvie3, Annane Djillali1
1Hôpital Raymond Poincaré, Garches, France; 2CHU de Montpellier, France; 3Hôpital de la Salpetrière, Paris, France
Correspondence: Heming Nicholas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-83
Introduction: The safest resuscitation fluid for surgical patients remains uncertain. We sought to compare the safety and efficacy of either crystalloids or colloids in surgical critically ill patients.
Patients and methods: Subgroup analysis of the multicenter randomized trial. All critically ill surgical patients were included in the current analysis. 741 patients were randomized to receive crystalloids or colloids. Patients were stratified as suffering from hypovolemia due to sepsis, trauma or other causes. Primary outcome measure was death by day 28. Secondary outcome measure included death by day 90.
Results: Crystalloids (n = 356) or colloids (n = 385) were administered for all fluid interventions other than fluid maintenance throughout the ICU stay. 484 (65.3%) patients were male, median [IQR] age was 66 [52 + 76] years. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) vs. colloids 100 (26%) (Adjusted odds ratio 0.86 [IC 95%, 0.61 to 1.21] + p = .49). Mortality by day 28 did not significantly differ among all three predefined strata (p = .52). Death by day 90 (111 (31.2%) vs. 122 (31.7%) (Adjusted odds ratio 0.97 [IC 95%, 0.70 to 1.33] + p = .86) did not significantly differ between groups.
Conclusion: This subgroup analyses of a randomized controlled trial, found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.
CO-84 Transient or persistent fluid responders: toward a new definition of fluid responsiveness? The FC-Rev study
Roger Claire1, Zieleskiewicz Laurent2, Demattei Christophe1, Lakhal Karim3, Piton Gaël4, Constantin Jean-Michel6, Chabanne Russell6, Faure Jean Sébastien6, Majhoub Yazine7, Desmeulles Isabelle8, Quintard Hervé9, Lefrant Jean Yves1, Muller Laurent1
1CHU de Nîmes, France; 2CHU de Marseille, France; 3CHU de Nantes, France; 4CHU de Besancon, France; 6CHU de Clermont Ferrand, France; 7CHU d’Amiens, France; 8CHU de Caen, France; 9CHU de Nice, France
Correspondence: Roger Claire - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-84
Introduction: Goal of a fluid challenge (FC) is in fine to increase the stroke volume (SV) or the cardiac index (CI) when an episode of hypovolemia or a preload dependence status are suspected. FC is one of the most common practices in ICUs, however, the way to assess the response to FC is not standardized. The present study aimed to evaluate whether the trans-thoracic echocardiographic (TTE) assessment of the response to FC immediately at the end of the infusion or delayed 20 min later could affect the results of the FC.
Patients and methods: Prospective, observational, multicentre study including all ICU patients in septic shock requiring a FC. Were excluded patients with—arrhythmias, poor echogenicity and severe mitral or aortic regurgitation. FC was performed administering 500 mL of crystalloids over 10 min. Fluid responsiveness was defined as a > 15% increase in stroke volume (SV). The following echocardiographic parameters were recorded—E wave, A wave, E A ratio, velocity–time integral (VTI), Ea wave and Sa wave. MAP, HR and TTE variables were collected at baseline (T0), at the end of fluid challenge (T10) and 10 (T20) and 20 min (T30) after the end of fluid challenge. Quantitative data are expressed as mean and standard deviation (SD) or median and interquartile (IQR), according to their distribution. Qualitative data are expressed as absolute number and frequency (%).
Results: From May 20th 2014 to January 7th 2016, a total of 143 patients were enrolled in 11 French ICUs (mean age—64 ± 14 years, median IGS II—53 [43–63], median SOFA score—10 [8–12]). Among the 76 143 (53%) patients responders to FC at T10, 37 patients were transient responders (TR), i.e. became non-responders at T30 (49%, 95% CI = [37–60]) and 39 (51%, 95% CI = [38–62])) patients were persistent responders (PR), i.e. remained responders at T30. Among the 67 non-responders (NR) at T10, 4 became responders at T30, (6%, 95% CI = [1.9–15.3]). In the subgroup analysis, no statistical difference in haemodynamic and echocardiographic parameters was found between non-responders, transient responders and persistent responders (Fig. 1).
Conclusion: The present study shows that, after a 15% VTI increase at the end of the FC, VTI returns to baseline at 30 min in half of the responders. Blood volume status (normo or hypovolemia) before initiating the fluid infusion could explain the transient or persistent response to FC observed in septic patients.
CO-85 Mottling score is a strong predictor of Day-14 mortality in sepsis patients independently of catecholamine dosing and other tissue hypoperfusion parameters
Dumas Guillaume1, Joffre Jérémie1, Hariri Geoffroy1, Bigé Naike1, Baudel Jean-Luc1, Razach Abdallah Idriss1, Chevret Sylvie2, Guidet Bertrand1, Ait Oufella Hafid1
1Hôpital Saint-Antoine, Paris, France; 2Hôpital Saint Louis, Paris, France
Correspondence: Dumas Guillaume - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-85
Introduction: Sepsis is a frequent critical condition. Mottling score, an hypoperfusion parameter, is well correlated with outcome. However, uncertainties persist regarding its value not only as a marker of patient severity but also as an independent predictor of mortality and treatment efficacy.
Patients and methods: We performed a post hoc analysis of four published prospective studies including sepsis patients with or without shock. We analyzed the relationship between the mottling score (from 0 to 5) and Day-14 mortality according to other prognosis covariates such as catecholamine dosing, urine output and plasma lactate levels. First, factors associated with outcome were determined by multivariate analysis. Second, mottling score-by-covariate interaction was studied to better understand its effect on mortality. Finally, effect of mottling score variation at different time point (H0–H6–H12–H24) was assessed.
Results: 274 patients were included. SAPSII at admission was 54 [41.2–70.0]. Six hours after ICU admission, 210 (76.6%) patients received catecholamine (norepinephrine (73.2%)), median dose of 0.3 [0.05–0.8] µg Kg min. At H6, the mottling score distribution was—grade 0 in 126 patients (48.6%), grade 1 in 36 (13.9%), grade 2 in 29 (11.2%), grade 3 in 29 (11.2%), grade 4 in 14 (5.4%) and grade 5 in 25 (9.7%). Day-14 mortality rate was 37.2%. Factors associated with Day-14 mortality were—mottling score (OR 2.16 [1.63–2.86]), lactate level > 5 mmol l (OR 3.74 [1.35–10.35]), urine output < 0.5 ml Kg h (OR 2.5 [1.09–5.7]) and SAPSII (OR 1.04 [1.02–1.06]). The predictive value of mottling score was not affected by catecholamine dosing (p = 0.45). OR of mottling score ranged from 2.38 [1.37–4.12] for patients without catecholamine to 3.84 [1.98–7.43] for patients receiving > 0.8 μg/kg/kg min. We did not find any significant interaction between mottling score prognosis value and urine output (p = 0.62) or lactate concentration (p = 0.09). A decrease of mottling score between the first 6 h of resuscitation was associated with outcome improvement (adjusted on SAPSII, p = 0.001).
Conclusion: Our results support the high prognostic value of mottling score for 14-day mortality, independently of catecholamine dosing and other hypoperfusion parameters. Mottling score variation during resuscitation is a strong predictor of mortality.
CO-86 Microcirculation in refractory cardiogenic shock on veno-arterial extracorporeal membrane oxygenation
Chommeloux Juliette1, Monteiro Santiago1, Franchineau Guillaume1, Lebreton Guillaume1, Bréchot Nicolas1, Hekimian Guillaume1, Leprince Pascal1, Luyt Charles-Edouard1, Combes Alain1, Schmidt Matthieu1
1APHP, Paris, France
Correspondence: Chommeloux Juliette - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-86
Introduction: Numerous studies have identified a relationship between microcirculation disorders and poor outcomes in cardiogenic shock patients. Despite the increasing interest for Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO), data on microcirculation in this context are scarce. Thus, we aimed to describe the evolution of microcirculation and its relationship with the outcomes of patients on VA-ECMO for refractory cardiogenic shock.
Patients and methods: Consecutive patients with refractory cardiogenic shock (cardiac arrest excluded) who required VA-ECMO were included. Microcirculation evaluation by video microscopy, global haemodynamic and Doppler echocardiography variables were obtained before and 2, 4, 12, 24 and 48 h after ECMO initiation. Patients who survived had additional evaluations six hours before and after VA-ECMO removal.
Results: Fourteen patients (median age 58 (interquartile range 56–62) years + SOFA score 14 (12–18) were included. Myocardial infarction (33%) was the main cause for shock. Mortality on VA-ECMO was 57%, whereas ECMO was successfully weaned in 6 (33%) patients. Proportion of Perfused Vessel (PPV), Perfused Vessel Density (PVD), Micro Flow Index (MFI) and Heterogeneity Index (HI) were severely impaired before ECMO. Re-establishing high and stable peripheral blood flow with VA-ECMO led to a rapid decrease in heart rate and vasoactive inotropic support and significantly improved all microcirculation parameters within 12 h. Total vessel density and PVD, measured before and after ECMO initiation, were better in patients successfully weaned from ECMO (p < 0.05) (Fig. 1).
Conclusion: Cardiovascular support with ECMO-VA rapidly improved macro and microcirculation in refractory cardiogenic shock patients. Total vessel density and perfused vessel density were significantly better in survivors 12 h after ECMO initiation and might therefore help to predict outcomes. Further studies are now needed to better define the utility of this technology in larger groups of VA-ECMO patients.
CO-97 Diagnostic, management and outcome of thyroid storm in intensive care unit: a retrospective multicenter study
Bourcier Simon1, Coutrot Maxime2, Sonneville Romain3, De Montmollin Etienne1, Persichini Romain3, Aubron Cécile4, Carreira Serge5, Nseir Saad7, Barbier François8, Razazi Keyva9, Hraiech Sami9, Terzi Nicolas10, Delmas Clément11, Peigne Vincent12, Lautrette Alexandre13, Aissaoui Nadia14, Kimmoun Antoine15, Demoule Alexandre1, Maizel Julien16, Schnell David17, Ferré Alexis18, Azoulay Elie19, Reuter Danielle20, Combes Alain1, Schmidt Matthieu1
1Hôpital Pitié-Salpêtrière, Paris, France; 2Hôpital Bichat, Paris, France; 3CHU de La Réunion de Saint-Denis, France; 4CHRU de Brest, France; 5Hôpital Saint-Camille, Bry-Sur-Marne, France; 6CHRU de Lille, France; 7CHR d’Orléans, France; 8CHU Henri Mondor, Créteil, France; 9Hôpital Nord, Marseille, France; 10CHU de, France; 11CHU Toulouse, France; 12CH Métropole de Savoie, Chambéry, France; 13CHU Gabriel Montpied, Clermont-Ferrand, France; 14Hôpital Européen Georges Pompidou, Paris, France; 15CHU Nancy, VandŒuvre-Les-Nancy, France; 16HU d’Amiens Picardie, France; 17CH d’Angoulême, France; 18CH de Versailles - Le Chesnay, France; 19CHU Saint-Louis, Paris, France; 20CH Sud Francilien, Corbeil-Essonnes, France
Correspondence: Bourcier Simon - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-97
Introduction: Thyroid storm is a rare but life-threatening disease related to thyrotoxicosis. It can lead to multiple organ failure including cardiovascular disorders or neurological impairment. To date, data on this disease in ICU patients are scarce and limited to case reports. We therefore aimed to describe clinical presentation, outcomes and management of thyroid storm in ICU patients.
Patients and methods: Local diagnoses coding database (from January 2000 to July 2017) from 22 French ICU were interrogated for main and secondary diagnoses codes including thyrotoxicosis based on the International Classification of Disease 10th revision. Thereafter two investigators reviewed all the medical records selected. Inclusion criteria were thyroid storm based on the diagnostic criteria of the Japan Thyroid Association (T. Satoh, Endocrine Journal 2016). It combines thyrotoxicosis with elevated levels of free triiodothyronine (FT3) or free thyroxine (FT4) with at least two of the following symptoms—central nervous system manifestation, fever, tachycardia > 130 bpm, congestive heart failure, or total bilirubin level more than 50 micromol/l. Clinical presentation, therapy used, and outcome were recorded.
Results: Sixty-two patients (median age 57 years (interquartile range 44–67) + SAPS II 45 (32–66) were included. Thyroid storm was the first manifestation of thyrotoxicosis in 18 (29%) patients. Graves’ disease (27%), amiodarone induced thyroiditis (26%), autoimmune thyroiditis (11%), and toxic multinodular goitre (10%) were the main causes of hyperthyroidism. Amiodarone, thyroid hormone toxicity, antithyroid drugs withdrawal or infectious trigger were identified in 59 (95%) patients. Organ support including mechanical ventilation, catecholamine infusion, renal replacement therapy and veno-arterial ECMO were used in 34, 31, 11, and 12 patients, respectively. Main thyroid storm treatments included antithyroid drugs (81%), betablockers (69%), corticosteroids (45%), and plasmapheresis (13%). Lastly, ICU-mortality was 16%, with multiple organ failure responsible of death in all patients.
Conclusion: Although its incidence appears low, ICU physicians should be aware of the multiple clinical features of thyroid storm. Our preliminary data reported various specific therapeutic management of this potentially fatal disease.
CO-98 Early differentiation of Shiga toxin-associated hemolytic uremic syndrome in critically ill adults with thrombotic microangiopathies—a case control study
Joseph Adrien1, Rafat Cédric1, Zafrani Lara1, Mariani Patricia4, Veyradier Agnès4, Hertig Alexandre1, Rondeau Eric1, Mariotte Eric4, Azoulay Elie4
1Hôpital Tenon, Paris, France; 2CHU Robert Debré, Paris, France; 3Hôpital Lariboisière, Paris, France; 4Hôpital Saint Louis, Paris, France
Correspondence: Joseph Adrien - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-98
Introduction: Thrombotic microangiopathies (TMAs) are severe diseases which often require admission in an intensive care unit (ICU). Prompt initiation of targeted therapies is required for atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP), but no specific therapy is consensual for Shiga toxin-associated hemolytic uremic syndrome (STEC-HUS). Thus, rapid differentiation of STEC-HUS is mandatory to tailor the initial treatment. Furthermore, apart from large outbreaks, characteristic features of this syndrome in adults have not been described.
Patients and methods: In this study, we retrospectively compared the characteristics of STEC-HUS, aHUS and TTP patients at admission in two expert ICUs. Patient were included if they presented with the triad of mechanical hemolytic anemia, thrombocytopenia and organ damage, and TMAs were classified using international criteria. Other causes than STEC-HUS, aHUS and TTP were excluded.
Results: Amongst 236 TMAs admitted between September 2003 and January 2017, 12 STEC-HUS, 21 aHUS and 91 TTP were included. STEC-HUS patients were older (64) than aHUS (36, p = 0.02) and TTP patients (43, p < 0.01). They presented with more frequent digestive symptoms (92 versus 62 and 37% for aHUS and TTP, p = 0.01 and < 0.01), but bloody diarrhea was rare (17%) and non-statistically different from other TMAs. Confusion was more frequent in STEC-HUS (33%) than aHUS patients (5%, p = 0.05). Biologically, STEC-HUS patients displayed elevated fibrinogen levels (5.1 vs 3.2 and 3.6 for a HUS and TTP, both p < 0.01) and severe renal failure. Forty-two percent required renal replacement therapy and 83% were treated with plasma exchange before the distinction from other TMAs could be made. Only 1 (8%) STEC-HUS patient died in the ICU (Fig. 1).
Conclusion: Characteristics supposed to identify STEC-HUS are largely shared with other TMAs. In particular, the differential diagnosis between aHUS and STEC-HUS appears to be more difficult than the stereotypical description derived from pediatric studies.
CO-99 Severe hyperglycemia in 1000 ICU patients: a higher mortality rate and a higher incidence of diabetes in a long-term follow-up study
Ben Hamou Adrien1, Robriquet Laurent1, Kipnis Eric1, Voisin Benoit1, Preau Sebastien1, Tamion Fabienne2, Vanbaelinghem Clement3, Thellier Damien4, Du Cheyron Damien5, Bignon Anne1, Poissy Julien Jaillette1, Emmanuelle, Jourdain Merce1
1CHRU LILLE, Lille, France; 2CHU ROUEN, Rouen Cedex, France; 3CH ROUBAIX, Roubaix, France; 4CH TOURCOING, Tourcoing, France; 5CHU CAEN, Caean, Francezz
Correspondence: Ben Hamou Adrien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-99
Introduction: Stress hyperglycemia frequently occurs in critically ill patients independently of preexisting diabetes. Some studies suggest an association with poor prognosis. The aim was to evaluate 28 and 90-day mortality after admission to the intensive care unit and the incidence of diabetes during follow-up at 6 and 12 months in patients who presented a severe hyperglycemia in their first 3 days in the ICU (glycemia > 200 mg dL, > 2 samples).
Patients and methods: We conducted a prospective multicentric study between April 2012 and August 2016 in French ICUs. Patient’ characteristics, medical history, blood tests, aetiology of ICU admission and organ dysfunctions were collected. Patients were divided into 4 groups—diabetic patients with severe hyperglycemia (HD), non-diabetic with severe hyperglycemia (HND), diabetic without severe hyperglycemia (NHD) and non-diabetic without severe hyperglycemia (NHND). Kaplan–Meier estimator was used to analyze survival adjusted to disease severity (Logistic Organ Dysfunction, Simplified Acute Physiology Score, Knaus, McCabe scores) and Kaplan–Meier survival curves were compared by Cox proportional hazards test. Fasting glycaemia above 126 mg dL was used to diagnose diabetes at 6 or 12 months.
Adrien BEN HAMOU The Kaplan–Meier survival curve Abstract SRLF 2018.
Results: 991 out of the 1000 enrolled patients were analyzed (62% men). Median age was 61 years old, median Body Mass Index was 27 kg m2 + 236 patients (24%) were diabetic. Among the 991 patients, 413 (42%) presented severe hyperglycemia and had a significant increase in mortality at day 28 (HR = 1.87, IC 95% [1.36–2.56], p = 0.0001), and day 90 (HR = 1.72, IC 95% [1.33–2.22], p < 0.0001), independently of the cause of death. Severe hyperglycemia was associated with increased mortality risk at days 28, when patients were admitted for shock, except septic shock, (HR = 1.70, IC 95% [1.01–2.87], p = 0.04) but not when admitted for coma, sepsis or cardiac arrest. Mortality rate was significantly higher in patients with severe hyperglycemia compared to those without, regardless of preexisting diabetes (HND HD vs. NHND NHD groups + p < 0.05). Patients with severe hyperglycemia had a higher incidence of type 2 diabetes at 6 (16 vs. 8% + p = 0.01) and 12 months (14 vs. 9% + p = 0.08) compared to those who did not.
Conclusion: Severe hyperglycemia occurring in the first 3 days of ICU admission was associated with higher mortality rate and an increased risk of diabetes in the following months regardless of preexisting diabetes.
CO-100 Relation between level of 25OH-vitamine D at ICU patient admission and outcomes
Khaldi Amina1, Prevedello Danielle1, Mickael Gardette1, Autphenne Myriam1, Preiser Jean Charles1
1Hopital ERASME, Bruxelles, Belgium
Correspondence: Khaldi Amina - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-100
Introduction: Vitamin D deficiency is frequent in Northwestern countries and could represent a modifiable risk factor for critically ill patients, in relation with its pleiotropic effects (1). Some studies reported an association between 25OH vitamin D (25OH) deficiency, chronic health status and ICU- and hospital-related outcomes. However, a large supplementation study have not been found to improve outcome of patients with moderate 25OH deficiency (< 20 ng ml) (2). The aim of the study is to analyze the relationship between the severity of 25OH deficiency at ICU admission, severity of illness and outcomes and ultimately to identify subgroups of patients in whom the likelihood of benefit of supplementation is larger.
Patients and methods: Consecutive patients admitted over a 4-month period who stayed at least 48 h in a medical surgical 32-bed ICU were included. In these patients, demographic data, Charlson co-morbidity score, severity scores (SAPS 3 and SOFA) and 25-OH (chemiluminescence, DiaSorin) were collected at admission. ICU and hospital length of stay (LOS) and mortality were recorded. Correlations were searched between 25OH and the different scores, and vital outcomes by non-parametric tests for continuous value and by cross dynamic board for categorical variables.
Results: A total of 185 patients have been analyzed. The mean (SD) age was 66 (15) years, and 50% were men, most often admitted for a medical reason (57.8%), Charlson score 2.5 ± 2.9, SAPS III 56.2 ± 20.5, SOFA 5.5 ± 4.5, ICU (LOS) 8.2 ± 9.2 days, Hosp LOS 28.4 ± 27.5 days, ICU mortality 17.8%, hospital mortality 23.8%. The mean 25OH at admission was 16.9 ± 11.5 ng ml. 25OH deficiency (> 20 ng ml) in 69.7%, severe deficiency (> 12 ng ml) in 47.5%, and a moderate deficiency (12–20 ng ml) in 22.2%. However, there was no correlation between vitamin D level at ICU admission, severity of illness, mortality and LOS (Fig. 1).
Conclusion: These findings confirm the high incidence of severe 25OH deficiency and a possible relation with a higher mortality in the subset of long-stayers. It reflects a marker of poorer health. Specific subsets of patients could benefit from vitamin D supplementation.
CO-101 Diagnosis, management and outcome of severe hypothyroidism in ICU: an observational multicenter study
Bourcier Simon1, Coutrot Maxime1, Van Grunderbeeck Nicolas2, Azoulay Elie3, Hraiech Sami4, Aissaoui Nadia5, Delmas Clément6, Ferré Alexis7, Messika Jonathan8, Terzi Nicolas9, Nseir Saad10, Carreira Serge11, Persichini Romain12, De Montmollin Etienne13, Reuter Danielle14, Contou Damien15, Lautrette Alexandre16, Bigé Naïke17, Lascarrou Jean-Baptiste18, Sztrymf Benjamin19, Combes Alain1, Schmidt Matthieu1
1Hôpital Pitié-Salpêtrière, Paris, France; 2CH de Lens, Lens, France; 3CHU Saint-Louis, Paris, France; 4CHU de Marseille - Hôpital Nord, Marseille, France; 5Hôpital Européen Georges Pompidou, Paris, France; 6CHU Toulouse - Hôpital Rangueil, Toulouse, France; 7CH de Versailles, Le Chesnay, France; 8Hôpital Louis Mourier, Colombes, France; 9CHU de Grenoble - Hôpital A. Michallon, Grenoble, France; 10CHRU de Lille - Hôpital Roger Salengro, Paris, France; 11Hôpital Saint-Camille, Bry -Sur-Marne, France; 12CHU La Réunion - Hôpital Felix Guyon, Saint-Denis, France; 13CH de Saint-Denis - Hôpital Delafontaine, Saint-Denis, France; 14CH Sud Francilien, Corbeil-Essonnes, France; 15CH d’Argenteuil, Argenteuil, France; 16CHU Gabriel Montpied, Clermont-Ferrand, France; 17CHU Saint-Antoine, Paris, France; 18CHU de Nantes, Nantes, France; 19CHU Antoine-Béclère, Clamart, France
Correspondence: Bourcier Simon - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-101
Introduction: Severe hypothyroidism manifestations including myxedema coma and tamponnade frequently lead to intensive care unit (ICU) admission. To date, data on this severe disease in ICU are scarce and limited to case reports. We aimed to describe clinical presentation, management and outcomes of severe hypothyroidism admitted in ICU.
Patients and methods: Local diagnoses coding database (from January 2000 to July 2017) from 15 French ICU were interrogated for main and secondary related to hypothyroidism and myxedema coma in the International Classification of Disease 10th revision. Two investigators therefore reviewed all medical records selected. Inclusion criteria were severe patients whom severe clinical hypothyroidism manifestations were the main reason for ICU admission. Clinical presentation, therapy used, and outcome were recorded.
Results: We report the preliminary data of 40 patients (80% female + median age 70 years (65–76) + SAPSII 58 (41–74)). Hypothyroidism was unknown before ICU admission in 68% patients. Median SOFA score at ICU admission was 6 (4–10). Myxedema coma, circulatory failure, respiratory failure, and severe hypothermia were respectively the main admission reason in 60, 18, 10, and 5% patients. A precipitating factor such as drugs thyroid toxicity, thyroid hormone withdrawal or infection was found out in only 13 (32%) patients. Main causes of hypothyroidism were thyroiditis and thyroidectomy. Thirty-two (80%) patients had alteration of consciousness with a median Glasgow score at 10 (6–13). In addition, median heart rate at ICU admission was 50 (35–65) bpm while hypothermia < 35 °C was noted in 24 (60%) patients. Median TSH level at admission was 78 (43–135) mUI l, T3 and T4 levels respectively 0 (0–0.45) pmol l and 2 (0–5.07) pmol l. Rhabdomyolysis was frequent with median CPK level 539 (192–1500) UI l. Organ support including mechanical ventilation, catecholamine infusion and, renal replacement therapy were respectively used in 58, 45, and 20% patients. Lastly, 70% patients received oral levothyroxine whereas the intravenous form was used in others. Overall ICU-mortality was 22%.
Conclusion: Our preliminary data showed that severe manifestations of hypothyroidism leading to ICU admission represent de novo hypothyroidism in two-thirds of patients, leading to a high mortality.
CO-102 Central nervous system infections management in the ED: a race against time!
Le Borgne Pierrick1, Perriguey Arnaud1, Dascalu Elena1, Ugé Sarah1, Kauffmann Philippe1, Kam Claire1, Quoirin Etienne1, Bilbault Pascal1
1CHU Strasbourg, Strasbourg, France
Correspondence: Le Borgne Pierrick - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-102
Introduction: When it comes to infections of the central nervous system (CNS), the greatest challenge in the Emergency Department (ED) is to identify patients that have a rare life-threatening diagnosis. Alone or in combination, fever, headache, altered mental status encompass a broad differential diagnosis. Antibiotics or antiviral therapy should be given as soon as possible, ideally after both blood and cerebrospinal fluid (CSF) have been obtained. Early treatment is associated with a lower mortality.
Patients and methods: We present here, a four-year (2012–2015) retrospective and monocentric study. During the period of the study, we included all adult patients with the diagnosis of CNS infection (positive CSF culture). We collected and analyzed all clinical, biological, imaging, treatments and evolution datas during the stay. A total of 67 patients with CNS infection have been included for statistical analysis. We analyzed a second group (n = 25) with suspected CNS infection (negative CSF) as a control group.
Results: In the study population, mean age was 43 ± 21.5 years old and the sex-ratio was 1.2. There were no difference between the two groups in terms of clinical signs except for more altered mental status in the control group (p = 0.02). All patients of the study (n = 92) benefited of lumbar puncture (LP) in the ED with an average time of 381 ± 370 min after admission. This delay was the same between the two groups (p = 0.76) but was significantly higher in the encephalitis subgroup (n = 13, p = 0.03). Patients who had imaging (CT or MRI) during the ED stay had more likely a delay in LP realization (450 vs 193 min, p = 0.0005). Patients where the CNS infection diagnosis was firstly evoke by the triage nurse had LP more quickly (p = 0.03). The median door to-antibiotic-time was 339 min (IQR 198–534) with no difference between the two groups of the study (p = 0.7). 94% of all patients were hospitalized for an average length of stay of 11.7 ± 15.5 days and 10% of them were admitted in the ICU. The in-hospital mortality was 14% in the study population.
Conclusion: Our study highlights the poor adherence to guidelines. The management of CNS infections remains slow and heterogeneous. Management practices, such as the timing of LP realization or antibiotics in relation to the return of CT scan or CSF results are the most important factors associated with antibiotic timeliness.
CO-103 Viral acute exacerbations of chronic obstructive pulmonary disease (COPD)
Elabbadi Alexandre1, Gounane Chérifa1, Gibelin Aude1, Taconet Clémentine1, Voiriot Guillaume1, Fartoukh Muriel1
1Hôpital Tenon, Paris, France
Correspondence: Elabbadi Alexandre - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-103
Introduction: There are numerous causes of acute exacerbations of COPD (AECOPD), the most common of which are bronchial and or pulmonary infections. Viral etiologies may account for 30% of AECOPD, but this rate is likely underestimated because of the limited performance of the conventional diagnostic tests. Multiplex molecular diagnostic tests may identify several pathogens including viruses and bacteria, from a single respiratory tract sample, with high sensitivity. Using these tests, respiratory viruses are identified in 30 to 60% of cases, according to the series. The objective of this work was to describe the microbial epidemiology, the management and the outcome of patients admitted to the intensive care unit (ICU) with moderate to severe AECOPD, in the era of multiplex testing.
Patients and methods: A prospective non interventional multicenter study conducted in two university-teaching hospitals. In addition to the usual samplings, a nasopharyngeal swab was performed for multiplex polymerase chain reaction (PCR), using respiratory panels FilmArray Biomérieux (17 viruses and 3 bacteria) or ePlex automaton (22 viruses and 4 bacteria) depending on the center.
Results: The preliminary results involve the 37 patients (29 males + 70 years (55–87)) included in Tenon hospital over a 6-month period. The mean FEV1 was 37% (21–60) median 35% [31–44]. Drug therapies included anticholinergics (n = 21 + 62%) and beta-2-mimetics (n = 24 + 71%), inhaled (n = 16 + 47%) or oral (n = 2 + 6%) steroids, and azithromycin (n = 5 + 23%). A respiratory virus was identified in 11 patients (30%), alone or in combination with a bacterium (n = 6). A bacterial pathogen was identified alone 9 times (21%). Therapeutic interventions did not differ depending on whether a virus was detected or not-exposure to antibiotics (10 ± 1.8 vs. 12.5 ± 2 d + p = 0.4), administration of oseltamivir (5/6 vs. 8/18 + p = 0.39), steroids (1/7 vs. 3/15 + p = 0.12) and mechanical ventilation (11/11 vs. 20/26 + p = .08). The ICU length of stay (5.8 ± 0.8 vs. 7.8 ± 1.1 d + p = 0.29) was similar. The ICU and 90d-mortality rates were 5.4 and 13.5%, respectively.
Conclusion: Respiratory viruses are frequently involved in moderate to severe AECOPD. The respiratory multiplex PCR should be performed in this setting and the results should be taken into account to more adequately use the anti-microbial treatments.
CO-104 Community-acquired co-infection in severe imported falciparum malaria in adults
Roujansky Ariane1, Missaoui Lamia1, Wolff Michel2, Matheron Sophie2, Roy Carine2, Biard Lucie3, Bruneel Fabrice3
1Paris, France; 2CHU Bichat, Paris, France; 3CHU de Versailles, France
Correspondence: Roujansky Ariane - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-104
Introduction: Co-infections during severe malaria have been widely studied among children in the endemic setting and there is evidence they result in worse outcome. Little is known about the epidemiology and impact of these co-infections (community-acquired or nosocomial) in the course of imported malaria in adults. We sought to describe community-acquired co-infections in severe imported malaria (SIM) in adults and to identify associated factors.
Patients and methods: We conducted a multicenter observational study in 52 French intensive care units (ICU), derived from a retrospective (2000–2006) and a prospective (2007–2010) study. We identified patients admitted for severe imported falciparum malaria according to 2000 World Health Organization (WHO) criteria adapted for imported malaria. Community-acquired co-infection was defined as an infection diagnosed within the first 48 h following ICU admission. Clinical and demographic data were collected from medical charts using standardized case-report forms. Factors associated with community acquired co-infection were identified by univariate and multivariate analysis.
Results: Between 2000 and 2010, 555 patients were admitted for SIM. Mean age was 44 years, and males represented 69% of our population. All patients were treated by intravenous quinine. Among them 119 patients (21%) presented with at least one episode of co-infection, including 42 (35%) community-acquired episodes and 77 (65%) of nosocomial origin. Overall in-hospital mortality was 9% with no significant difference between patients with or without co-infections at admission. Among community-acquired co-infections (n = 42), pulmonary infection (43%), bacteraemia (31%), and urinary tract infection (12%) were the most common + Escherichia coli, Streptococcus pneumoniae, Pseudomonas aeruginosa and non-pneumoniae streptococci were predominant (16, 12, 10 and 10% of bacterial isolates respectively). By multivariate analysis, 3 variables at ICU admission were independently associated with community-acquired co-infection—male sex, respiratory distress (WHO modified criteria—requirement for noninvasive and or endotracheal mechanical ventilation, or spontaneous breathing with PaO2 < 60 mmHg (if FiO2 0.21), and or respiratory rate > 32 min), and acidosis (WHO criteria—pH < 7.35 or serum bicarbonate < 15 mmol L) (Table 1).
Conclusion: Our study shows that in a large population of adults admitted to ICU for SIM, 7.5% have a community-acquired co-infection, mainly bacteraemias and pulmonary infections. These results emphasize the need to search for co-infection in these patients and make therapeutic adaptations accordingly. Male sex, respiratory distress and acidosis at admission may help to identify patients most at risk.
CO-105 Severe leptospirosis in metropolitan France, a retrospective multicentre study
Miailhe Arnaud-Félix1, Le Thuaut Aurélie1, Lascarrou Jean-Baptiste1, Bourhy Pascale2, Grall Maximilien3, Henry-Lagarrigue Mathieu4, Mercier Emmanuelle5, Maamar Adel7, Sedillot Nicolas8, Goursaud Suzanne8, Reignier Jean1
1CHU de Nantes, France; 2Institut Pasteur, Paris, France; 3CHU de Rouen, France; 4CHU de La Roche-Sur-Yon, France; 5CHU de Tours, France; 6CHU de Rennes, France; 7CHU de Bourg En Bresse, France; 8CHU de Caen, France
Correspondence: Miailhe Arnaud-Félix - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):CO-105
Introduction: Leptospirosis is a worldwide zoonosis, and is more common in tropical area. Epidemiological data reported increased incidence during the past 10 years in Metropolitan France. Most of the cases are asymptomatic or sparsely symptomatic, but some patients develop severe leptospirosis, requiring hospitalisation in intensive care units (ICU). Only few studies exist on severe leptospirosis and data on severe leptospirosis in Europe are very scarce. We performed a retrospective multicentre study in metropolitan France in order to identify the characteristics, treatments and prognostic factors of severe leptospirosis in this context.
Patients and methods: LeptoRea was a retrospective multicentre study performed in 73 French ICUs. Each unit was requested to include all the patients admitted in ICU, between 2012 and September 2016, over than 18 years old, and with leptospirosis diagnosed with at least one positive test (PCR, MAT, ELISA). For each patient, a case report form was completed and hospitals report was sent to the study coordinator (AFM). A descriptive analysis was performed to assess the patients characteristics, treatments received and mortality rate. A univariate analysis was performed to identify factors associated with mortality.
Results: Of the 73 participating ICUs, 26 (35.6%) did not admit any patient with leptospirosis during the study period. 147 patients were included. 90% were male. Median age (years) and IGS2 [95% CI] were 54 [38 + 65] and 39 [28 + 56], respectively. Median delay between the onset of symptoms and ICU admission was 5 [4 + 6] days. Risk factors for leptospirosis and pre-existing comorbidities are detailed in the Table 1. Median SOFA score on day 1 [95% CI] was 10 [8 + 4]. 52 (35%) patients had ARDS and 23 (16%) had intra-alveolar haemorrhage. During their ICU stay, 85 patients (58%) were treated with vasoactive support, 52 (35%) with mechanical ventilation and 50 (34%) patients received renal replacement therapy. Median ICU and hospital length of stay were 4 [2 + 10] and 11 [7 + 17] days. ICU mortality was 8.9%.
Conclusion: This study is the first large multicenter study on severe leptospirosis in Metropolitan France and the world’s largest series on leptospirosis in ICU. Our data show that severe leptospirosis is uncommon in ICUs of Metropolitan France. Despite high IGS2 and SOFA score, mortality rate was lower than expected and previously reported.
CO-106 Functional outcomes in adult patients with herpes simplex encephalitis admitted to the ICU: the HERPETICS multicenter study
Jaquet Pierre1, De Montmollin Etienne2, Dupuis Claire1, Sazio Charline3, Conrad Marie4, Susset Vincent5, Demeret Sophie6, Argaud Laurent7, Barbier François8, Sarton Benjamine9, Chabanne Russel10, Daubin Delphine11, Brulé Noelle12, El Kalioubi Ahmed13, Alves Mikael14, Tadie Jean-Marc15, Bouadma Lila1, Timsit Jean-François1, Sonneville Romain1, Encephalitica Study Group16
1Hopital Bichat, Paris, France; 2Hopital Delafontaine, Paris, France; 3CHU de Bordeaux, France; 4CHU de Nancy, France; 5CHU de Chambery, France; 6Hôpital Pitié-Salpêtrière, Paris, France; 7Hôpital Edouard Herriot, Lyon, France; 8CHU d’Orléans, France; 9CHU de Toulouse, France; 10CHU de Clermond-Ferrand, France; 11CHU de Montpellier, France; 12CHU de Nantes, France; 13CHU de Lille, France; 14CHU de Poissy, France; 15CHU de Rennes, France; 16Paris, France
Correspondence: Jaquet Pierre - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):CO-106
Introduction: Herpes simplex encephalitis (HSE) remains the most common infectious cause of encephalitis in Europe and is associated with a poor prognosis. Little is known about management and functional outcomes of severe HSE cases requiring ICU admission. This study aimed to identify factors associated with poor neurological outcome in HSE patients admitted to the ICU.
Patients and methods: We conducted a large retrospective multicenter study on consecutive patients diagnosed with HSE in 46 ICUs in France, between January 2006 and December 2016. Patients were included if they met the International Encephalitis criteria for confirmed HSE, i.e. an acute encephalitis syndrome and a positive cerebrospinal fluid PCR for Herpes simplex virus. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3–6 (indicating severe disability or death) on the modified Rankin Scale (mRS). Data are presented as number (percentage) or median [interquartile range].
Results: Overall, 227 patients (age 64 [55–73] years) with confirmed HSE (HSV-1 infection—181 (95.8%) patients) treated with intravenous acyclovir were included. SAPS2 score was 43 [32–56] and 43 (18.9%) were immunocompromised. At ICU admission, the score on the GCS was 9 [6–12], body temperature was 38.7 [38–39.2] °C, seizures and status epilepticus were present in 78 (34.4%) and 22 (9.7%) patients, respectively. Invasive mechanical ventilation was required in 148 (65.2%) patients, and 33 (14.6%) received norepinephrine. Acyclovir was initiated 0 days [-1–0] after ICU admission at a dose of 10 [10–11.9]mg/kg/8 h for 21 [20–21] days. ICU and hospital mortality were 14.5% (n = 32) and 18.6% (n = 40), respectively. At 90 days, 164 (72.2%) patients had a poor outcome (including 43 (18.9%) deaths). Multivariate logistic regression analysis identified older age, immunocompromised status, body temperature > 38.5 °C, invasive mechanical ventilation at admission and MRI brain lesions > 3 lobes to be independently associated with poor outcome. By contrast, direct admission to the ICU (versus initial ward admission) and early brain MRI had a protective effect (Table 1). Status epilepticus, hemodynamic, renal, coagulation or hepatic failures had no impact on outcome.
Conclusion: In adults with HSE requiring ICU admission, only 28% patients had functional independence at 90 days (mRS 0–2). Immediate ICU admission, early brain MRI and elevated body temperature represent modifiable factors that may impact patients’ outcome.
F-01 Prophylactic non invasive ventilation after extubation in severe brain injured patients
Zarrouki Youssef1, Ait Souabni Sara2, Ziadi Amra2, Samkaoui M Abdenasser2
1CHU Mohammed VI, Marrakech, Morocco
Correspondence: Zarrouki Youssef - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-01
Introduction: Prophylactic non-invasive ventilation (NIV) is a well established method for prevention of post-extubation acute respiratory failure in hypercapnic patients. However, its role in the post-extubation period, in traumatic brain injury patients, is uncertain. Especially, because of effects of the brain injury, on respiration and airway control. We perform a study to assess the impact of prophylactic NIV after extubation among patients with severe traumatic brain injury.
Patients and methods: Over a period of 1 year, adult patients with isolated severe traumatic brain injury, who were under invasive mechanical ventilation for more than 48 h were eligible for inclusion in the study. They were randomized, after decision of extubation, to receive conventional therapy or conventional therapy associated with NIV. Conventional therapy consisted of oxygen delivery by facial mask, semi-recumbent position, mucus suctioning and nebulization therapy. The main objective of the study is to assess the impact on reintubation rate. Extubation succes was defined by the absence of need for reintubation within the 7 days. The secondary objective is to evaluate the effect on ICU length of stay after extubation.
Results: Fifty-three patients ranging in age from 17 to 61 years, were included in the study. They have no history of respiratory disease. 26 patients to receive NIV and 27 to receive conventional therapy. NIV was delivered with mean levels of inspiratory positive-airway pressure of 11.1 ± 1.8 cm H2O and expiratory positive-airway pressure of 5 ± 1.00 cm H2O for a mean period of 19.85 ± 10 h for 6 to 11 h day. Reintubation rates among NIV group (34.61%) and conventional group (44.44%) were similar (p = 0.39). The duration of intensive care unit stay after extubation (8.5 ± 2.55 vs 9.35 ± 1.72 days, p = 0.83) in both groups were comparable.
Conclusion: NIV is safe to use in severe brain injured patients soon after extubation, although clear benefit is not documented in this study. In order to establish a potential benefit of NIV in this type of patients, it is probably necessary to study it in the subgroup of hypercapnic patients in the post-extubation period.
F-02 Non-invasive ventilation in acute hypoxemic respiratory failure
Cayrol Elsa1, Guesdon Charlotte2, Vargas Frédéric1, Georget Aurore3, Bui Hoang-Nam1, Sazio Charline1, Gruson Didier1, Boyer Alexandre1, Clouzeau Benjamin1, Pillet Odile1, Hilbert Gilles1
1CHU Bordeaux, Bordeaux, France; 2CH Pau, Pau, France; 3Université de Bordeaux (ISPED), Bordeaux, France
Correspondence: Cayrol Elsa - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-02
Introduction: The clinical benefit of non-invasive ventilation (NIV) in patients with acute hypoxemic respiratory failure (ARF) is being called into question. Indeed, in a multicenter randomized trial recently conducted in hypoxemic ARF patients (Pa02 Fi02 < 300), intubation rate in the NIV group was 50% and intensive care unit (ICU) mortality rate was 25%, numbers higher than in the standard-oxygen group (1). An excessive tidal volume under NIV is a hypothesis to explain these bad outcomes (2). Our experience does not seem to support these data. Therefore we wanted to—investigate the rate of NIV success in hypoxemic ARF and global in-ICU mortality. Estimate the average expired tidal volume and identify predictive factors of NIV failure.
Patients and methods: Observational cohort study conducted in a medical ICU, including all patients treated with NIV for hypoxemic ARF over a 3 years period.
Results: During the study period, 57 patients were included (mean age 57.9 ± 15.1 years, median SAPS II 43 (29–54), median Pa02 Fi02 151 (111–186)) and 23 had acute respiratory distress syndrome (ARDS). Intubation rate was 28.1% and in-ICU mortality was 14%. Patients with a Pa02 Fi02 ratio < 150 during the first NIV session had a mortality rate five times higher than those with a Pa02 Fi02 ≥ 150 (37.5 vs 7.3% p = 0.047). More than 2000 h of NIV were analysed. Median expired tidal volume was 10 ml/kg of predicted body weight (PBT) (8–11 ml/kg PBT), whether the patients were intubated (NIF failure) or not (NIV success). In multivariate analysis, only the presence of ARDS was independently associated with NIV failure.
Conclusion: With a success rate of 71.9% and a mortality rate of 14% it seems legitimate not to exclude VNI of the management of patients with hypoxemic ARF. Moreover, the hypothesis of a deleterious effect related to an excessive tidal volume has not been confirmed in our study.
F-03 Non-invasive ventilation following unplanned extubation: Is it a suitable option?
Kudela Agathe1, Prat Dominique1, Jacobs Frédéric1, Millerux Maude1, Moneger Guy1, Dumenil Anne Sylyvie1, Demars Nadege1, Trouiller Pierre1, Sztrymf Benjamin1
1Hôpital antoine Béclère, Clamart, France
Correspondence: Kudela Agathe - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-03
Introduction: Unplanned extubation (UE) occurs in up to 33% of ICU patients. Reintubation is required in 28.5 to 74.7% because of respiratory failure, or other hemodynamic, neurologic or laryngeal matter. Very few data is available regarding the effect of non-invasive ventilation (NIV) performed after UE.
Patients and methods: Retrospective analysis of prospectively collected data on a 4 years period. A NIV local procedure, based on current guidelines, is available in the investigating centre, but UE is not mentioned. The decision to perform NIV in this setting was only based on the attending physician’s judgment. All patients experiencing an UE were included. We registered demographic data, patient’s characteristics and evolution after UE according to the occurrence of NIV. Prophylactic NIV denoted NIV performed after extubation without sign of respiratory failure, whereas curative NIV was a mean to treat post extubation respiratory failure.
Results: 106 UE occurred during the study period. Age was 59.4 [41.1–74.4] years, SAPS II 45 [36–54]. Reintubation was needed in 30 cases, within 1.8 [0.33–21.5] hours after UE, mostly for acute respiratory failure (n = 25). The death was associated with the need for reintubation (10 30 vs 0 76, p < 0.0001). NIV was performed in 21 cases. In all but 8 patients, NIV was used to treat an acute respiratory failure, the remaining indications being described as preventive of reintubation without evidence of respiratory failure. Respiratory failure as an indication for NIV was more often associated with reintubation (10/13 vs. 1/8, p = 0.008). NIV was also associated with death (5/21 vs. 5/85, p = 0.02). As a comparison, during the same period, 536 patients ventilated at least 48 h had a planned extubation (age 67 [54–80] years, SAPS II 49 [35–62]). Regarding NIV in this subgroup, data were available in 438 patients. NIV was used 141 times, with prophylactic NIV being more frequent (n = 118) as compared to rescue NIV (n = 23). Reintubation rates were similar as compared to UE patients for prophylactic NIV (16 118 vs. 1 8, p = 0.94) and rescue NIV (9 23 vs. 10 13, p = 0.26).
Conclusion: Though limited by its design, our study seems to show a similar efficacy of NIV following UE as compared to planned extubation, with a safety concern for rescue NIV and a potential interest for “prophylactic” NIV. Further data is warranted.
F-04 Predictive factors of noninvasive ventilation failure during acute respiratory failure due to bronchiectasis exacerbation
Lahmar Manel1, Tilouche Nejla1, Mnif Karama1, Sikali Habiba1, Gharbi Rim1, Fekih Hassen Mohamed1, Elatrous Souheil1
1EPS Taher Sfar, Mahdia, Tunisia
Correspondence: Lahmar Manel - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-04
Introduction: Noninvasive ventilation (NIV) is the gold standard in the treatment of COPD exacerbation. NIV in acute respiratory failure (ARF) due to bronchiectasis exacerbation remain less recommended. Objectives—to evaluate the utility and factors predicting failure of NIV during bronchiectasis exacerbation.
Patients and methods: we conducted a retrospective study between 2001 and 2016 in the Medical intensive care unit in the hospital of Taher Sfar in Mahdia. All patients with bronchiectasis exacerbation and requiring NIV were enrolled. Only the first episode of exacerbation was recorded and analyzed. At admission we collected the following parameters—demographic details, etiology of exacerbation, comorbidities, the SAPSII score, arterial blood gases, respiratory, hemodynamic and neurologic parameters, NIV failure, nosocomial infection, duration of NIV, length of stay and mortality.
Results: 4900 patients were hospitalized in our medical intensive and 89 patients met the inclusion criteria. Bronchiectasis was associated with other pulmonary diseases in 16 patients. Bronchitis was the most common etiology of exacerbation (56%). three patients pseumononas aeruginosa in sputum cultures. NIV was successful in 71% of patients. The mortality was 19%. Length of stay was 12 ± 10 daysThe NIV failure group was older 67 ± 14 vs 59 ± 18, had a lower pH (7.25 ± 0.96 vs 7.31 ± 0.068) and elevated SPAS II score (33 ± 15 vs 24 ± 10). Factors associated with NIV failure were the SAPSII score (OR 2, IC 95% (1.5–3.02), p = 0.038) and the pH at admission (OR 6, IC 95% (2.04–8.06), p = 0.012). Nosocomial infection (54 vs 5%) and mortality (30 vs 2%) were significantly lower in NIV success group. However, Duration of NIV and length of stay were similar between the two groups.
Conclusion: NIV in bronchiectasis exacerbation reduce mortality and nosocomial infections. The rate of NIV failure was high. The SAPSII score and pH were the predictive factors of NIV failure.
F-05 Evaluation of the risk of hyperoxia-induced hypercapnia in obese cardiac surgery patients: crossover comparison of two saturation targets and two oxygen titration modes
Denault Marie-Hélène1, Ruel Carolanne1, Simon Mathieu1, Bouchard Pierre-Alexandre1, Lellouche François1
1Institut universitaire de cardiologie et de pneumologie, Québec, Canada
Correspondence: Denault Marie-Hélène - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-05
Introduction: Noxious effects of hyperoxia have been described for more than 60 years. Recent studies on stable obesity-hypoventilation syndrome (OHS) patients have risen concern about hyperoxia-induced hypercapnia in this population, but many questions remain unanswered. How important is this risk in acute care? Is there a risk in non-OHS obese patients as well? This study aims to evaluate the risk of hyperoxia-induced hypercapnia in post-op obese cardiac surgery patients.
Patients and methods: 30 obese patients (BMI > 30) having coronary artery bypass grafting (CABG) are currently being recruited. Informed written consent is obtained before inclusion. With a crossover design, we are comparing two oxygenation strategies immediately after extubation, in terms of their effect on arterial partial pressure of carbon dioxide (PaCO2)—a peripheral oxygen saturation (SpO2) target of > 95% achieved with manual titration (control period) and a SpO2 target of 90% achieved with automatic titration by a closed-loop system (FreeO2 period). Every patient is delivered oxygen according to both strategies for 30 min each, in a randomized order. FreeO2 (Oxynov, Québec, Canada) is a closed-loop oxygen delivery system which titrates oxygen flow according to the patient’s real-time SpO2 and a target set by the physician. SpO2, oxygen flow and heart rate are continuously recorded by FreeO2 during both periods. Hemodynamic parameters are checked at 10 min intervals and arterial blood gases are collected at the end of each period. The primary outcome is the change in PaCO2 between periods.
Results: 17 patients have been included so far and data for 16 patients are presented here. 13 are men, mean age is 60 ± 8 years and mean BMI is 34 ± 4 kg m2. 9 patients are responders, as shown by an elevation in PaCO2 in control period compared to FreeO2 period, and 7 patients are non-responders. Two distinct oxygenation profiles are being studied (see Fig. 1). The mean SpO2 for FreeO2 period is 91.1 ± 1.3% while it is 97.2 ± 1.4% for control period. Mean oxygen flow is 0.7 ± 0.7 L min for FreeO2 period (equivalent to < 24% FiO2) while mean FiO2 is 51 ± 10% for control period.
Conclusion: FreeO2 is helpful in maintaining oxygenation within target. High SpO2 values may cause an elevation in PaCO2 in obese patients after CABG, but more analyses are required for this outcome. Characteristics of responders and non-responders will be analyzed after study completion.
F-06 Automated patient-ventilator asynchrony monitoring in the ICU (CURVEX)
L’Her Erwan1, Hourmant Baptiste2, N’Guyen Quang-Thang3, Pateau Victoire2, Lellouche François4
1LATIM INSERM UMR 1101, Brest, France; 2CHUY de la Cavale Blanche, Brest, France; 3Oxynov, Plouzané, France; 4Centre de Recherche de l’IUCPQ, Québec, Canada
Correspondence: L’Her Erwan - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-06
Introduction: Optimal patient-ventilator synchronisation improves patients’ comfort and avoids unnecessary WOB. Asynchronisms are currently diagnosed by direct bedside ventilatory curves analysis, which is yet operator dependent and time-consuming, or by invasive methods including esophageal pressure or diaphragmatic electromyogram measurements. The main purpose of this study was to assess the relevance of Curvex as a noninvasive diagnostic and classification tool for asynchronism management.
Patients and methods: This project is based on a prospective physiological tracing data-warehousing program (Rea STOC, clinicaltrials.gov # NCT02893462) that aims to record 1500 consecutive ICU patients, over 3-years. All consecutive patients were recorded for a 2-hours period during 24-h following ICU admission. All measurements were recorded with the patient laying supine, with a 30° bed angulation. Raw ventilatory pressure and flow curves were transferred to a centralized server using a dedicated network. The physician in charge of the study was informed of the online analysis on a routine basis. Physiological recordings were associated with metadata collection. Asynchronisms detection is based on a non-parametric hypothesis testing (Random Distortion Testing), that requires no prior information on the signal distribution. Beside Asynchrony Index monitoring (AI), five asynchronism’s types were qualified—ineffective efforts (IE), short cycles (SC), multiple cycles (MC), prolonged inspiration (PI) and premature cycling (PC).
Results: 72 patients were included (age 61.2 ± 13.8 yr + 52 male 20 female + SAPS II 53.6 ± 2.4), of whom 15 with chronic respiratory diseases. Reason for admission was respiratory distress (47%), hemodynamic failure (29%), and neurological failure (22%). 92% patients where under invasive mechanical ventilation (12.8 ± 18.7 days) and 32% under sedation. Asynchronies were frequent (less 10% patients with AI < 10%) and mean AI was 34 ± 18%. IE were the most frequent asynchronisms (39.7 ± 28.6%). Concordance between visual and automatic evaluation was 97.2%. An attempt to reduce AI according to a standardized protocol was performed in 56/72 patients. Significant AI reduction (≥ 10%) was observed for only 10 patients (mean AI reduction = 15.5 ± 3.9%). PC were reduced for 28/56, SC for 27/56, PI for 25/56, MC for 25/56, and IE for 20/56 patients. No correlation was depicted between AI and patients status.
Conclusion: Asynchronies are frequent during MV and can be efficiently and noninvasively monitored using Curvex. The impact of asynchronism on patients’ prognosis and the availability of correction measures require further investigation.
F-07 Early mechanical ventilation in patients with Guillain-Barré syndrome at high risk of respiratory failure: a randomized, controlled study
Melone Marie-Anne1, Mompoint Dominique2, Aboab Jérôme2, Meng Paris2, Clair Bernard2, Salomon Jérôme2, Sharshar Tarek2, Orlikowski David2, Annane Djillali2
1Rouen, France; 2Hôpital Raymond Poincaré
Correspondence: Melone Marie-Anne - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-07
Introduction: About 30% of patients with Guillain-Barré syndrome (GBS) need mechanical ventilation (MV), of whom roughly 75% may develop pneumonia, in particular those with swallowing impairment. This trial aimed at assessing the benefit of early mechanical ventilation (EMV) in the prevention of onset of pneumonia in GBS patients.
Patients and methods: Design—this was a single centre, open-label, randomized controlled trial performed on two parallel groups. Patients—50 ICU adults admitted for GBS and risk factors for endotracheal intubation, i.e. time from onset to admission of < 7, inability to lift the head, and forced vital capacity of < 60%. Intervention—patients were randomized to receive EMV via face mask or endotracheal intubation owing to the presence or absence of impaired swallowing (experimental arm), or to receive conventional care that may include invasive mechanical ventilation whenever acute respiratory failure occurred (control arm). Outcomes—the primary outcome was the time to onset of pneumonia up to ICU discharge (or 90 days, pending of which occurred first). Secondary outcomes included the total number of episodes of pneumonia, time to and length of mechanical ventilation, length of hospital stay, mortality and any serious adverse events.
Results: Twenty-five patients were randomized in each group. In EMV, 44% required invasive mechanical ventilation. There was no evidence for clinically relevant differences in baseline characteristics between groups (Vital capacity—47% [40 + 54], PaCO2—5.3 kPa [4.6 + 5.6], PaO2—11.8 kPa [9.6 + 12.3]). 48% of patient in experimental group and 52% in control group had swallowing impairment. There was no significant difference between groups for the time to pneumonia (p = 0.50, Gray test). There were 16/25 (64%) and 15/25 (60%) of patients that presented at least one episode of pneumonia (p = 1.00), in the experimental and control groups, respectively. During follow-up, 16/25 (64%) patients in the control group were eventually mechanically ventilated (all invasively) and 25/25 (100%) in the experimental arm (p < 000.1). The time on ventilator was non-significantly shorter in the experimental arm (14 [7 +29] versus 21.5 [17.3 +35.5], p = 0.10). There were no significant differences between groups for length of hospital stay, neurological scores, the proportion of patients who needed tracheostomy, in-hospital death, or serious adverse events.
Conclusion: In Guillain-Barré syndrome patients at high risk of respiratory failure, early mechanical ventilation did not prevent the onset of pneumonia.
F-08 Background and training of French Intensive Care fellows: a national survey
Messika Jonathan1, Helms Julie2, Vieillard-Baron Antoine3, Guidet Bertrand4, Ricard Jean-Damien1
1Hôpital Louis Mourier, Colombes, France; 2CHU de Strasbourg, France; 3Hôpital Ambroise paré, Boulogne, France; 4Hôpital Saint Antoine, Paris, France
Correspondence: Messika Jonathan - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-08
Introduction: French hospital fellows’ missions are threefold—teaching, research and care. Although some diplomas are welcome (Master 2, for instance), prerequisites to become a fellow are limited to graduation in a specialized medical degree, and a medical thesis. Hence, fellows in the ICU may have a very varied background. We therefore decided to perform a survey of the scientific, clinical and educational training of intensive care medicine fellows, at the dawn of a new degree in intensive care medicine, and analyse heterogeneity causes.
Patients and methods: We conducted a national survey among the current and former fellows (2014–2017) of French medical and mixed critical care units, with an electronic questionnaire.
Results: One hundred and fifty-seven current and former fellows were contacted, among whom 123 (78%) responded (age—33 years [32–35], men 60.2%)—56.9% completed a complementary degree in intensive care, while 37% were on their way to graduate. Their background speciality was anaesthesiology (47.2%), nephrology (13%), cardiology and pneumology (12.2% each), internal medicine (11.4%), or another medical speciality (4%). One hundred and eighteen respondents (87.8%) had at least one university diploma. Seventy-one respondents had graduated with a Master 2 degree and 16 of them had a Ph.D. while 29 anticipated its completion. Medical education training was mainly provided by the Universities, when the fellows entered their position (n = 38 + 30.9%). The scientific production of the respondents was valorised by at least one presentation in a congress (83.7%) or by a scientific article published or to be published as first author (51.2%). There were heterogeneities—more Master 2 degree holders in Ile-de-France and older fellows were more trained in pedagogy.
Discussion: The increasing demand for fellow positions and the stability of their number calls for a clear definition of criteria for position attribution. Although a Master 2 degree is usually required to perform experimental research, no counterpart is necessary for clinical research.
Conclusion: This survey shows a diverse, but solid scientific and clinical training of French critical care fellows, attested by a high rate of Master degree and Ph.D. This inventory must be addressed in other medical specialities.
F-09 Is micro-convex better than standard linear vascular probe for echo guided internal jugular and axillary venous puncture: a randomized controlled study on an inanimate manikin
Maury Eric1, Bonsey Michael1, Bouys Lucas1, Joffre Jéremie1, Dumas Guillaume1, Baudel Jean-Luc1, Ait Oufella Hafid1, Bigé Naïke1
1Hôpital Saint-Antoine, Paris, France
Correspondence: Maury Eric - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-09
Introduction: International guidelines recommend ultrasound (US) guidance for central venous catheter (CVC) insertion. However, evidence is lacking for several aspects of guidance such as probe shape or whether the needle has to be in plane (IP) or out-of-plane (OOP). We assessed these issues in a randomized trial.
Patients and methods: 53 Health Care Workers [mean age—27 [22–31], male (28), senior (n = 18), resident (n = 13), student (n = 22), having previously inserted > 10 US guided CVC (n = 29)] were proposed to take part to a pilot study. Naive HCWs received a training (course and hands-on). Right Internal Jugular Vein (RIJV) and Right Axillary Vein (RAV) with either linear probe (LP) [HFL38, with the M-Turbo®, Sonosite, Bothewell, MA], or micro-convex probe (MCP) [GE8C, with a Vivid 7®, General Electric, 78457 Velizy, France] using IP and OOP approaches were performed on an inanimate manikin (Blue Phantom II, CAE Healthcare St. Louis, MO). Procedure was stopped at 180 s. The order of the 8 punctures—site probe approach—was randomized. Success at first pass, number of attempts (needle passes), success, times between skin contact and needle skin penetration and between needle skin penetration and liquid back flow in the syringe were recorded. Qualitative and quantitative values are expressed as number (percentage), and median (range), and were compared using the Wilcoxon matched pairs test and the Fisher exact test, respectively.
Results: For IJV puncture, first attempt success rate was more than 80% and was neither influenced by probe shape nor approach (Table 1). Conversely for RAV puncture, using LP with IP approach was more frequently successful at first attempt (45 vs 34%, p = 0.2). Time elapsed between needle skin penetration and liquid back flow was shorter for RAV puncture using IP approach (16 s vs 34 s, p = 0.03). Time elapsed between probe appliance on skin and liquid back flow was significantly shorter with the linear probe for IJV whatever the approach and for RAV using IP approach. RAV puncture was more frequently impossible with MCP (10 vs 3%, p = 0.08). Arterial puncture occurred more frequently with MCP (7 vs 3%, p = 0.08). LP use and IP approach were associated with more free event puncture (93 vs 87%, p = 0.03). Analysis according to previous experience disclosed similar trends.
Conclusion: This study suggests no benefit of MCP over LP for CVC insertion and supports IP approach for axillary puncture.
F-10 Validation of heart rate variability monitoring in high fidelity cardiac arrest simulation training in PRESAGE simulation center
Satre Buisson Lea1, De Jonckheere Julien1, Duburcq-Gury Emilie1, Jourdain Merce1
1CHU de Lille, France
Correspondence: Satre Buisson Lea - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-10
Introduction: Simulation training is an effective teaching tool, preeminently in high-risk situations such as advanced cardiac life support (ACLS). Sudden cardiac arrest (CA) in clinical conditions or high fidelity simulation (HFS) represents a highly stressful medical situation. Stress measurement and its correlation to technical and non-technical performances could be a tool to improve teaching methods. Heart rate variability (HRV) is mediated by the autonomic nervous system and a lower HRV reflects parasympathetic inhibition therefore it could reflects stress. The aim of this study was to validate the feasibility of objective stress measurement by heart HRV monitoring during CA in HFS. Analyzing the relation between ANI, self-reported stress and performance was the second objective.
Patients and methods: An open monocentric prospective study was conducted from December 2015 to December 2016 in Lille’s medical simulation center PRESAGE. Intensive care residents from Lille Medical University played team leader in a CA scenario. Objective stress was measured from recordings of three leads electrocardiogram portable device (PhysioDoloris® monitor, MDoloris Lille, France). HRV was obtained by analyzing time interval between successive R waves and transformed in the Analgesia Nociception Index (ANI). ANI gives both a qualitative and quantitative measurement of HRV. Self-reported stress was assessed with a visual analog scale (VAS). Results were expressed in numbers (%), mean (± Standard Derivation). Correlations were tested using the non-parametric Spearman rank test (Rho). p < 0.05 was considered significant.
Results: Sixty-four intensive care residents were monitored for HRV in simulation training. 36 signals (56.3%) were fully interpretable. Team leader’s self-reported pre-HFS stress VAS was 43.3 (± 22.4) and maximal stress VAS was 58.7 (± 21.7). Team leaders’ maximal heart rate was 157 bpm (± 20). Minimal ANI, reflecting intense stress was 33.7 (± 9.9). Objective and subjective stress of each team leader is shown in Fig. 1. There was a significant negative linear correlation between minimal ANI and maximal HR (Rho = − 0.52, p = 0.001). There was no significant correlation between self-reported stress VAS (neither pre HFS or maximal stress) and minimal ANI.
Conclusion: HRV monitoring is a feasible method to evaluate continuous physiological stress for team leaders in highly stressful simulation-teaching. Upgrading signal connection by Bluetooth 4.0 or Wi-fi could improve the method. Focusing on specific stressful time points might improve stress assessment and its correlation with performance.
F-11 Simulation based-training: perception of ICU students and residents of the faculty of Monastir
Ouanes Islem1, Sik-Ali Habiba1, Ouanes-Besbes Lamia1, Fekih-Hassen Mohamed1, Hammouda Zaineb1, Dachraoui Fahmi1, Elatrous Souheil1, Abroug Fekri1
1CHU F. Bourguiba, Monastir, Tunisie
Correspondence: Ouanes Islem - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-11
Introduction: Simulation training has become available in Health sciences faculties and proposed in many specialties. Intensive Care is one of the fields of development of simulation based training. The aim of the present study was to report the experience of the Faculty of Medicine of Monastir Simulation Center in training medical students and residents in Intensive Care and to compare their respective perceptions.
Patients and methods: This was a descriptive study including students (5th year of the medical curriculum) and residents who received training during the last academic year (2016–2017), in the simulation center during their ICU traineeship. Simulation training was based on high-fidelity mannequins for students and seminars with high fidelity and procedural simulation training for residents. Three sessions per group were organized for students and a total of five sessions for residents. We collected participant characteristics and used Likert scale (from 1 to 5) to assess participant satisfaction, simulation fidelity, impact on clinical practice, stress level and instructor behaviors. Chi 2 test was used to compare students’ and residents’ perception of the simulation based-training.
Results: During the study period 91 students (of the 269 students’ whole promotion) and 88 residents actively participated at least in one of the simulation-based training sessions. Median students’ and residents’ ages were respectively 24 years (24–24) and 29 years (27–30). Participants were mainly females in 78 and 73.8% respectively in students and residents. Prior to the study period all the students received simulation-based training, whereas 48.9% of residents assisted for the first time in a simulation based training. For all participants, satisfaction (levels 4 and 5 of the Likert scale) was reported in 87.2%, simulation fidelity in 60.3%, possible impact on clinical practice in 77.1%, 40.8% perceived training as stressful and 85.5% noted favorably instructors’ behaviors. Compared to ICU residents, students were significantly less satisfied (80.2 vs 94.3% + p = 0.005), perceived training more stressful (59.3 vs 21.6% + p < 0.001) and noted less favorably instructors’ behaviors (79.1 vs 92%; p = 0.014), whereas the other items were comparable (Fig. 1).
Conclusion: We observed globally a favorable appreciation of ICU students and residents of the simulation based training differences in perceptions’ items could be mainly explained by different previous experiences with the real life in the hospital of the two study groups.
F-12 Use of social media by Tunisian intensive care residents
Dachraoui Fahmi1, Nouira Wiem1, Tlili Mariem1, Hammouda Zaineb1, Bouker Nouha1, Hraiech Kmar1, Boukadida Sana1, Ouni Amal1, Zorgati Hend1, Ouanes Islem1, Ouanes Besbes Lamia1, Abroug Fekri1
1CHU Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Dachraoui Fahmi - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-12
Introduction: Social media (SM) can be used to improve or enhance professional networking and education, organizational promotion, patient care, patient education, and public health programs. Little data are available about perceptions among young medical practitioners although unconstrained online social activity is the norm for them. The aim of the present study is to describe the actual use and perception of the role of SM by Tunisian residents in intensive care medicine.
Patients and methods: This was a prospective observational study involving intensive care residents at the university hospitals of Sousse, Monastir and Mahdia (Tunisia). Residents were invited to participate and answer an anonymous questionnaire about social media in clinical medicine, accessibility to the internet, their personal and academic use of SM and their perception of the use of SM. The questionnaire comprised 22 different types of questions—Likert style, multiple choices, yes no, ranking and short and open response questions.
Results: Overall, 52 residents (36 females, age = 27.5 ± 3.9 years) responded to the questionnaire (66%) + 84.6 and 65.5% of them had smartphones and laptops, respectively. Sixty-five percent had mobile Internet access or a home WIFI network, while 13.5% said they had access to the Internet only through their faculty or hospital where they were exercising. Facebook and YouTube were the most frequently daily used SM for both personal and academic use, 94–32.7 and 61.6–34.6% respectively. In contrast, 94.2% said they had never used Twitter. The daily use of medical applications on Smartphones and weekly e-learning platforms were reported by 65.4 and 63.5% of residents respectively. Eighty-eight percent of the residents thought that YouTube should play a key role in their training. The use of SM was supposed to improve the collaboration between residents and with their supervisors respectively in 88.4 and 86.5%. Nearly half of the residents (42.3%) were opposed to communication with patients and or their families by SM. Respondents in the survey suggested that medical schools should use SM to keep them informed on training cycles, and that they should adopt a policy that would govern the use of SM in 94.2 and 88, 6% respectively.
Conclusion: Facebook and YouTube are the most used social media by Tunisian residents in intensive care medicine. They remain however, little contributors in their training course.
F-13 Performance of the electronic referential ANTIBIOGARDE® in initial antibiotic prescription in a French ICU
Allary Chloé1, Mentec Hervé1
1Hôpital Victor Dupouy, Argenteuil, France
Correspondence: Allary Chloé - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-13
Introduction: Hospitals are encouraged to edit local antibiotic therapy guidelines. ANTIBIOGARDE® is an electronic antibiotic prescription referential developed by a multidisciplinary team of French physicians, regularly updated, and locally customizable, which has been purchased by more than 170 French hospitals. We compared adequacy of initial antibiotic prescription by ICU clinicians, ANTIBIOGARDE® proposal and national or international guidelines.
Patients and methods: Between January and June 2016, initial antibiotic prescriptions in an ICU were retrospectively analyzed when microbiologically documented. ANTIBIOGARDE® and guidelines proposals were simulated, considering data available at the time of initial prescription. Adequacy was defined when all bacteria responsible for infection were sensitive to at least one prescribed proposed antibiotic. National guidelines were used when published after 2011. Otherwise, most recent international guidelines were used.
Results: 120 initial prescriptions were analyzed (45 monotherapy) in 97 patients (median age 63y, median SAPS II 53, median SOFA on prescription 7, ICU mortality 41%, 17% immunocompromised). Main sources of infection were lung (n = 75) and intra-abdominal (n = 23). Leading isolated bacteria were Enterobacteriaceae (n = 67, antibiotic resistance in 14), Streptococci (n = 55), non-fermenting Gram negative bacilli (n = 27, antibiotic resistance in 12) and Staphylococci (n = 25, resistance to methicillin in 5). In the 120 clinical settings analyzed, there was a proposal by ANTIOGARDE® in 97 (81%) and a guideline available in 102 (85%) (p = 0.39). Initial antibiotic regimen prescribed by clinicians was adequate in 107 120 settings (89%, 95% CI [82–94%]). Considering only settings with a proposal, ANTIBIOGARDE® was adequate in 90 97 (93%, 95% CI [86–96%]) (p = 0.36 vs clinicians), and guidelines in 102 102 (100%, 95% CI [96–100%] (p < 0.001 vs clinicians and p < 0.001 vs ANTIBIOGARDE®). Considering all settings and no proposal as inadequacy, ANTIBIOGARDE® was adequate in 90 120 (75%, 95% CI [67–82%]) (p = 0.004 vs clinicians), and guidelines in 102 120 (85%, 95% CI [78–90%] (p = 0.34 vs clinicians and p = 0.05 vs ANTIBIOGARDE®). The antibiotic regimen prescribed by clinicians had a narrower spectrum against Gram negative bacilli than ANTIBIOGARDE® and guidelines proposals in 70 and 68% of cases respectively. Proportions of prescriptions, ANTIBIOGARDE® proposal and guidelines proposal including antibiotics active against methicillin resistant staphylococci were 12, 25 and 37% respectively (p < 0.00005).
Conclusion: ANTIBIOGARDE® electronic referential could allow even non expert ICU physicians to adequately (93%) prescribe initial antibiotic therapy in most clinical settings (81%).
F-14 Learning and performances of the face-to-face intubation technique in difficult intubation situation on a high-fidelity manikin—Macintosh laryngoscope versus Airtraq videolaryngoscope
Tabatchnik Xavier1, Descoins Médéric1, Winer Arnaud1
1Hôpital Gabriel Martin, Saint Paul, Reunion
Correspondence: Tabatchnik Xavier - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-14
Introduction: Intubation is plagued with a high morbimortality, especially in emergency situations. It is now acknowledged that a seated position allows for optimized preoxygenation (1). However, there is no guideline concerning the patient’s position for intubation. The patient is most often laid in a supine position, leading to a higher risk of aspiration (2). Face-to-face intubation in sitting position (FtFi) would allow for an easier intubation and a lower morbidity. We focused on learning the FtFi technique using the Macintosh laryngoscope and the Airtraq videolaryngoscope in simulated difficult intubation situation and comparing the performance of the FtFi with the classic technique.
Patients and methods: The participants would intubate a high-fidelity manikin (SimMan3G, Leardal, Norway) configured with a tongue edema (Cormack 2b-3). For each trial, time to intubate (TTI), success and complication rate, intubation difficulty and glottis exposure were noted. In classic position, three trials were performed with the Airtraq followed by the laryngoscope in order to obtain baseline parameters. In FtFi, at least 30 intubations were performed by each participant for each device. The utilization order was randomized.
Results: Thirty physicians, with an experience of at least 200 intubations each, were included. Figure shows the learning curves of the FtFi based on the evolution of the TTI measured for the Airtraq and the laryngoscope. In classic position, the mean TTI with the Airtraq was 30.5 ± 19.1 s versus 27.3 ± 16.7 s with the laryngoscope (p = ns). In FtFi, once the technique mastered, the TTI was 14 ± 2.9 s with the Airtraq versus 17.5 ± 2.4 s with the laryngoscope (p < 0.05). Success rate, TTI, complication rate, intubation difficulty and glottis exposure were better using FtFi versus classic intubation (p < 0.05). These parameters were even better with the Airtraq than with the laryngoscope (p < 0.05).
Discussion: The learning profile of FtFi is different between the Airtraq and the laryngoscope. It could be due to the participants’ lesser familiarity with the Airtraq. The better performances in FtFi could be due to better ergonomics allowing easier glottis exposure and learning (3).
Conclusion: Face-to-face intubation in sitting position is easy to learn. It provides better performances and fewer complications than the classic intubation technique which might result in a lower morbidity. The Airtraq provides even better results than Macintosh laryngoscope. All participants recommend their colleagues to be trained in face-to-face intubation.
F-15 Non invasive ventilation use for Acute Chest Syndrome in French speaking Pediatric Intensive Care Units, online survey
Heilbronner Claire1, Grimaud Marion1, Oualha Mehdi1, Sommet Julie1, Rambaud Jerome1, Brousse Valentine1, Allali Slimane1, Renolleau Sylvain1
1Hopital Necker Enfants Malades, Paris, France
Correspondence: Heilbronner Claire - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-15
Introduction: Acute chest syndrome (ACS) is the leading reason of admission in Pediatric Intensive Care unit (PICU) for patients with Sickle Cell Disease (SCD). Non invasive ventilation (NIV) is nowadays unavoidable for the management of respiratory failure in PICU. Few studies assessed NIV’s impact on ACS outcome. We sought to investigate the clinical practice and particularly the use of NIV for ACS management in PICU or high dependency care unit (HDU) in France and French speaking countries.
Patients and methods: Participants were sought via e-mail through membership in the French Group for Paediatric Intensive Care Emergencies (GFRUP) to complete a 78-questions online survey for children admitted to PICU during the 1 year (2015). Demographics, clinical data and management’s description of ACS were collected.
Results: Seventeen PICUs or HDU with a total of 145 and 95 beds, respectively answered to the survey from June 2016, 10th to November 2016, 10th. Fifteen centres (88%) had a local transfusion center and 14 (82%) had a local blood centre and 14 (82%) were in connection with a SCD reference centre. During the 1 year 2015, 360 SCD patients were managed (median 7 SCD per centre, range 0–127) of which 137 (38%) for an ACS (median 4ACS per centre, range 0–34). Median length of PICU stay for ACS was 5 days, range 2–11 days. Three centres (totalling 62 beds) in the Parisian agglomeration hosted 146 SCD patients (40% of all SCD patients reported) with a total of 83 ACS (65% of ACS reported). Simple blood transfusion was performed in 73 patients with an ACS (53%). Sixteen patients (12%) received exchange transfusion. For patients who observed an ACS—bronchodilatators nebulisations were administrated in 47 (34%) of them, incentive spirometry was performed by 94 patients and 64 (47%) received standard oxygen therapy. Among non-invasive respiratory support, NIV with bilevel pressure was the most frequent (n = 68, 50%) before CPAP (n = 23, 17%) and high flow oxygen (n = 21, 15%). The proportion of patients on NIV was up to 71% in the centres hosting more ACS patients.
Conclusion: Despite the absence of evidence from randomized controlled trials NIV is nowadays commonly used in PICU and HDU for SCD patients with ACS, especially in centres taking in charge a high number of SCD patients. Future physiological studies and randomized controlled trials might help to choose between the different ventilatory support options for ACS.
F-16 Transfusion practices in children with pediatric acute respiratory distress syndrome: a retrospective cohort study
Emeriaud Guillaume1, Paquin Marie-Eve1, Shemyakina Ilona1, De Cloedt Lise1, Tucci Marisa1, Lacroix Jacques1, Jouvet Philippe1
1CHU Sainte Justine, Université de Montréal, Montréal, Canada
Correspondence: Emeriaud Guillaume - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-16
Introduction: Restrictive transfusion practices are increasingly used in pediatric intensive care unit (PICU), but evidence is lacking for deciding transfusion in children with severe acute respiratory distress syndrome (PARDS). This study aims to describe the red blood cells (RBC) transfusion practices during PARDS, to identify the main transfusion determinants in this population, and to describe the evolution of the patients after the transfusion.
Patients and methods: Patients with PARDS were prospectively screened in the PICU of a university affiliated pediatric hospital, from June 2015 to October 2016. Patients aged between 3 days and 18 years with a PARDS lasting at least 6 h were included. Baseline patient characteristics, PARDS data (for a period of 72 h), RBC transfusion characteristics, and main outcome data in the PICU were retrospectively collected in the electronic medical records. PARDS severity was classified based on PALICC definition. Results are reported as median (25th–75th percentile), and comparisons were made using Mann–Whitney test and Friedman test.
Results: 27 patients aged 36 (16–79) months were included. No transfusion was given in children with mild ARDS. At least one RBC transfusion was given during the PARDS period in 3 6 patients with moderate PARDS, and 7/15 patients with severe PARDS. At baseline, transfused patients had higher PRISM III score (10 (8–13) vs 4 (2–6), p < 0.05) and higher Oxygen Saturation Index (OSI 22 (13–27) vs 9 (6–18), p < 0.01). In transfused patients, the pre-transfusion hemoglobin was 8.1 (7.5–9.3) g dL in moderate PARDS and 7.5 (6.9–7.3) g dL in severe PARDS. The evolution of hemoglobin, OSI, ScvO2 and lactate after the transfusion is reported in the Table 1.
Conclusion: In our PICU, a relatively restrictive policy of RBC transfusion was observed even in patients with severe PARDS. Decision to transfuse seemed associated with the general severity status of the patient and with the hemoglobin level. Further studies are needed to explore the generalizability of these findings, and to investigate the impact of transfusion on oxygen transport consumption balance in pediatric acute respiratory distress.
F-17 Impact of pediatric acute respiratory distress syndrome severity on adherence to PALICC guidelines for low tidal volume ventilation
Nardi Nicolas1, Sauthier Michael1, Proulx Francois1, Mortamet Guillaume1, Roumeliotis Nadia1, Jouvet Philippe1, Emeriaud Guillaume1
1CHU Sainte Justine, Université de Montréal, Montréal, Canada
Correspondence: Nardi Nicolas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-17
Introduction: Pediatric acute respiratory distress syndrome (PARDS) is associated with a high mortality rate of 30%. Lung protective strategies in ARDS advocate using low tidal volume and high positive end expiratory pressure (PEEP) while limiting the inspiratory plateau pressure in the recent international consensus conference on PARDS (PALICC)1. Our objectives were to evaluate the adherence to the guidelines for lung protective ventilation proposed by the PALICC and determine whether variations in tidal volume were related to the severity of oxygenation impairment.
Patients and methods: All patients, admitted to our tertiary pediatric ICU from January 2013 to May 2015, who received conventional ventilation for severe PARDS using PALICC definition and who had data to calculate ideal body weight (IBW) were retrospectively included. We excluded children with pulmonary bronchodysplasia and those admitted after cardiac surgery. Expiratory tidal volume (VTe), PEEP, peak inspiratory pressure, mean airway pressure, FiO2 and PaO2 were collected from electronic medical record (ICCA, Philips), using SQL Server 2008 (Microsoft, USA) + data were collected for 10 days following onset of conventional mechanical ventilation. Adherence proportions were analyzed with the non-parametric Cochran’s Q test, using cut-off values of VTe ≤ 8.0 mL kg. Mixed model analysis was performed to test the hypothesis that variations in tidal volume were related to the severity of oxygenation impairment.
Results: Twenty-one patients reached inclusion exclusion criteria, with median age of 5 years (interquartile [IQR] + 2.5–12 years) and a median weight of 17 kg ([IQR] + 12–30). Mortality rate was 38% (8/21) with a median duration of mechanical ventilation of 10 days ([IQR] + 7–32 days). On 1780 measurements of respiratory parameters, 72% of VTe measurements were ≤ 8.0 mL kg with median VTe of 6.7 mL kg ([IQR] + 5.6–8.3). During the first 10 days of conventional mechanical ventilation (159 patient-days), there were a significant variations in the daily rates of adherence to low tidal volume ventilation (p < 0.001) and a significant decrease in VTe with the highest oxygenation index (p = 0.02).
Conclusion: In our centre, adherence to PALICC guidelines for low tidal volume ventilation in PARDS is not perfect. However the adherence to protective ventilation strategy was higher in the most severe patients, in line with the recommendations. We plan to test if the implementation of a clinical decision support system can improve the adherence to guidelines at the bedside.
F-18 Treatment level for children with polyhandicap admitted in ermergency in pediatric intensive care units in Paris
Tencer Jérémie1, Billette de Villemeur Thierry2, Leger Pierre-Louis2
1Hôpital Necker, Paris, France; 2Hôpital Trousseau, Paris, France
Correspondence: Tencer Jérémie - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-18
Introduction: Children with polyhandicap are a complex medical and ethical situation. There are few studies about their admission in intensive care units, despite them having a strong risk of acute diseases. Our objetive was to describe the hospitalization of children with polyhandicap in intensive pediatric care units.
Patients and methods: This is a retrospective study in 4 pediatric intensive care units in Paris. Children with polyhandicap hospitalized in emergency from January 1st 2013 to December 31st 2015 were included. We looked at epidemiological datas, medical supports and medications at admission and treatment level (respiratory, circulatory, neurologic, invasive procedures), and limitations of treatments.
Results: 96 patients were included, representing 143 hospitalizations. At admission average age was 11 ± 5 years, mean number of medical support per patient was 1 ± 0.6 and mean number of neurological medication per patient was 2.5 ± 1.8. The main admission criteria were—respiratory failures (59%), neurological failures (20%) and circulatory failures (10%). Respiratory support was needed in 56%, circulatory support in 31% and nutritional support in 20% of patients. During these hospitalizations 25 consultation meetings have been held. Forty-two percent of patients did not have to be submitted to any invasive procedures. Overall mortality was 16%.
Conclusion: children with polyhandicap admitted in intensive care units are at school age and are mostly having respiratory or neurological failures. There is a strong rate of rehospitalisation. There are few therapeutic limitations that have been found. Anticipating a crisis is a major point to provide the best care for these children.
F-19 Piperacillin dosing regimen optimization in critically ill children according to their renal function
Béranger Agathe1, Benaboud Sihem2, Urien Saïk3, Moulin Florence4, Bille Emmanuelle4, Genuini Mathieu4, Lesage Fabrice4, Hirt Déborah5, Renolleau Sylvain4, Tréluyer Jean-Marc4, Oualha Mehdi2
1Montrouge, France; 2Université Paris Descartes, Paris, France; 3Hôpital Tarnier, Université Paris Descartes, Paris, France; 4Hôpital Necker, Université Paris Descartes, Paris, France; 5Hôpital Cochin, Paris Descartes University, Paris, France
Correspondence: Béranger Agathe - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-19
Introduction: Pharmacokinetic parameters are altered in critically ill patients. For instance, in adult patients, it has been well demonstrated that augmented renal clearance results in subtherapeutic antibiotic concentrations. Our objectives were to build a pediatric population pharmacokinetic model for Piperacillin, in order to optimize individual dosing regimen.
Patients and methods: All children admitted in pediatric intensive care unit, aged less than 18 years, weighing more than 2.5 kg, and receiving intermittent Piperacillin infusions were included. Piperacillin was quantified by high performance liquid chromatography. Pharmacokinetics were described using the non-linear mixed effect modelling software MONOLIX. Monte Carlo simulations were used to optimize dosing regimen, in order to maintain plasma concentration above the minimum inhibitory concentration (16 mg L−1 for Pseudomonas aeruginosa) throughout the dosing interval (100% fT > MIC).
Results: We included 50 children with a median (range) post natal age of 27.2 (1.1–222.9) months, median (range) body weight of 11.9 (2.7–50) kg, median (range) PELOD-2 score of 4 (0–16) and median (range) estimated creatinine clearance of 142 (29–675) mL.min-1.m-2. A one compartment model with first-order elimination adequately described the data. Median (range) values for Piperacillin clearance and volume of distribution were respectively 3 (0.71–10) L h−1 and 3.8 (0.72–25.8) L. Body weight (allometric relationship), estimated creatinine clearance and PELOD-2 severity score were the covariates explaining the estimated between subject variability. A third of the cohort attained the target, according to our dosing regimen and to the European guidelines. To reach the target and according to the simulated dosing regimens, children with acute kidney injury should receive intermittent infusion every 6 h, administered on 30 min. Those with augmented renal clearance should receive a continuous infusion.
Conclusion: To reach the target, standard intermittent Piperacillin dosing regimen in critically ill children is not appropriate. In addition to body weight, dosing regimens should take into account the creatinine clearance. Continuous infusion is adequate for children with augmented renal clearance. Piperacillin individualized dosing regimens and therapeutic drug monitoring are mandatory in pediatric intensive care unit.
F-20 Comparison between the NIPE® index (Neonatal Infant Parasympathetic Evaluation) and the DAN scale for pain assessment during acute procedural pain in preterm infants
Ros Barbara1, Tandonnet Olivier1, Cramaregeas Sophie1, Duchateau Josselin1, Brissaud Olivier1, Nolent Paul1, Renesme Laurent1
1CHU de Bordeaux, Bordeaux, France
Correspondence: Ros Barbara - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-20
Introduction: All data support the need for early recognition, evaluation of pain in the NICU. Multiparametric analysis including physiological parameters could be useful to have a more objective evaluation of pain in the NICU compared to scales built on external-evaluation. The Newborn Infant Parasympathetic Evaluation (NIPE®) was developed to assess pain in newborns and infant, from preterm to the age of 2 years.
Patients and methods: We conducted a monocentric, prospective study to compare the instantaneous NIPE® index value (NIPEi®) to the DAN scale during acute procedural pain (PICC line insertion) in preterm infants (under 37 GW). The operators and the nurse were blinded to the continuous recording of NIPEi® during the entire procedure. DAN scale was assessed every 5 min by a third person, trained to this scale and blinded to NIPEi®. A direct correlation assessment between the DAN scale and the NIPEi® was performed by calculating the Pearson’s linear correlation coefficient. The differences between the NIPEi® of non-painful (DAN < 3) and painful (DAN ≥ 3) infants were estimated by the Wilcoxon–Mann–Whitney test. The usefulness of NIPEi® as a new tool for pain assessment in neonates was estimated by the corresponding ROC curve. Our study was approved by our local ethic institutional review board.
Results: Thirty-five preterm infants were included, NIPEi® data were incomplete in 3 infants. Fifty percent of newborns were born before 31 GW, and 66% had non-invasive respiratory support (continuous positive airway pressure CPAP). At the time of the procedure, newborns had a median post-natal age of 3 days and a median weight of 1180 grams. There was a moderate correlation between the NIPEi® index and the DAN scores (r = 0.605 + p < 0.001). The median NIPEi® index was 59 for non-painful events vs. 43 for painful events, p < 0.001. The area under the ROC curve was 0.92. For a threshold of NIPEi® < 50, the sensitivity was 91.3%, the specificity was 83%. Positive likelihood ratio was 5.36 and the negative likelihood ratio was 0.10 (Fig. 1).
Conclusion: We showed a correlation between the DAN scale and the NIPEi® index for pain assessment in preterm infants. The NIPE® monitor could be a useful and non-invasive tool for pain assessment in neonates. Further studies are needed to confirm our results and to define more precisely the place of such monitors for pain evaluation in daily clinical practice in the NICU.
F-21 Prospective evaluation of acute pituitary hormone dysfunction following severe Traumatic Brain Injury (endocTC study)
Javouhey Etienne1, Courtil-Teyssedre Sonia1, Cour-Andlauer Fleur1, Wroblewski Isabelle2, Desrumeaux Amélie2, Ginhoux Tiphanie1, Dupuis Clémentine2, Bernoux Delphine1, Kassai Behrouz1, Nicolino Marc1, Faure Patrice2, Plotton Ingrid1
1Hospices Civils de Lyon, Bron, France; 2CHU Grenoble, La Tronche, France
Correspondence: Javouhey Etienne - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-21
Introduction: The aim was to identify factors associated with the occurrence of acute pituitary hormone dysfunction in children with moderate to severe TBI and to describe the impact of this dysfunction on the stability of the children.
Patients and methods: Prospective bicenter study including all children aged between 1 month to 17 years, admitted to PICU for a moderate-severe TBI and with an expected stay > 2 days. Setting—Pediatric intensive care units of Grenoble and Lyon, from 2010 to 2017. Endocrine explorations at the second morning following admission and 24 h before discharge were performed—cortisol 24 h cycle with free cortisol and ACTH dosages every 4 h (or 6 h if no central line) + free 24H urinary cortisol + TSH and T4L, 24H urinary LH and FSH, blood level of testosterone or estradiol for children aged > 10 years, and IGF1. Patients were classified as having cortisol insufficiency if all the cortisol dosages were < 200 nmol l and all ACTH were < 12 pg l. TSH deficiency was defined as T4 l < 11.5 pmol l and TSH < 4.2 mUI l. Gonadotropin defciency was defined as urinary LH < 0.14 UI 24 h and urinary FSH < 1.52 UI 24 h for males + urinary LH < 0.018 UI 24 h and urinary FSH < 2.24 UI 24H in female. Patients with deficiency (ACTH and any deficiency) were compared to those without deficiency in terms of hemodynamic instability, respiratory instability, neurological and infectious complications For continuous variables means and 95% confidence interval were calculated and compared by t student test. Chi-2 test was used to compare proportions.
Results: Among the 110 patients evaluated, 12 had ACTH deficiency, and 23 had at least one acute pituitary dysfunction. Comparison of patients who presented ACTH deficiency with those who were not deficient found no differences in terms of patients characteristics, cause of TBI, level of severity and level of injury. Paitents with ACTH deficiency required more frequently fluid bolus at day2 (67 vs 34%, p = 0.03). All the markers of severity were higher and the need of vasoactive drugs were more frequent but the differences were not statistically significant. Table 1 shows comparison between patients with at least one pituitary hormone deficiency to those without deficiency. The same result was found. Glycemia levels were lower in the group with deficiency.
Conclusion: We didn’t find any predictive factors of pituitary hormone deficiency in children with moderate-severe TBI justifying a systematic screening of those patients.
F-22 Can we satisfy parents of patients in intensive care unit ?
Fathallah Ines1, Tobich Mariem1, Habacha Sahar1, Ben El Arbi Rim1, Ben Abderahim Amina1, Sakis Dorra1, Kalel Hela1, Boujelben Mohamed1, Selami Ali1, Kouraichi Nadia1
1Hôpital Régional de Ben Arous, Ben Arous, Tunisia
Correspondence: Fathallah Ines - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-22
Introduction: Most intensive care unit (ICU) patients cannot make decisions themselves. Familiy members are actively involved in the care process as surrogate decision-makers and judges of care quality. However, family satisfaction with care is complex and is not clearly defined. The aim of this study is to evaluate the different procedures (reception book and staff education for aid and relationship) used in a new ICU to improve the family care.
Patients and methods: We included in our study patients who had spent more than 48 h in our department. A questionnairy, adapted to our population, was performed by our staff and validated by the Hygiene and Quality Care departement. We proceded by phone calls, 10 months after the inauguration of our ICU.
Results: Sixty-five questionnaires were included (Fig. 1). The average of age was 52 ± 20 with a sex ratio of 2. The average of the simplified acute physiology score (SAPSII) was 36 ± 17. The median stay was 7 days [4–16] with a total mortality rate of 25%. Mostly, we interrogated first-degree parents (n = 52). Only three families recieved reception book at admission. Visit in patient room was autorised only for 27% (n = 17) of family members. Only four persons said they were disturbed in visit hours for architectural reasons (tight space). Disponibility was found excellent in 40% (n = 24) of cases for medical staff, 45% (n = 26) for paramedicals. Informations provided by physicians were clear in 71.5% (n = 53) of cases. Fifteen of the family members (23%) asked psychology support. Only 15% of parents felt involved in the management care decisions. Most parents (87%) opted for making all dicisions related to doctors. Patients management was judged excellent in 74% (n = 48) of cases. There was no difference according to satisfaction between families of dead patients and families of surviving ones.
Conclusion: To optimise patients care and families satisfaction specific psychological support is necessary.
F-23 Predictors of 1 year mortality rate for AE COPD ICU-admitted patients
Ben Saida Imen1, Zarrougui Wafa1, Ennouri Emna1, Fraj Nesrine1, Limam Manel1, Ayachi Jihene1, Sma Nesrine1, Khedher Ahmed1, Azouzi Abdelbaki1, Boussarsar Mohamed1
1Hôpital Universitaire Farhat Hached, Sousse, Tunisia
Correspondence: Ben Saida Imen - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-23
Introduction: Acute exacerbations of COPD (AE COPD) is one of the most common causes of admission in the intensive care unit (ICU). The prognosis of COPD requiring ICU seems to be poor with high in-hospital and long-term mortality. Predictors of post ICU mortality for those patients are still not well defined. This study was carried out to define the predictors of 1 year mortality in patients admitted to the ICU with AE COPD.
Patients and methods: A prospective cohort study was performed in a Tunisian medical ICU between 2014 and 2016. A follow-up was performed on ICU survivors admitted for AE COPD during 1-year using phone interviews. Univariate and multivariate analyses were used to predict 1 year mortality. Stepwise backward elimination was performed to identify independent factors, with retention of predictors with p < 0.2.
Results: Among 119 patients admitted for AE COPD in ICU during the study period, 76(63.8%) patients were discharged alive. The mean age was 67.24 ± 10.9 years. 85% were male. Exacerbations were mainly caused respectively by—tracheobronchitis, 49(81.7%), community acquired pneumonia, 5(8.3%), lung edema, 4(6%) and bronchial hyperresponsiveness, 2(3.3%). 36(60%) required intubation, and the median duration of mechanical ventilation (MV) was 2 days with extremes ranging from 0 to 21 days. 30(39.5%) required inotropic agents. The most common ICU adverse events were respectively acute renal failure 20(26.3%), cardiac arrhythmia 21(35%), nosocomial infection in 9(15%) and difficulty in weaning 10(13.2%). The in-hospital mortality rate for the study group was 36%. The follow up was performed for 60(79%). The mortality rate at 1 year was 33.33%. Univariate analysis identified three factors associated with 1 year fatal outcome—invasive mechanical ventilation (p = 0.0015), WHO performance status (p = 0.0001) and decline in functional status (p = 0.000). Multivariate logistic regression analysis showed only two independent variables associated with long term mortality—SAPS II (OR, 1.14 + 95% CI [1.04–1.25] + p = 0.004) and performance status at discharge (OR, 3.11 + 95% CI [1.55–6.23] + p = 0.001).
Conclusion: In the present study, severity of illness and physiological reserve at discharge were identified as independent predictors of long term mortality after ICU discharge in AE COPD. Therefore, caregivers should allocate adequate strategies for the prevention and control of COPD patients.
F-24 Long-term outcome according to ventilation mode in ICU survivals from AE COPD
Ben Saida Imen1, Zarrougui Wafa1, Ennouri Emna1, Sma Nesrine1, Limam Manel1, Fraj Nesrine1, Ayachi Jihene1, Khedher Ahmed1, Azouzi Abdelbaki1, Boussarsar Mohamed1
1Hôpital Universitaire Farhat Hached, Sousse, Tunisia
Correspondence: Ben Saida Imen - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-24
Introduction: Randomized controlled trials have confirmed the evidence and helped to define when and where NIV should be the first line treatment of acute exacerbation of COPD (AE COPD). Its effectiveness in preventing endotracheal intubation and reducing intensive care mortality is undeniable. Few studies have evaluated the relationship between ventilation modalities (noninvasive ventilation [NIV] versus invasive mechanical ventilation [IMV] and long-term survival in COPD patients treated in the intensive care unit (ICU). The aim of this study was to investigate one-year survival stratified by mechanical ventilation modality in COPD patients treated in the ICU.
Patients and methods: An observational prospective cohort study including all patients admitted to a Tunisian Tertiary ICU for AE COPD and discharged alive between January 2014 and December 2015. Patients were followed up via phone calls during 1 year after discharge. Characteristics on admission and outcomes after discharge were analyzed stratified by ventilation modality NIV vs IMV. The overall survival was analyzed on the basis of the Kaplan–Meier curves.
Results: During the predetermined period of data collection, the follow-up involved 60 patients. 24 patients were treated by NIV (group1) and 36 patients needed IMV (group2). There was no difference between the 2 groups in age (p = 0.69), severity of COPD (p = 0.39), physiological reserve at discharge (p = 0.14) and ICU readmission (p = 1). Short term outcomes were not different between the 2 groups—1-month readmission (16.7 vs 25% respectively in NIV and IMV, p = 0.52) and 1-month mortality (4.2 vs 19.4%, p = 0.18). However, one-year Mortality rate was lower in NIV group (16.7 vs 44.4%, p = 0.02). Long-term survival analyzed with the Kaplan–Meier method was significantly greater in the NIV group (p = 0.016) (Fig. 1).
Conclusion: In the present study while the characteristic of AE COPD patients’ prior to ICU admission and at discharge were similar, long term survival was higher in the NIV managed patients. Invasive mechanical ventilation seems to be a negative salient feature in the natural course of the COPD. Avoiding IMV by early treatment with NIV in AE COPD needing critical care is associated with better long-term survival.
F-25 A predictive triage model for ICU discharge to identify patients at risk of 30-day post ICU mortality
Ben Saida Imen1, Ennouri Emna1, Zarrougui Wafa1, Ayachi Jihene1, Limam Manel1, Fraj Nesrine1, Sma Nesrine1, Khedher Ahmed1, Azouzi Abdelbaki1, Boussarsar Mohamed1
1Hôpital Farhat Hached, Sousse, Tunisia
Correspondence: Ben Saida Imen - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-25
Introduction: The major challenge of intensivists is to reduce intensive care mortality rate. However, less attention is paid to outcomes beyond ICU discharge. A predictive triage model may influence decision making at ICU discharge and hence help caregivers to decrease short term post ICU mortality. The aim of this study was to develop a predictive triage model for discharge to identify patients at risk of 30 days post ICU mortality.
Patients and methods: An observational prospective cohort study was performed in a Tunisian medical ICU between January 2014 and December 2015. The study included all survivors after ICU admission. The mortality was assessed by telephone interviews at thirty days after discharge. Univariate and multivariate analysis were performed to identify candidate variables for the model.
Results: Among 573 patients admitted during the study period, 215 were included. The 30 days mortality rate was 16%. In univariate analysis, predictors of 30-days mortality of ICU survivors were Charlson comorbidity index (p = 0.001), baseline functional impairment ≥ 3 (p = 0.003), SAPS II ≥ 30 (p = 0.0001), Tachycardia (Heart rate ≥ 90b min) at discharge (p = 0.011), performance status ≥ 3 (p = 0.0001) and decline in functional status (p = 0.0001). Multivariate regression analysis identified the following independent risk factors, SAPS II ≥ 30 (OR, 3.258 + 95% CI [1.1–9.6] + p < 0.032), tachycardia at discharge (OR, 3.024 + 95% CI [1.01–9.11] + p < 0.049), decline in functional status (OR, 15.868 + 95% CI [15.18–48.56] + p < 0.000) and performance status ≥ 3 (OR, 6.57 + 95% CI [2.03–21.25] + p < 0.002). Based on these results, the following variables were used to develop the model—SAPSII ≥ 30, tachycardia, decline in functional status and performance status ≥ 3. These four items were weighted by their respective OR SAPSII ≥ 30, 3 points + tachycardia, 3 points + decline in functional status, 16 points + performance status ≥ 3, 6 points. The area under the ROC curve value of this predictive model obtained from the development cohort was 0.914 (95% CI [0.86–0.96]), a level deemed to be good discrimination (Fig. 1).
Conclusion: This discharge triage model is a simple, didactic, not time-consuming, costless and minimally invasive tool. It may afford the opportunity to critical care practitioners to identify patients at risk of early post-ICU mortality.
F-26 Child morbidity and mortality in an adult polyvalent intensive care unit
Merhabene Takoua1, Ben Slimène Abdelaziz1, Jamoussi Amira1, Ayed Samia1, Ben Khelil Jalila1, Besbes Mohamed1
1Hôpital Abderrahman Mami, Ariana, Tunisia
Correspondence: Merhabene Takoua - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-26
Introduction: Background—intensive care physicians rarely have to manage children less than 18 years of age. In Tunisia, lack of pediatric intensive care units (ICU) requires their hospitalization in adult units. Purpose—To assess the effectiveness of child care in a polyvalent adult ICU and determine the relevant mortality risk factors.
Patients and methods: Methods—Retrospective study including children less than 18 years old at admission in the adult polyvalent intensive care unit of Abderrahman Mami Hospital in Ariana between January 1st 2008 and August 31th 2017. Data were analyzed using Student test or logistic regression as appropriate.
Results: Out of 4994 admissions, 80 patients (incidence = 1.6 1000 admission) were enrolled according to established criteria. 10.1% were asthmatic, 3.9% were diabetic, 2.6% have a neuromuscular disease and 83.4% have no previous comorbidities. Mean age was 14.9 ± 3 years [5–18]. Sex ratio was 1.42. Acute respiratory failure (69.7%) complicating community acquired pneumonia, neurologic disorders (15.6%) and acute poisoning (12.8%) were the main causes of admission. References from our emergency room represent 53.7% of cases, wards of our hospital 19.1%, pediatric units 5.2% and onco-hematologic units 5.2%. Mean PRISM during the first 24 h was 6 ± 6.6. Septic shock was observed in 3.9% of cases, 36.6% were invasively ventilated, 22.5% were non-invasively ventilated, 8.75% had a combination of invasive and non-invasive ventilation (NIV) and 41.2% did not receive ventilatory support. 20% of patient developed complications during their hospital stay—it was predominately nosocomial infection (16.6%) complicated by septic shock in 22.5%, acute renal failure (13.8%) and barotrauma (5.6%). Average ICU stay was 6.28 ± 9.72 days with a mortality rate of 21.3%. Multivariate analysis showed that independent factors predictors of mortality were—organ dysfunction at admission (acute respiratory failure, coma and hemodynamic failure), use of mechanical ventilation, occurrence of complications during hospital stay and PRISM ≥ 18.32.
Conclusion: Pediatric mortality remains high in our adult intensive care unit. Presence of organ failure at admission and occurrence of complications were the major factors for worse prognosis.
F-27 Current knowledge of the ICU healthcare providers on the post-intensive care syndrome
Prevedello Danielle1, Devroey Marianne1, Maetens Yves1, Preiser Jean-Charles1
1Hôpital Erasme, Bruxelles, Belgique
Correspondence: Prevedello Danielle - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-27
Introduction: Post-intensive care syndrome (PICS) has been recently described as a combination of physical, cognitive and mental impairments appearing during a stay in an intensive care unit (ICU). The prevention and detection of PICS require the participation of each category of healthcare workers. However, the level of knowledge is unknown. We sought to assess the awareness among our ICU staff in preparation for a follow-up consultation.
Patients and methods: The study used a short multiple-choice survey filled on a voluntary basis. All members of the staff were asked to fill the questionnaire over a one-week period. The assessment was composed by seven structured questions which aimed measure basic knowledge of post-intensive care syndrome and general strategies to diagnose that syndrome and the tests used.
Results: Fifth five workers (30% of the staff) of the department of intensive care answered the questionnaires (67% nurses, 7% physiotherapists, 20% physicians). The estimated ranges of prevalence of psychological problems were very low (0–25%) for 3.63%, low (25–50%) for 25.45%, intermediate (50–75%) for 50.9%, and high (75–100%) for 18.18%. The ability to return at work was thought as very low, low, intermediate and high for 49.09, 43.63, 5.45 and 0% of the respondents, respectively. The other results are displayed in the Table 1.
Discussion: In spite of the sample size and of the voluntary character of this survey, these data indicate an ample room for improvement of the awareness of PICS in our ICU. The knowledge of the specific tests used for the assessment of PICS is mostly determined by the professional background. Hence, the implementation of a follow-up clinic is challenging as it requires educational training. Large similar projects have been successful after intensive training and awareness campaigns.
Conclusion: Knowledge of PICS is poor in the absence of training and education. Post-ICU follow-up clinics require skill and motivation from a large variety of ICU healthcare workers.
F-28 Evaluation of death certificates drafted in emergency and intensive care departments
Wiem Ben Amar1, Zribi Malek1, Ennouri Hassen1, Karray Narjess1, Bardaa Sami1, Hammami Zouheir1, Maatoug Samir1
1Hôpital Habib Bourguiba, Sfax, Tunisia
Correspondence: Wiem Ben Amar - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-28
Introduction: Drafting a death certificate (DC) is a procedure considered as a part of doctor’s daily practice, especially in emergency and intensive care departments. This certificate represents a civil, social, epidemiological and medico-legal act. It can engage the liability of the certifying doctor. The objectives of our study were to examine the content of DC drafted in emergency and intensive care departments, assess the quality of writing, and analyze drafting errors.
Patients and methods: A prospective study extended over a period of 12 months from January to December 2015, including all DC emanating from emergency and intensive care departments and received in the forensic department of Habib Bourguiba hospital in Sfax.
Results: During the study period, 120 DC meeting the inclusion criteria were collected. Although confidential, the medical part of the DC was sealed by the doctor in onlyone third of cases. In the administrative section, nine socio-demographic parameters were studied. In 10% of the cases, less than four of the nine criteria were found. In the section concerning the certifying doctor data, 7 parameters were screened. 67.1% of the certifying doctors met at least six criteria. The most frequently missing parameter in this section was the identity of the person to whom the certificate was issued. The identity of the doctor was not mentioned in 10% of the cases. Forensic data (4 items) was complete in over three quarters of the certificates. Nevertheless, in 26.7% of cases, the medicolegal obstacle to burial box was left empty (8.3%) or not ticked even if judicial investigation was required (18.3%). The section on causes of death was the source of almost all of the drafting errors. We have classified these errors into six major ones, according the classifications reported in the literature. The percentage of certificate without faults was 13%. The most common major error was insufficient cause of death found in 40.4% of cases followed by incorrect sequence of causes of death (28.8%), medicolegal obstacle to burial not ticked although required (26.6%), several causes of death mentioned simultaneously (16.7%), unacceptable cause of death (10.8%) and mechanism of death mentioned instead of the cause of death (5.8%).
Conclusion: Our study showed that the quality of drafting of DC suffered from several insufficiencies, which encourages us to provide more effort in training doctors and to review the current official model of DC.
F-29 Validation of a delocalized measurement method of lactate for septic patients
Jouffroy Romain1, Leguillier Teddy1, Boisson Marie1, Boussaroque Agathe1, Nivet Antoine Valérie1, Beaudeux Jean Louis1, Vivien Benoit1
1Hôpital Necker Enfants Malades, Paris, France
Correspondence: Jouffroy Romain - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-29
Introduction: Septic shock is defined as a sepsis with hyperlactaemia greater than 2 mM after correction of hypovolemia requiring vasopressors to maintain MBP > 65 mmHg . It can be observed in pre-hospital emergency medicine (PHEM). The use of a reliable portable device for measuring lactate in PHEM would allow a better evaluation of septic patient facilitating their orientation towards intensive care unit (ICU) or emergency department (ED). This portable delocalized biology device must be validated against the laboratory reference method (NFEN ISO 22870) . The aim of this study was to clarify the validity of a delocalized measure of lactatemia.
Patients and methods: We performed a prospective study including 47 patients admitted into ICU for septic shock (CPP number 2015-08-03 SC). Lactate was measured in parallel on 2 samples—one capillary with the portable device (Lactate StatStrip Xpress, Nova Biomedical) and the other venous on a centrifuge tube for plasma analysis (Architect C16000 Abbott Diagnostics). We evaluated the analytical performance (coefficients of variation (CV) for repeatability and reproducibility evaluated at 2 levels of quality control (QC)—1.6 and 3.6 mM) and then the concordance between lactate levels measured by the devices and lactate levels measured by laboratory analyzer.
Results: At the QC concentrations tested, the CVs were in agreement with the limits set by the French Society of Clinical Biology—CV < 3% for repeatability and < 5% for reproducibility. An excellent correlation was observed between the 2 measurements—correlation coefficient R2 = 0.98, slope = 0.95 and ordered at the origin = 0.1. The latter suggested a low positive bias of the device not confirmed by Bland–Altmann graph analysis and graph of the differences.
Conclusion: We verified the analytical performance of the device and showed an excellent correlation with the laboratory measurement. The delocalized measure can be used in PHEM in patients with suspected sepsis syndrome. This measure should allow a more accurate and early assessment of their severity in order to improve triage and hospital orientation between ED and ICU.
F-30 Association between hyperoxia and mortality for patients treated by Extra Corporeal Life Support after Out Hospital Cardiac Arrest
Halter Maryline1, Jouffroy Romain1, Saade Anastasia1, Philippe Pascal1, Carli Pierre1, Vivien Benoit1
1Hôpital Necker Enfants Malades, Paris, France
Correspondence: Halter Maryline - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-30
Introduction: We examine whether values of PaO2 taken immediately after starting Extra Corporeal Pulmonary Resuscitation (eCPR) inserted in a intensive care unit (ICU) is associated with death in patients treated by eCPR after refractory Out Hospital Cardiac Arrest (OHCA).
Patients and methods: We performed a retrospective observational study. Patients were divided into 3 groups defined on oxygen partial arterial pressure (PaO2) on the first arterial blood gas analysis after starting eCPR. Hyperoxia was defined as PaO2 greater than 300 mmHg + hypoxia as a PaO2 of less than 60 mmHg and normoxia, not classified as hyperoxia or hypoxia. The main outcome was mortality at day 28 (D28).
Results: Sixty-six consecutive patients, 77% male, with a mean age of 51 ± 14 years, were admitted to the ICU after refractory OHCA requiring eCPR. Aetiologies of OHCA were mainly due to acute coronary syndrome (67%), hypertrophic cardiomyopathy (8%) and cardiotoxic overdose (8%). Mortality at D28 reached 61%. Mean PaO2 at admission was 227 ± 124 mmHg. We observed an association between D28 mortality and PaO2—OR 1.010 [1.005–1.015], (p = 0.0005). Area Under Curve (AUC) for PaO2 after starting eCPR was 0.77 [0.65–0.89]. In a model controlling for potential confounders (age, no flow and lo flow duration, lactate level, pH and carbon dioxide partial pressure), hyperoxia exposure had an odds ratio for D28 mortality of 3.92 (95% CI 1.14–16.50) (p = 0.04) whereas in normoxia had an odds ratio for D28 mortality of 0.25 (95% CI 0.06–0.91) (p = 0.04).
Conclusion: There is an association between mortality at D28 and hyperoxia in patients admitted in ICU for refractory OHCA requiring eCPR. These data underline the potential toxicity of high dose of oxygen and suggest that control of oxygen administration in such patients is an important part of the treatment. A value of PaO2 between 100 and 300 mmHg after starting eCPR seems to be a target during treatment of OHCA treated by eCPR.
F-31 Validation of qSOFA score in the Emergency Department (ED): a prospective study
Lafon Thomas1, Vallejo Christine1, Zmiri Camilia1, Organista Alexandre1, Coroller Louis1, Baisse Arthur1, Herafa Isabelle1, Vignon Philippe1, François Bruno1
1CHU Dupuytren, Limoges, France
Correspondence: Lafon Thomas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-31
Introduction: Sepsis has been defined as a dysregulated host response to infection leading to life-threatening organ dysfunction (Singer M et al., JAMA 2016). A qSOFA score relying on 3 simple clinical criteria (respiratory rate, mental status and systolic blood pressure) has been proposed to better identify septic patients with associated higher mortality outside the intensive care unit (Seymour CW et al., JAMA 2016). The study aim was to evaluate the ability of qSOFA to predict the development of organ failure and increased 28-day mortality in patients admitted for suspected sepsis in the Emergency Department (ED).
Patients and methods: Prospective study conducted over a period of 6 months comparing the prevalence of organ failure and 28-day mortality according to the value of qSOFA at admission to the ED between group A (qSOFA > = 2) and group B (qSOFA < 2). As part of routine care, an electronic sepsis form was specifically created to identify prospectively and exhaustively all eligible patients on-line. For the purpose of the study, sepsis diagnosis was independently validated off-line by an adjudication committee which included three physicians who reviewed clinical, biological and microbiological data. For each patient, demographic data, source of infection, qSOFA and SOFA score, biological data and 28-day mortality were recorded.
Results: From November 2016 to April 2017, of the 476 patients identified, 374 patients were included after adjudication and 77 patients (20.5%) had a positive qSOFA score and constituted group A (46 men + median age = 77 years [23–95]). Tachypnea, confusion and low blood pressure were noted respectively in 82, 71 and 70% of group A patients. In group A, organ failure occurred in 64 patients (83.1%), 30 of them exhibiting septic shock (39%). Median SOFA score was 4 [2–12] and median lactate level at baseline was 3.31 [0.5–27.13]. Seventy-six patients of group A (99%) were hospitalized, of whom 25 were admitted to the intensive care unit (32.5%), and 28-day mortality reached 46.7%. In group B, only 32 patients developed an organ failure (10.7%) and 28-day mortality was 4.3% (Table 1).
Conclusion: The present study confirmed that the qSOFA score is a reliable and practical tool to predict the development of organ failure and higher 28-day mortality in patients with suspected sepsis in the ED.
F-32 Limits of CT scan criteria and intravascular contrast extravasation to define pelvic angioembolization need: a specific assessment on the risk of false-positive
Ramin Séverin1, Charbit Jonathan1, Hermida Margaux1, Deras Pauline1, Capdevila Xavier1
1CHU de Montpellier, France
Correspondence: Ramin Séverin - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-32
Introduction: Intravascular contrast extravasation (ICE) on CT imaging is commonly considered as the marker of pelvic active arterial bleeding, which justifies immediate performing of an pelvic angiography and trans-arterial angioembolization (TAE). However, ICEs lack of specificity in detecting arterial injuries especially in cases of bones or venous bleeding. The objective of present study was to determine the predictive performance of different ICEs characteristics for the need for Trans-arterial embolization (TAE) and the risk factors for false positive for arterial bleeding.
Patients and methods: A retrospective study was performed in our trauma center between 2010 and 2015. All severe trauma patients with pelvic fracture were included. Pelvic ICE characteristics on CT scan were specifically studied—arterial (aS2ICE), portal surface (pS2ICE) and extension (exS2ICE), anatomical relationships (ICE contact with complex bone fractures, direct relation between ICE and large retroperitoneal Hematoma. The overall predictive performance of ICE surfaces for pelvic TAE use was analyzed thanks ROC curves. The analysis then focused on the study of risk factors for false positives.
Results: Among 311 severe trauma patients with pelvic ring fracture (mean age 42 ± 19, mean ISS 27 ± 19), 94 (30%) had at least one pelvic ICE on initial CT scan. Patients requiring pelvic TAE had aS2ICE and pS2ICE significantly larger than others (p = 0.001 and p = 0.035, respectively). The global ability of ICE surfaces was either modest (aS2ICE AUC 0.76 [CI 95% 0.64–0.90] + p = 0.011) or non-significant (pS2ICE and exS2ICE) to predict pelvic TAE. The high sensitivity threshold was defined as an aS2ICE greater than 20 mm2. Using this threshold, 76% of patients were false-positives. Risk factors of false-positives were—admission low systolic blood pressure (OR 6.7 [CI 95% 1.2–36.7]) and low transfusion needs (OR 15.0 [CI 95% 1.7–133.6]), the extravasation in contact with complex bone fracture (OR 7.8 [CI 95% 1.4–59.7]) or the absence of direct relation between the extravasation and large retroperitoneal hematoma (OR 7.6 [CI 95% 1.4–42.3]).
Conclusion: A significant pelvic ICE during arterial phase does not guarantee the need for pelvic TAE. Three-quarter of patients with an aS2ICE greater than 20 mm2 did not experienced pelvic TAE. TAE may be performed in cases of direct relation between ICE and large retroperitoneal hematoma or an ICE without contact with complex bone fracture.
F-33 Role of mitochondrial Cyclophilin-D in cardiac resuscitability and survival after asphyxial cardiac arrest in mice
Jahandiez Vincent1, Cour Martin1, Pillot Bruno2, Gallo-Bona Noelle2, Ovize Michel2, Argaud Laurent1
1Hôpital Edopuard Herriot, Lyon, France; 2INSERM-U1060, Lyon, France
Correspondence: Jahandiez Vincent - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-33
Introduction: Opening of the mitochondrial permeability transition pore (PTP), triggered by Cyclophilin-D (CypD) binding under stress conditions, plays a key role in ischemia–reperfusion injury. We sought to determine, using transgenic mice, whether CypD deletion (CypD −) would improve resuscitability and survival after experimental cardiac arrest (CA). Additionally, we compared the protective effects of CypD deficiency with that of targeted temperature management (TTM).
Patients and methods: Anesthetized mice underwent a 5 min asphyxial CA followed by resuscitation (cardiac massage, resumption of ventilation, epinephrine). Four groups of animals were studied—Sham, Control (Ctrl), CypD-CA using mice lacking CypD (knockout mice), and TTM-CA with fast hypothermia induced by external cooling at reperfusion (33 °C for 1 h). Two hours after CA, the following measurements were carried out (n = 6–9 group)—echocardiography, cellular damage markers (including S100B protein and troponin Ic) and mPTP opening in mitochondria isolated from brain and heart. Additional mice (n = 7–12 group) were included in the same 4 groups for survival follow-up (24 h and 7 days).
Results: Characteristics of CA were similar among groups. Rate of restoration of spontaneous circulation (ROSC) was significantly higher in CypD—and TTM groups compared to controls (p < 0.05). Time to ROSC was shorter in CypD—versus TTM and Ctrl (p < 0.05). Genetic loss of CypD and TTM prevented to a similar extent CA-induced myocardial dysfunction, increase in blood levels of both S100B protein and troponin Ic (p < 0.05 versus Ctrl). CA resulted in a significant increase in PTP opening only in mitochondria isolated from brain (p < 0.05 versus Sham). CypD deletion as well as TTM limited CA-induced PTP opening in brain (p < 0.05 versus Ctrl). Short-term survival (24 h) was significantly improved in the CypD—and TTM groups when compared to controls (p < 0.05). However, only therapeutic hypothermia improved survival at day 7 (p < 0.05 versus Ctrl).
Conclusion: In our murine CA model, genetic loss of CypD increased resuscitability and short-term survival but, unlike therapeutic hypothermia, failed to improve 7-day survival.
F-34 Predicting coma outcome using resting-state fMRI and machine learning
Pugin Deborah1, Hofmeister Jeremy1, Van de Ville Dimitri1, Gasche Yvan1, Vulliemoz Serge1, Haller Sven1
1HUG de Genève, Switzerland
Correspondence: Pugin Deborah - Deborah.email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-34
Introduction: Early prediction of neurological outcome of post-anoxic comatose patients after cardiac arrest (CA) is challenging. Prognosis of comatose patient relies on multimodal testing—clinical examination, electrophysiological testing and structural neuroimaging (mainly diffusion MRI). This prognostication is accurate for predicting poor outcome (i.e. death) but not sensitive for identifying patients with good outcome (i.e. consciousness recovery). Resting state functional MRI (rs-fMRI) is a powerful tool for mapping functional connectivity, especially in patients with low collaboration. Several studies showed that rs-fMRI can differentiate states of consciousness in chronically brain-damaged patients. A recent study also showed that functional neuroimaging can early detect signs of consciousness in patient with acute traumatic brain injury. However, rs-fMRI has not been assessed for the early prognostication of post-anoxic comatose patient.
Patients and methods: We assessed whole-brain function connectivity (FC) of 17 post-anoxic comatose patients early after CA using rs-fMRI. Nine patients ultimately recovered consciousness (good outcome) while eight died (poor outcome). We estimated FC for each patient following a procedure previously described. We statistically compared whole-brain FC between good and poor outcome group, to assess which brain connections differed between them. Then, we trained a machine-learning classifier (a Support Vector Machine, SVM) to automatically predict coma outcome (good poor) based on whole-brain FC of comatose patients. Finally, we compared this outcome prognostication based on functional MRI to those using standard structural diffusion MRI.
Results: Good and poor coma outcome groups were similar in terms of demographics, except for time to ROSC. Good outcome group showed significant increase in whole-brain FC between most cortical brain regions + with the strongest changes occurring within and between occipital and parietal, temporal and frontal regions (Fig. 1). Using whole-brain FC and a SVM classifier to predict coma outcome yielded to an overall prediction accuracy of 94.4%(AUC 0.94). Interestingly, automatic outcome prognostication using functional neuroimaging achieved better results that structural neuroimaging methods like DWI (accuracy 70.6%).
Conclusion: We used rs-fMRI to predict coma outcome in a cohort of post-anoxic comatose patients early after CA. We deliberately chose to include only patients with indeterminate prognosis after standard multimodal testing, to assess the contribution of rs-fMRI in the early prognostication of coma outcome. We found that automatic prediction based on functional neuroimaging yielded much better results than current DWI methods, notably for identifying patients who recovered consciousness.
F-35 Neurological Pupil index for early neuroprognostication
Miroz John-Paul1, Solari Daria1, Eckert Philippe1, Oddo Mauro1, Ben-Hamouda Nawfel1
1Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
Correspondence: Miroz John-Paul - John-Paul.Miroz@chuv.ch
Annals of Intensive Care 2018, 8(Suppl 1):F-35
Introduction: ECMO is increasingly used in critical care. Neurologic complications are frequent however there are no quantitative tools for outcome prediction in this setting. The aim of the study is to examine the value of quantitative pupillometry to predict neurologic outcome in patients on veno-arterial ECMO (VA-ECMO).
Patients and methods: Preliminary cohort analysis (June 2016-August 2017) of consecutive patients with VA-ECMO, in whom Npi®-200 pupillometer (Neuroptics®, USA) was repeatedly performed (12–72 h) to measure % pupillary light response (qPLR) and Neurologic Pupil index (NPi). Mortality was assessed at 3 months. Using simplified 4-channel EEG (Masimo SedLine®, USA) depth of sedation (using PSI—Patient State Index and SR— % suppression ratio on EEG) was recorded in parallel.
Results: A total of 28 patients (mean age 56 years [23–81] + mean APACHE II 28 [12–47], mean SOFA 14 [9–18]) were analyzed—14 patients (50%) had refractory cardiogenic shock and 14 had refractory cardiac arrest. Mortality at 3 months was 78%. NPi < 3 and qPLR < 11% were associated with 100% mortality. NPi = 0 (n = 7) was associated with highly suppressed EEG (SR 64–100%) and early death within 96 h. Among survivors (n = 5) NPi was > 4 on all measurements.
Conclusion: Automated infrared pupillometry, and particularly the quantitative Neurological Pupil index, may be useful for early neuroprognostication in VA-ECMO patients. Further study is undergoing at our center to confirm these preliminary data in a larger cohort.
F-36 Elaboration of a consensual endpoint to evaluate antimicrobial treatment efficacy in future HAP VAP clinical trials
Weiss Emmanuel1, Ewig Santiago2, Zahar Jean-Ralph1, Adler Jeff3, Asehnoune Karim1, Bassetti Matteo4, Bonten Marc5, Chastre Jean1, De Waele Jan6, Dimopoulos George7, Eggimann8, Philippe, Engelhardt Marc8, Kollef Marin3, Lipman Jeffrey9, Luna Carlos10, Martin Loeches Ignacio11, Pagani Leonardo4, Palmer Lucy3, Papazian Laurent1, Poulakou Garyphallia7, Prokocimer Philippe3, Rello Jordi12, Rex John12
1Hôpital Beaujon, Clichy, France; 2Hôpital de Bonn, Germany; 3Hôpital Saint Joseph, Ohio, USA; 4Hôpital Santa Maria Misericordia, Udine, Italy; 5Hôpital de Utrecht, Netherlands; 6Hôpital de Ghent, Belgium; 7Université d’Athènes, Grèece; 8CHUV Lausanne, Switzerland; 9Université du Queensland, Australia; 10Université de Buenos Aires, Argentina; 11HôpitaI Saint James, Dublin, Ireland; 12Hôpital Vall d’Hebron, Barcelone, Spain
Correspondence: Weiss Emmanuel - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-36
Introduction: Hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are often selected for randomized clinical trials (RCTs) aiming at new drug approval. A recent systematic review (Weiss et al. Crit Care 2017) reported a significant heterogeneity in endpoints used in RCTs comparing treatment of severe pneumonia that may influence their ability to demonstrate differences between studied drugs. Clinical cure was the most frequently used endpoint but its definition was highly variable. These results are not surprising as far as even guidance from regulatory agencies on how to evaluate HAP VAP treatments differ. The aim of this work was to reach a consensus on the most appropriate endpoint to consider in future clinical trials evaluating the efficacy of antimicrobial treatment for HAP VAP, using Delphi method.
Patients and methods: Twenty-six international experts from intensive care, infectious disease and from the industry were consulted using Delphi method (four successive questionnaires) from January 2016 to January 2017. More than 70% of similar answers to a question were necessary to reach a consensus.
Results: According to 60% the experts, clinical cure was the most desirable primary outcome among those found in the literature but two other endpoints were highly rated—all-cause mortality and mechanical ventilation (MV)-free days. Consequently, 88% of the panelists agreed to use a composite endpoints and even a hierarchical composite endpoint to combine these items together in which clinical cure and MV-free days would be assessed at day 28 and clinical cure at day 7 after end of therapy. For VAP, mortality was considered as the most clinically significant item by 75% of the experts, followed by MV-free days and finally clinical cure (Fig. 1). For HAP, a dual composite endpoint that only included all-cause mortality and clinical cure was chosen (Fig. 1). Among the various elements of clinical cure definition found in the literature, only three were retained by the experts—resolution at end of therapy of signs and symptoms present at enrolment, no further antimicrobial treatment needed and resolution or lack of progression of radiological signs of pneumonia. Finally, we found a consensus on the signs and symptoms that should trigger the suspicion of pneumonia—worsening of gaz exchange, purulent tracheal secretions, hypotension and or vasopressor requirements and fever or hypothermia.
Conclusion: We provide here two consensual endpoints (for VAP and HAP) that would help addressing the efficacy of antimicrobial molecules for HAP VAP treatment in future clinical trials.
F-37 Ventilator associated pneumonia due to Stenotrophomonas maltophilia: risk factors and outcome
Merceron Sybille1, Ibn Saied Wafa1, Schwebel Carole1, Le Monnier Alban1, Garrouste-Orgeas Maité1, Marcotte Guillaume1, Ruckly Stéphane1, Souweine Bertrand1, Darmon Michael1, De Montmollin Etienne1, Mourvillier Bruno1, Reignier Jean1, Papazian Laurent1, Siami Shidasp1, Azoulay Elie1, Bédos Jean-Pierre1, Timsit Jean-François1
1Hôpital Le Chesnay, Versailles, France
Correspondence: Merceron Sybille - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-37
Introduction: Stenotrophomonas maltophilia (SM) is a Gram negative bacteria rarely involved in ICU acquired infections. Empirical treatment is challenging, as SM is resistant for almost all clinically-relevant antibiotics. SM ventilator-associated pneumonia (SM-VAP) have been associated with frequent inadequate antimicrobial therapy and increased ICU stay and mortality. Identifying risk factors for SM-VAP could be useful.
Patients and methods: We conducted a retrospective analysis of prospectively collected data in a multicenter database in France. VAP was determined as microbiologically documented pneumonia occurring after at least two days of mechanical ventilation. All patients admitted from 2000 to 2015 presenting at least one episode of VAP were included. SM-VAP were compared with VAP due to other micro-organisms (VAP-other). To assess risk factors and day-30 (D30) mortality, SM-VAP were matched (1 − n) with VAP-other based on center, time from ICU admission to VAP occurrence, and SAPS II score.
Results: Of the 20 968 patients included, 1 659 presented at least one episode of VAP. Among them, 102 (6.2%) suffered from SM-VAP. Patients with SM-VAP were men (61.3%), aged 62 [53–76] with SAPS II score 50 [40–65] and 20% were immunocompromised. Median length of stay in ICU was longer in SM-VAP (Table). 93 SM-VAP were matched with 380 control patients. In univariate analysis, risk factors for SM-VAP were—male gender, chronic heart failure, respiratory, cardiovascular and coagulation SOFA scores two days before VAP, median number of antibiotics used, percentage of time with antibiotics before VAP, parenteral nutrition, dialysis, catecholamine use and exposure to Ureido-carboxypenicillin, Ciprofloxacin, Tazobactam or Imipenem-Meropenem during the week before VAP (Table). Patients with SM-VAP were less likely to receive initial adequate therapy (56 vs 70%, OR 0.53, p = 0.01). There was no statistical difference for ICU or D30 mortality. D60 mortality was higher for SM-VAP (Table). In multivariate analysis, exposure to Imipenem-Meropenem during the week before VAP, respiratory and coagulation SOFA scores two days before VAP were independent risk factors for SM-VAP.
SAPSII: Simplified Acute Physiology Score; SOFA: SOFA (Sequential Organ Failure Assessment); SOFA Resp: SOFA respiratory score;
SOFA coag: SOFA coagulation score; SOFA cardio: SOFA cardiovascular score
Conclusion: SM-VAP represented 6.2% of VAP. We observed no differences in patients characteristics between the groups. Imipenem-Meropenem use during the week before VAP was the most important risk factor for SM-VAP. The higher risk of inadequate initial therapy with SM-VAP had no impact on D30 mortality but D60 mortality was significantly higher.
F-38 Personal feedback with ultraviolet inspection cabinets for undergraduate students education to hand hygiene and nosocomial infection prevention
Lehingue Samuel1, Forel Jean-Marie1, Cassir Nadim1, Papazian Laurent1
1Hôpitaux de Marseille, Marseille, France
Correspondence: Lehingue Samuel - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-38
Introduction: Education of undergraduate students is key to improve Hand hygiene (HH) behavioral changes amongst doctors [1.2]. Our aim was to evaluate personal feedback using Ultraviolet (UV) light inspection cabinets in a 2 years program. Our hypothesis was that its use for Alcohol hand rub (AHR) application on first year would increase complete AHR application on 2nd year.
Patients and methods: This was a simple blind randomized trial comparing HH training with personal feedback using UV cabinet to a control group. On first year, students had access to a theoretical formation then were convened by groups for a demonstration of the correct execution of world health organization’s (WHO) procedure . Before HH training, each group underwent a cluster randomization. In the control group, the student hand rubbed under visual supervision and advises of a trainer. In the intervention group after the same visual assessment, completeness of AHR hand application was recorded under UV light and shown to the student. He was given free access to the UV cabinet to repeat the technique, until perfect application complete under UV light. An enhancement with a scenario-based learning was proposed to both groups. On second year, every student were asked to hand rub with the fluorescent AHR. A supervisor blinded to the group of randomization assessed the quality of the HH procedure visually, the completeness of hand application under UV light and compliance with the WHO’s opportunities for HH during the simulation.
Results: After randomization 140 students were included in the intervention group and 102 in the control group. On second year, the rate of complete application of the AHR under UV was increased in the intervention group as compared with the control group (60% versus 30.4% p < 0.001) (Fig. 1) despite that visual assessment of HH procedures was similar between the two groups. In a logistic regression model including gender, intercurrent HH formation, intercurrent UV cabinet use, surgical unit traineeship and report of regular use of AHR, the hazard ratio for the intervention was 3.837 (IC 2.086–7.058). The rate of perfect compliance with the HH opportunities in the intervention group was increased (58.1% versus 42.4% p < 0.018) and the effect persisted in the logistic regression.
Conclusion: UV cabinets for undergraduate students’ HH education improve the technique and the compliance with HH opportunities. Included in a multifaceted education program, it must be considered a key tool for training.
F-39 Bacterial colonization of healthcare workers’ mobile phones in an intensive care unit (ICU) effects of disinfection
Missri Louai1, Smiljkovski Daniel1, Prigent Gwénolé2, Lesenne Aude2, Obadia Thomas3, Joumaa Mohsen1, Chelha Riad1, Chalumeau-Lemoine Ludivine1, Obadia Edouard1, Galbois Arnaud1
1Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France; 2Cerballiance Paris sud, laboratoire de Bactériologie, Wissous, France; 3Institut Pasteur, Paris, France
Correspondence: Missri Louai - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-39
Introduction: Bacterial colonization of environmental surfaces or medical devices can lead to nosocomial infections, especially in ICU. Mobile phones are commonly used by healthcare workers. However, very few studies assessed bacterial colonization of healthcare workers’ mobile phones in ICU and the impact of disinfection.
Patients and methods: We conducted a prospective monocentric study in a 15-bed medical ICU with 54 healthcare workers. Swabs were used to assess bacterial colonization of healthcare workers’ mobile phones before and after 5 min of disinfection with bactericidal Anios© wipes. Results were compared to those observed in administrative staff. Swabs were incubated at 37 °C for 24 h on different types of agar. Bacterial identification was conducted by mass spectrometry (MALDI-TOF) combined with the VITEK2 automated antibiotic device for the search for antibiotic-resistant strains.
Results: We report in this abstract preliminary results after inclusion of 47 healthcare workers in ICU and 27 in administrative staff. All healthcare workers participating in the study reported keeping their mobile phone during their shift. Only 5 47 (10.6%) declared to wash it monthly. All of the ICU’s mobile phones were colonized by bacterial skin flora, 53.2% by environmental flora and 43% were colonized by pathogens (coagulase negative staphylococcus excluded). Only one MRSA was identified and no ESBL was detected. Results were similar in administrative staff’ mobile phones (Table). No variable (healthcare workers, profession, mobile phone brand, use of cover case, routine disinfection…) was associated with pathogens colonization. Following disinfection, bacterial colonization decreased—105 (20–315) UFC mL vs. 1000 (295–1000) UFC mL (p < 0.001). After disinfection, only 5 (10.6%) mobile phones were sterilized but 75% (15 20) of pathogens colonized mobile phones became pathogen-free.
|Variable||ICU healthcare workers’ mobile phones (n = 47)||Administrative staff’ mobile phones (n = 27)||p value|
|Bacterial colonization, n (%)||47 (100)||27 (100)||1|
|Skin flora||47 (100)||27 (100)||1|
|Oropharyngeal flora||4 (8.5)||2 (7.4)||1|
|Digestive flora||3 (6.4)||2 (7.4)||1|
|Environmental flora||25 (53.2)||17 (63.0)||0.47|
|Pathogens colonization (CNS excluded), n (%)||20 (42.6)||11 (40.7)||1|
|Staphylococcus aureus||9 (19.1)||5 (18.5)||1|
|Digestive flora||4 (8.5)||2 (7.4)||1|
|K. oxytoca||1 (2.1)||0|
|E. cloacae||1 (2.1)||1 (3.7)|
|E. fecalis||1 (2.1)||0|
|E. faecium||1 (2.1)||0|
|Oropharyngeal flora||5 (10.6)||2 (7.4)||1|
|Moraxella sp.||1 (2.1)||1 (3.7)|
|Raoultella ornithinolytica||1 (2.1)||0|
|Haemophilus parainfluenzae||1 (2.1)||0|
|Streptococcus salivarius||1 (2.1)||0|
|Aerococcus viridans||0||1 (3.7)|
|Bacillus cereus||6 (12.8)||3 (11.1)||1|
|MRSA, n (%)||1 (2.1)||0||1|
|ESBL, n (%)||0||0|
Conclusion: Colonization of mobile phones is similar in healthcare workers in ICU and in administrative staff. In our ICU, all mobile phones are colonized by skin flora and 43% with pathogens. Our assessed disinfection protocol appeared insufficient. Intensivists should be aware of these results to help prevent nosocomial infections.
F-40 Absence of extended-spectrum beta-lactamases-producing Enterobacteriaceae fecal carriage cross-transmission in a medical ICU
Prevel Renaud1, Cockenpot Thibault1, M’Zali Fatima1, Andre Catherine1, Boyer Alexandre1, Dubois Veronique1, Gruson Didier1
1Hôpital Pellegrin, Bordeaux, France
Correspondence: Prevel Renaud - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-40
Introduction: Extended-spectrum beta-lactamases-producing Enterobacteriaceae (ESBL-E) are disseminating worldwide. ESBL-E fecal carriage is known to increase the risk of ESBL-E infections and so untailored empirical probabilistic antibiotherapy and mortality. The aim of this work was to study the mechanisms of dissemination of ESBL-E fecal carriage in an intensive care unit (ICU).
Patients and methods: We screened every in-patient at admission and every 7 days in a two units of medical ICU (25 beds) for 6 months according to current practice. Every ESBL-E found was characterized by ESBL genes PCR amplification and sequencing and the clonal dissemination was assessed by Pulsed-Field Gel Electrophoresis (PFGE).
Results: Over that 6-month period, among the 608 screened patients, 57 (9.4%) were found to be colonized by ESBL-E. Among these 57 patients, 7 (1.2%) acquired the ESBL-E fecal carriage during their stay in the ICU. No cross-transmission of ESBL-E occurred (as assessed by PFGE analysis) even for ICU-acquired fecal carriage. ESBL genes were found to be mostly from the CTX-M group mainly CTX-M group 1 (36 57) enhancing the community origin of the ESBL-E fecal carriage even in ICU. ESBL-E caused infections occurred in 5 57 patients always consisting in ventilator-associated pneumonia caused by the colonizing strain.
Conclusion: Hygiene isolation procedures seem to be well applied in our units as we do not have any ESBL-E fecal carriage cross transmission case. But still cases of ICU-acquired ESBL-E fecal carriage occurred suggesting an endogenous origin in a non-outbreak situation. Therefore, the mechanisms of ESBL-E expansion in the community and of endogenous ESBL-E acquisition in ICU are still to investigate.
F-41 Bloodstream infections in adults undergoing extracorporeal membrane oxygenation: epidemiology and risk factors
Perrin Caroline1, Conil Jean-Marie1, Georges Bernard1, Seguin Thierry1, Crognier Laure1, Fourcade Olivier1, Bounes Fanny1, Minville Vincent1, Silva Stein1, Delmas Clément1
1CHU de Toulouse, France
Correspondence: Perrin Caroline - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-41
Introduction: Detection of nosocomial infections (NIs) occurring during extracorporeal membrane oxygenation (ECMO) is difficult and their related side effects appear to contribute to the high mortality rates (40–50%) of these patients. The most common ones are ventilator-associated pneumonia and bloodstream infections (BSI). Thus we empirically developed a standardized protocol with systematic blood cultures on days 2, 6, 10 and 15. The objectives of this study were to analyze BSI incidence, distribution of microorganisms, risk factors in adult undergoing ECMO support and to evaluate the efficiency of our protocol.
Patients and methods: We prospectively included all adult patients who underwent veinoarterial (VA-ECMO) or veinovenous extracorporeal membrane oxygenation (VV-ECMO) between May 2014 and March 2016. Anamnestic data and blood culture results using the protocol and additional blood samples were analyzed.
Results: Among the 81 patients who underwent ECMO support for more than 48 h, 10 patients in the VA-ECMO group (n = 10 56 + 17.9%) and 3 patients in the VV-ECMO group (n = 3 25 + 12%) developed 18 BSI, corresponding to a global rate of 22.4 BSI per 1000 ECMO days. Microorganisms associated with these infections were most frequently gram-negative bacilli. Only the duration of ECMO was significantly correlated with BSI occurrence, with a median duration of 6.5 days for “patients without BSI” and of 14 days for “patients with BSI” (p = 0.0170). The efficiency of the protocol in diagnosing BSI was roughly 5% (5 96) for the VA-ECMO group and around 6% (3 49) for the VV-ECMO group.
Conclusion: Probability of developing BSI in adults undergoing ECMO increases with ECMO duration. Systematic blood cultures do not appear to be an effective way of improving BSI detection.
F-42 Epidemiology of bacteriological analyses in adult patients supported by veinoarterial extracorporeal membrane oxygenation
Perrin Caroline1, Conil Jean-Marie1, Georges Bernard1, Marcheix Bertrand1, Seguin Thierry1, Ruiz Stéphanie1, Fourcade Olivier1, Bounes Fanny1, Minville Vincent1, Silva Stein1, Delmas Clément1
1CHU de Toulouse, France
Correspondence: Perrin Caroline - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-42
Introduction: Nosocomial infections (NIs) occurrence during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support and their complications appear to contribute to the high mortality rates (40–60%) of these patients. The most common ones are ventilator-associated pneumonia and bloodstream infections (BSI). In clinical practice, detection of NIs is difficult due to confounding factors caused by the device. The objectives of our study were to analyze BSI and positive tracheal aspirate (TA) culture incidences, distribution of microorganisms and risk factors in adult undergoing veinoarterial ECMO (VA-ECMO).
Patients and methods: We prospectively and consecutively included all adult patients who underwent VA-ECMO between May 2014 and March 2016 in our intensive care unit. Anamnestic data, blood culture and TA culture were analyzed. Primary endpoint was the occurrence of a BSI or a positive TA culture more than 24 h after ECMO initiation and within 48 h after ECMO discontinuation.
Results: Among the 56 patients who underwent ECMO support for more than 48 h, the BSI prevalence was 27.4 cases per 1000 ECMO days and microorganisms associated were most frequently gram-negative bacilli. As for positive TA cultures, microorganisms associated were oropharyngeal germs and gram-negative bacilli. Two risk factors were associated with nosocomial bacteria occurrence in TA cultures—prior antibiotics and duration of mechanical ventilation more than 5 days. We demonstrated a link between “positive TA culture” and “positive blood culture” and we showed a protective effect of using an antibioprophylaxis on “positive TA culture” and “global positive cultures” development.
|Positive blood culture no/yes||29 (80.6%)/7 (19.4%)||16 (80%)/4 (20%)||0.9604|
|Positive tracheal aspiration culture no/yes||4 (11.1%)/32 (88.9%)||12 (60%)/8 (40%)||0.00037*|
|Positive tracheal aspiration culture (> 106 UFC/ml) no/yes||19 (52.8%)/17 (47.2%)||17 (85%)/3 (15%)||0.02068*|
|Global positive culture no/yes||16 (44.4%)/20 (55.6%)||15 (75%)/5 (25%)||0.0484*|
Conclusion: Use of an antibioprophylaxis at ECMO implantation is associated with a decrease of global positive cultures development.
F-43 Management of status epilepticus in the intensive care unit: evaluation of the current pharmacological practice and risk of drug–drug interactions
Alexandre Destere1, Vallée Estelle1, Mouly Stéphane1, Linares-Lloret Celia1, Megarbane Bruno1
1Hôpital Lariboisière, Paris-Diderot University, Paris, France
Correspondence: Alexandre Destere - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-43
Introduction: The majority of recommended drugs to treat status epilepticus (SE) patients have a limited safety margin with potential risk of drug–drug interactions. Cytochrome P450 (CYP) induction may result in insufficient dosage and subsequent therapeutic inefficiency of the patients’ co-treatments including the anticonvulsive drugs administered to treat the SE. Our objective was to describe the anticonvulsive drugs administered to SE patients and determine the resulting theoretical risk of drug–drug interactions with the patients’ treatments.
Patients and methods: Patients admitted during 1 year (Jan–Dec 2016) in our University Hospital intensive care unit (ICU) were selected using the Program of Medicalization of the Information system (PMSI). The usual demographic, clinical, and outcome data were collected with a special focus at the patients’ treatments taken before ICU admission and treatments administered during the ICU stay including the anticonvulsive drugs. We used the table of drug–drug interactions of the Geneva University Hospitals (1) and the DrugBank website (2) to determine the risks of drug–drug interactions.
Results: Sixty-one patients (74% males 26% females + age—56 years [16 + 92] (median [percentiles 25, 75]) were included in this study. Patients were chronic alcoholics (41%) and drug users (16%). The following anticonvulsive drugs were administered—levetiracetam (N = 46, 75%), fosphenytoine (N = 40, 66%), clonazepam (N = 37, 61%), clobazam (N = 28, 46%), midazolam (N = 22, 36%), valproic acid (N = 10, 16%), carbamazepine (N = 7, 12%) and phenobarbital (N = 7, 12%). Among the 46 61 patients (77%) treated with a CYP inducer, 26 patients (63%) received at least one drug with liver metabolism of which plasma concentrations might have been altered by such potential drug–drug interactions, thus representing 43% of the SE patients admitted to the ICU. Drugs at risk of pharmacokinetic alterations were cardiovascular, metabolic and psychotropic drugs.
Conclusion: Drugs with potential risk of drug–drug interactions used to treat SE patients in the ICU are relatively frequent. Such drug–drug interactions are at risk of altering the plasma concentrations of the anticonvulsive drugs as well as several other patients’ co-treatments, highlighting the usefulness of pharmaceutical advice at the bedside when choosing the anticonvulsive drugs to administer.
F-44 Delirium in the intensive care unit (ICU): perception of healthcare professionals
Fahmi Dachraoui1, Hraiech Kmar1, Mariem Tlili1, Nouira Wiem1, Bouker Nouha1, Hend Zorgati1, Sana Boukadida1, Amal Ouni1, Hammouda Zaineb1, Islem Ouanes1, Lamia Ouanes Besbes1, Abroug Fekri1
1CHU Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Fahmi Dachraoui - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-44
Introduction: Delirium in the ICU is often under-diagnosed despite its related burden and impact on patients’ morbidity, mortality and prolongation of hospital length of stay. The aim of this study was to assess the medical and paramedical community beliefs and practices regarding delirium in Tunisian ICUs.
Patients and methods: Between August 1st and 31/2017, healthcare professionals working at the ICUs of university hospitals of Monastir and Mahdia (Tunisia) were asked to participate in the survey by completing a questionnaire anonymously (that specified participants’ characteristics (age, gender, function, years of experience in ICU) and their knowledge and perception of delirium in ICU. The questionnaire consisted in 10 questions of different types: Likert style (: widespread scale in psychometric questionnaires in which the respondent expresses his or her degree of agreement or disagreement with an assertion), multiple choice, ranking and yes/no).
Results: During the study period, 96 respondents out of 163 (60% female, nurses: 52%), aged between 20–30 years in 70%, responded to the questionnaire. Healthcare professionals experience in the ICU was < 1 year in 39.6%; 1–5 years in 32.3%, and > 5 years in 28.1%. Participants asserted that the “most characteristic signs of delirium” were: insomnia (25%); confusion (22%); agitation (21%) and aggressiveness (20%). Three-quarters of participants said they did not systematically search for signs of delirium in their patients. 33% thought that delirium was “an insignificant problem” or that “it was not a problem”. Only one and three participants respectively, said they attended a conference and read an article about delirium in ICU the last year. Half of the respondents felt that the most appropriate treatment for a patient with delirium was restraint. Nearly one-third of participants thought that delirium was an under-diagnosed entity and only 6% felt that it was associated with long-term neuropsychological deficits. Factors considered to be determinant in the occurrence of delirium were ARDS, shock, age, mechanical ventilation, postoperative status in 70, 66, 63, 55 and 17%, respectively.
Conclusion: Most Tunisian healthcare professionals consider delirium as a common, underdiagnosed, and serious problem in the ICU. Yet, few participants actually monitor this condition.
F-45 The influence of sedation choice on the delirium occurrence in critically ill poisoned patients: a randomized controlled trial
Khzouri Takoua1, Mrad Aymen1, Foudhaili Nasreddine1, Barghouth Manel1, Fatnassi Meriem1, Bachrouch Mayssa1, Mahdhaoui Soumaya1, Ben Hamida Samia1, Brahmi Nozha1
Correspondence: Khzouri Takoua - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-45
Introduction: Delirium is a common manifestation of acute brain dysfunction in critically ill patients. It is associated with a healthcare cost increase, and extension of the hospital stay length. The present study aimed to explore influence of patient characteristics and analgesic-sedation on delirium incidence and to analyze its risk factors.
Patients and methods: It is a prospective single blind randomized controlled trial, started on the first July 2017 in a 12-bed toxicological Intensive Care Unit, including all mechanically ventilated patients requiring sedation who were admitted for acute poisoning. They were randomly divided into two groups G1 et G2 receiving respectevily Propofol-Remifentanil and Midazolam—Remifentanil. Delirium assessment scores were judged not adapted to our population and we retained the diagnosis of delirium on arguments inspired from diagnostic and statistical manual of mental disorders fourth edition (DSM-IV).
Results: Until the 15th September 2017, 35 patients were included, with 22 patients in G1 and 13 in G2. The two groups were comparable in terms of epidemiological characteristics. Delirium was developed in 9 patients (26%) (n = 5 in G1 and n = 4 in G2) with an average duration of 18 ± 13 h [6–48] with no difference between the 2 groups (13 ± 10 h for G1–24 ± 16 h for G2, p = 0.268). Compared to those without delirium, no differences were found in the patient characteristics among these two groups with regard to sex, age, psychiatric history and severity of illness (APACHE II, IGS II score) and even with regard to hypnotic choice (5 vs 4 p = 0.599). Delirium was associated to prolonged duration of mechanical ventilation (69 ± 73 h vs 39 ± 69 h, p = 0.280) and length of ICU stay (91.51 h vs 54.05 h, p = 0.132) without significant differences. Delirious patients had more hypotension (p = 0.008), and received more atropine (0.026). Multiple logistic regression analysis identified atropine (OR 2.333, 5%Cl 0.992–5.489, p = 0.026) as an independent risk factor for delirium.
Conclusion: The diagnosis and prevention of ICU delirium are subjects of multiple ongoing investigations. We carried out this study to detect the risk factors of delirium in order to prevent it. It is important to note that our results are influenced by the studied population and are only preliminary. We rely on the study pursuit and the sample enlargement to better inform us as well on risk factors as protective.
F-46 Predictive factors for complications in patients with severe alcohol withdrawal syndrome (Delirium tremens) requiring large dosages of benzodiazepines in ICU: observational retrospective study
Mateos François1, Haler Renaud1, Letheulle Julien1, Fillatre Pierre1, Barbarot Nicolas1, Legay François1, Debarre Matthieu1, Lhommet Claire1, Godard Aurelie1, Bousser Jérôme1, Tadie Jean Marc2, Courte Anne1
1Centre hospitalier de Saint Brieuc, Saint Brieuc, France; 2CHU de RENNES, Rennes, France
Correspondence: Mateos François - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-46
Introduction: Background: Severe alcohol withdrawal syndrome is a common cause of hospital admission. Delirium tremens is a potentially fatal complication of alcohol withdrawal. In severe delirium, very large dosages of benzodiazepines can be required despite well described side effects, such as coma and hypoxic cardiac arrest, although there is no recommendations for standardized treatments. Objective -The aim of this study was to describe outcomes and risk factors for complications in patients with severe alcohol withdrawal syndrome treated in intensive care unit with continous infusion of benzodiazepine (BZD).
Patients and methods: We retrospectively reviewed the medical records of all patients hospitalized for alcohol withdrawal syndrome between 2006 and 2016. Only those who received continous-infusion of BZD, associated with close clinical monitoring and the evaluation of RASS and Cushman scores, without systematic recourse to mechanical ventilation, were included.
Results: We studied 104 patients hospitalized in ICU for severe alcohol withdrawal syndrome. The mean age (SD) was 48.7 ± 8.7 years, mean ICU admission SAPS (simplified acute physiology score) II score was 20 ± 6.1. All of them have received continous infusion of midazolam, with a median maximum perfusion velocity of 8 mg h (interquartile range, (5, 12)). The median duration of treatement was 2 days (interquartile range, (1, 3)). Thirteen patients (12%) developed pneumonia, and or required intubation, and 8 (8%) have had seizures. No cardiac arrest and death was observed. ICU length of stay (LOS) was 3 days (2, 5) (median, interquartile range). Patients who requiried intubation and or developed pneumonia, received substantially more BZD (median total dose, 428 mg of midazolam vs. 147 mg in the non-complicated group + p < 0.001), and their ICU LOS was higher (median, 5 days vs. 3 days + p < 0.001). Endotracheal intubation and or development of pneumonia were associated with a higher maximum perfusion velocity of midazolam (> 8 mg h) (OR 18.83, IC 95% (2.11–168.15), p = 0.009). Previous episodes of delirium tremens before ICU admission were associated with higher complications such as mechanical ventilation and or pneumonia (OR 11.29, IC 95% (1.45–87.60), p = 0.02).
Conclusion: In severe delirium, very large dosages of benzodiazepines can be used without systematic mechanical ventilation with a low incidence of complications.
F-47 Impact of daylight exposure on delirium in ICU patients receiving invasive mechanical ventilation—the Delirium and dayLIGHT exposure (D-LIGHT) study
Smonig Roland1, Magalhaes Eric1, Andremont Olivier1, Essardy Fatiha1, Mourvillier Bruno1, Lebut Jordane1, Dupuis Claire1, Neuville Mathilde1, Lermuzeaux Mathilde1, Bouadma Lila1, Timsit Jean-Francois1, Sonneville Romain1
1Hôpital Bichat, Paris, France
Correspondence: Smonig Roland - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-47
Introduction: Delirium is frequent in intensive care unit (ICU) patients and is associated with increased mortality, increased hospital stay, increased cost and long term cognitive impairment in survivors. Numerous pharmacological and non-pharmacological strategies have been investigated for delirium treatment without success. Therefore delirium prevention strategies are recommended by current critical care practice guidelines. Among the potentially modifiable risk factors for delirium, the impact of daylight exposure on delirium incidence and or duration has not been studied. The objective of this study was to investigate whether daylight exposition would reduce delirium burden in critically ill patients.
Patients and methods: We conducted a prospective study in a 27-bed medical intensive care unit (ICU) over a 1-year period (January 2016–January 2017). All consecutive adult patients receiving invasive mechanical ventilation (MV) for 2 days or more were eligible for the study. Patients were assigned to a room with windows allowing daylight exposure (“Light” group) or without window (“Dark” group), depending on bed availability. Delirium was evaluated with the Intensive Care Delirium Screening Checklist (ICDSC) for a maximum period of 28 days. Delirium was defined by a ICDSC score ≥ 4 for two consecutive days. Agitation was defined by a RASS > or = +2. The primary endpoint was cumulative incidence of delirium. Data are presented as median (interquartile range) or number (percentage).
Results: A total of 195 patients were included (age—50 [50 + 69] years, SAPS2—51 [36 + 64], SOFA score—9 [7 + 11], medical admission—69%). Of them, 110 patients were admitted to a “Light” group and 85 to a “Dark” group. Incidence of known risk factors for delirium was similar in the two groups. Delirium occurred in 65 (64%) patients in the “Light” group and in 55 (71%) patients in the “Dark” group (p = 0.28). The duration of delirium was 3 [1 + 7] days. Patients in the “Light” group received significantly less neuroleptics to treat agitation than patients in the “Dark” group (13 vs. 25%, p = 0.04). This protective association persisted after adjustment for confounders in multivariate analysis (Odds ratio = 0.40 + [0.17 + 0.90] + p = 0.03).
Conclusion: Daylight exposure does not impact on delirium burden in ICU mechanically ventilated patients. However, daylight exposure is independently associated with a reduced prescription of neuroleptics to treat agitation.
F-48 Multicenter retrospective study of early in-ICU anesthetic drugs’ management in convulsive status epilepticus
Zeidan Sinéad1, Rohaut Benjamin1, Outin Hervé2, Bolgert Francis1, Navarro Vincent1, Demeret Sophie1
1Pantin, France; 2CHI de Poissy, France
Correspondence: Zeidan Sinéad - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-48
Introduction: Patients with convulsive status epilepticus (CSE) frequently require mechanical ventilation (MV), either for general anesthesia in case of refractory generalized CSE, or for airway protection. Guidelines for the management of refractory generalized CSE currently recommend general anesthesia for 24–48 h, followed by gradual withdrawal. Our objective is to evaluate the incidence of refractory generalized CSE among patients who required MV during pre-hospital management of status epilepticus, and to describe the management of general anesthesia in intensive care unit (ICU).
Patients and methods: This ongoing multicenter retrospective observational study is conducted in 4 French ICUs. All patients admitted in ICU under mechanical ventilation between 01-01-2014 and 12-31-2016 with disease-code “Status Epilepticus” are included. Exclusion criteria are—age < 18 years, post anoxic SE, acute traumatic brain injury, initiation of MV in ICU, transfer from another ICU, inclusion in a therapeutic trial on SE, non-convulsive SE. Collected data include reason for MV, antiepileptic treatment, dosage and duration of general anesthesia, mode of EEG monitoring. Outcomes are—relapse of SE, MV duration, in-ICU length of stay and mortality.
Results: Among the 211 medical files reviewed, 77 met the inclusion criteria and were analyzed, and 134 were excluded. A minority of patients (18.2%) had a refractory generalized CSE, most patients (64.9%) had a non-refractory generalized CSE + the others had mostly partial CSE. The main reason for intubation was coma (n = 45, 58.4%). The duration of general anesthesia was not significantly different in refractory CSE patients compared to non-refractory CSE patients (p = 0.18). Data regarding main outcomes are summarized below-.
Conclusion: These preliminary data suggest that the majority of the patients admitted in ICU under MV for CSE do not have a refractory status. Indication of MV is mainly coma without persistent convulsions. The mean duration of general anesthesia before withdrawal is < 24 h, and thus in discrepancy with guidelines, but does not seem associated with a frequent relapse of SE. If this low rate of RSE for patients admitted in ICU and the safety of rapid withdrawal of GA are confirmed, the recommended 24–48 h duration of general anesthesia in ICU could be challenged.
F-49 Brain imaging findings in patients with wake-up delay after induced coma
Nèji Henda1, Affes Mariem1, Attia Monia1, Marhbène Takoua1, Baccouche Ines1, Hantous-Zannad Saoussen1, Ben Miled-M’Rad Khaoula1
1Hôpital Abderrahmen Mami, Ariana, Tunisia
Correspondence: Nèji Henda - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-49
Introduction: Induced coma in intensive care patients protect them against pain and neurologic disorders. However, a few of them may present a delayed wake-up when the sedation is interrupted. The aim of this work is to assess brain imaging findings in patients with this condition.
Patients and methods: Retrospective review of imaging data of 27 patients (21 males and 6 females), aged between 32 and 84 years, admitted in intensive care unit (ICU) between June 2015 and September 2017, who had sedation or general anesthesia and presented a delayed wake-up. They were explored either by MRI (n = 11) or computed tomography (CT) (n = 16). Patients with traumatic lesions were excluded.
Results: Patients were admitted in the ICU because of chronic obstructive pulmonary disease exacerbation (n = 7), infectious pneumonia or pleural effusion (n = 6), acute respiratory failure (n = 5), heart disease (n = 2). Two patients underwent general anesthesia. Septic shock and circulatory collapse occurred in 3 and 5 patients respectively. MRI and CT showed lesions that may explain the wake-up delay in 6 of 11 and 4 of 16 patients, respectively. Brain anomalies included anoxic lesions (n = 4) with basal ganglia involvement (n = 3), ischemic or hemorrhagic strokes (n = 4), hepatic encephalopathy (n = 1) and herpetic encephalitis (n = 1).
Conclusion: Brain imaging techniques help diagnosing causes of delayed wake-up after induced coma. Anoxic lesions and strokes are mostly behind this condition. MRI is more accurate than CT.
F-50 Confirming gastric tube placement in ICU: effectiveness of gastric ultrasonography
Abily Julien1, Derville Sébastien1, Lemaitre Caroline1, Lagache Laurie1, Grangé Steven1, Carpentier Dorothée1, Girault Christophe1, Le Bouar Gurvan1, Grall Maximilien1, Misset Benoit1, Tamion Fabienne1, Béduneau Gaëtan1
1CHU de Rouen, France
Correspondence: Abily Julien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-50
Introduction: Gastric tubes are common in intensive care units used for enteral feeding, administration of drugs or aspiration of the digestive tract. These tubes offer an excellent tolerance but malposition may have serious consequences that can lead to patient’s death. The actualy gold method to confirm their correct placement is chest X-ray. We report a study which evaluate the performance of gastric ultrasonography for the validation of the good positioning of the gastric tube.
Patients and methods: We carried out a prospective, monocentric study in a Medical Intensive Care Units. For each included patient, we compared the results of a gastric ultrasonography to the interpretation of a chest X-ray.
Results: One hundred and thirteen gastric ultrasonographies were performed from July 2016 to May 2017. In 87 cases, ultrasonography concluded that the gastric tube was correctly positioned, confirmed by chest X-ray. In 24 cases, ultrasonography did not visualize the tube in gastric area. Among these 24 cases, only 4 malpositions were detected by the chest X-ray. The sensitivity and specificity of gastric ultrasonography were 0.81 [0.72 + 0.87] and 1 [0.51 + 1]. Positive and negative predictive values were 1 and 0.17, respectively. The ultrasonography was performed 54 min [50.3 + 57.6] after the gastric tube placement while the chest X-ray was interpreted 211 min [170.9 + 251.7] after this same placement (p < 0.0001).
Conclusion: Our results suggest a good performance of gastric ultrasonography to check the positioning of the gastric tube. This result must be interpreted with caution because of a low power of the study. We planned a multi-center study to confirm our results.
F-51 Neutrophil-to-lymphocyte ratio improves prediction of mortality in cirrhotic patients hospitalized more than 3 days in intensive care
Giabicani Mikhael1, Lemaitre Caroline1, Grangé Steven1, Carpentier Dorothée1, Beduneau Gaetan1, Girault Christophe1, Misset Benoit1, Piton Gaël1, Paugam-Burtz Catherine1, Weiss Emmanuel1, Tamion Fabienne1
1CHU Beaujon, APHP, Clichy, France
Correspondence: Giabicani Mikhael - mikhael.giabicani@aphp.Fr
Annals of Intensive Care 2018, 8(Suppl 1):F-51
Introduction: Prognosis of cirrhotic patients hospitalized in intensive care unit (ICU) remains poor. In many ICUs, cirrhotic patients are widely admitted and revalued after receiving optimal treatments. Little is known about risk factors involved in the evaluation of the prognosis at day 3, except the persistence of organ failure. This susceptibility to organ failure would be related to an alteration of the regulation mechanisms of the systemic inflammatory response. The blood neutrophil-to-lymphocyte ratio (NLR) is an inflammation biomarker reported to predict clinical outcome in unselected critically ill patients and in patients with stable liver cirrhosis, but has never been studied in critically ill cirrhotic patients. The aim of this study was to evaluate the blood NLR as parameter to predict mortality of cirrhotic patients hospitalized > 3 days in ICU.
Patients and methods: Retrospective monocentric study including consecutively cirrhotic patients hospitalized in a medical ICU from 2010 to 2016. For each patient, clinical and biological data at admission and day 3 were collected. NLR at admission (“NLRD0”), at day 3 (“NLRD3”) and its variation between admission and D3 (“delta NLR”) were calculated. Statistical analysis used appropriate non parametric tests and Cox regression for survival analysis. The ability of the variables to discriminate survivors from non-survivors was determined using ROC curves and a Net Reclassification Index (NRI).
Results: 140 patients (median Child–Pugh score = 9 [7–11], median MELD score = 25 [19–30]) were hospitalized more than 3 days in ICU. The major causes for ICU admission were sepsis (56.4%), gastrointestinal bleeding (15%) or respiratory failure (6.4%). Patients were followed up for 38.5d [13–339]. 74 (53%) patients died—38 (27%) in ICU, 21 (15%) after ICU discharge and 15 (11%) after hospital discharge. In univariate analysis, factors significantly associated with mortality were—at D3, NLR, MELD and SOFA scores + and between D0 and D3—delta NLR, delta SOFA and delta MELD. Predictors of death in multivariate analysis are shown in Table 1. Area under delta NLR ROC curve was 0.74 (CI = 0.69–0.79). NRI revealed that delta NLR was more efficient than delta SOFA (NRI = 8.7%) to identify patients with a 85% mortality risk at least.
Conclusion: NLR is a novel inflammation index known to predict poor clinical outcomes. Delta NLR is an independent predictor of mortality in critically ill cirrhotic patients and could be more effective than delta SOFA in predicting hospital mortality in these patients.
F-52 Severe liver dysfunction acute liver failure related to exertional heatstroke: outcomes, histological features and role of liver transplantation
Ichai Philippe1, Camus Christophe1, Boutonnet Mathieu2, Laurent-Bellue Astrid1, Moreau David3, Boudon Marc1, Aigle Luc3, Peron Jean Marie4, Gregoire Emilie5, Ichai Carole6, Quinart Alice7, Cousty8, Julien, Saliba Faouzi1, André Stéphane1, Coilly Audrey1, Antonini Teresa1, Samuel Didier1
1Hôpital Pontchaillou, Villejuif, France; 2Hôpital des Armées, Clamart, France; 3France; 4CHU de Toulouse, France; 5Hôpital de la Timone, Marseille, France; 6CHU Pasteur, Nice, France; 7CHU de Bordeaux, France; 8CHU Saint Pierre, La Réunion, France
Correspondence: Ichai Philippe - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-52
Introduction: Severe acute liver injury and failure (sALI ALF) is a grave complication of exertional heatstroke (EH). Liver transplantation (LT) may be a therapeutic option, but the criteria for, and timing of, transplantation have not been clearly established. The aim of this study was to define the profile of patients who require transplantation in this context.
Patients and methods: This was a multicentre, retrospective study of patients admitted with a diagnosis of exertional heatstroke-related sALI ALF with a prothrombin time (PT) lower than 50%, with or without hepatic encephalopathy.
Results: 24 male patients (median age—27.5 years) with ALI ALF related to exertional heatstroke were studied + nine of them (37.5%) were listed for emergency LT. The latter differed from those who were not listed with respect to their more severe liver failure after D1, a clear deterioration in their PT and ALT values between D0 and D3, and more marked organ dysfunction. Four of these nine patients were subsequently transplanted. At the time of LT, all had PT levels lower than 10%, a marked rise in bilirubin levels and required support for at least one organ (or x organs were involved). Histological findings on the explanted livers demonstrated massive or sub-massive necrosis and little potential for effective mitosis with a mitonecrotic appearance. The 15 unlisted patients (62.5%) were still alive 6 months later and had not experienced any after-effects.
Conclusion: Survival without liver transplantation in patients with heatstroke-related ALI ALF reaches 83.5%. The indication for liver transplantation is based on an evolving dynamic. The lack of any signs of an improvement in liver function at or after D3, in patients presenting with other organ dysfunctions or failure, means that liver transplantation should be envisaged. The peculiar histological features observed on all the explanted livers, and the aspect of abortive mitoses in hepatocytes could be attributed to the effects of heatstroke.
F-53 Should we use Prometheus for fulminant hepatitis ?
Roubin Johanna1, Kelway Charlotte2, Nafati Cyril2, Reydellet Laurent2, Blasco Valery2, Harti Karim2, Cungi Pierre Julien2, Albanese Jacques2
1Hôpital de la Timone, Marseille, France; 2CHU de Toulon, France
Correspondence: Roubin Johanna - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-53
Introduction: Without any treatment, patients with fulminant hepatitis die in 70 to 90% of cases. The Prometheus system allows to purify toxin bounded to albumin through adorption. Up to now, there a little data concerning its use during fulminant hepatitis. The aim of this study was to evaluate the Prometheus system on mortality and the need for liver transplant among patients with fulminant hepatitis.
Patients and methods: We conducted a retrospective observational study in a single polyvalent ICU of a teaching hospital. From December 2011 to December 2015 every patient admitted for fulminant hepatitis was included. We defined two groups—Prometheus group versus standard medical care group. Exclusion criteria were the contraindications for liver transplant.
Results: 45 patients were admitted for fulminant hepatitis during the study period, 21 patients were excluded. 12 patients had Prometheus and 12 had standard medical treatment. The average age was 40 (18–61), the mean SAPSII was 42 (15–99). On admission, the mean PT was 18.5% (8–42), the mean total bilirubin was 157 umol l. Paracetamol poisoning was the principal etiology with 45% of the patients—66% in the Prometheus group versus 25% in the standard group (p = 0.106). The hepatic encephalopathy grade was significantly higher in the Prometheus group—3 versus 0.5 in the standard group (p = 0.029). There was no difference between the two groups concerning mortality on day 28 (p = 1) or day 90 (p = 0.59). There was no difference concerning the length of stay in intensive care unit or in hospital between the two groups. 13 patients (37.1%) were transplanted. There was a statistical difference between the two groups concerning liver transplantation (p = 0.041)—4 transplant (40%) in the Prometheus group versus 9 transplant (75%) in the standard medical care group. There was a significant improve of encephalopathy after the Prometheus session (p = 0.002).
Discussion: Our study does not show any difference on mortality in fulminant hepatitis by using Prometheus. We found a statistical difference concerning the need for transplant which is significantly diminished after Prometheus. Prometheus may be a bridge to recovery. It is difficult to conclude because our study is retrospective and with only 24 patients. Also, there is a trend to have a majority on paracetamol poisoning in the Prometheus group.
Conclusion: Prometheus does not change the mortality in fulminant hepatitis. Prometheus may be a bridge to recovery with less need for liver transplantation.
F-54 Extra corporeal liver therapy in the intensive care: a 12 years MARS® experience from a French center
Monet Clément1, De Jong Audrey1, Prades Albert1, Chanques Gerald1, Conseil Matthieu1, Belafia Fouad1, Jaber Samir1
1Hôpital Saint Eloi, Montpellier, France
Correspondence: Monet Clément - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-54
Introduction: The Molecular Adsorbent Recirculating System (MARS®) is a device based on an albumin-enriched dialysis, allowing removal of albumin-bound toxins that accumulate during acute liver failure. Data on MARS® are scarce and little is known on efficiency and tolerance. MARS® therapy has been used in our ICU since 2005. We report here our experience with a focus on efficacy as well as tolerance.
Patients and methods: From March 2005 to August 2017 all patients who have undergone MARS® therapy in our ICU were included consecutively and prospectively in the cohort. MARS® therapy performed using a double lumen dialysis catheter in the femoral or jugular vein. We used the monitor MARS® 1 TC (Teraklin) coupled with the dialysis machine Prismaflex® (Gambro). The albumin dialysate circuit consisted of 500 ml of 20% human albumin and was regenerated by an anion-exchange column and an uncoated charcoal column (diaMARS® IE250, diaMARS® AC250).
Results: Ninety patients were included for 300 sessions. The mean duration was 7 h 38 min (± 1 h 43 min). The population treated consisted of 5 groups—acute-on-chronic liver failure (AoCLF), acute liver failure (ALF), post-surgery liver failure (post transplantation, post hepatectomy), refractory pruritus and drug intoxication (Fig. 1). Regarding biological efficacy—total bilirubin was lowered in AoCLF and post-surgery groups (p < .001), also in the ALF group although not significatively. MELD score was lowered in the AoCLF and ALF group (p < .001). However clinical variables (Glasgow score and encephalopathy) didn’t improve significatively. In the refractory pruritus group, pruritus decreased in 20 out of 25 patients (p < .001). Bile acid levels decreased to 34.8% of its mean baseline level (p < .001). In the drug intoxication group improvement of the Richmond Agitation-Sedation Scale (RASS) from deeply sedated (RASS < = − 3) to minimal sedation (RASS > = − 2) was obtained in 5 out of 6 patients. Out of 300 sessions, catheter-related adverse effects were low (1.3%), thrombocytopenia was the main adverse effect (26.7%).
Conclusion: We report our MARS® experience with the largest cohort of patients referred from a single hospital. We showed biological efficacy in all 5 indications, although clinical efficacy was uneven. MARS® therapy in patients with refractory pruritus yielded promising results. Tolerance was good and the main adverse effect was thrombocytopenia. Global transplantation-free survival was low in patients with liver failure, reinforcing the need for a liver transplantation center when using MARS®.
F-55 Digestive complications in veno-arterial ECMO-assisted patients after cardiac surgery
Margetis Dimitri1, Dujardin Olivier1, Bernard Remy1, Bouglé Adrien1, Amour Julien1
1Pitié-Salpetriere, Paris, France
Correspondence: Margetis Dimitri - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-55
Introduction: Postoperative low cardiac output syndrome occurs in 4–26% after cardiac surgery. In case of refractory cardiogenic shock, veno-arterial extra corporeal membrane oxygenation (VA-ECMO) is used when pharmacological support fails to restore adequate perfusion. There is little evidence about severe digestive complications in this specific population. The aim this study was to investigate the incidence and the risk factors of gastrointestinal bleeding and mesenteric ischemia in patients assisted by VA-ECMO after cardiac surgery.
Patients and methods: Retrospective, observational study in a university hospital cardiac surgery department. All VA ECMO-assisted patients admitted in intensive care unit after cardiac surgery in a two-year period were included. Our study has been approved by ethic committee CPP Ile de France 5.
Results: At all, 160 patients have been included. Digestive complications occurred in 53 patients (33.1%). We observed 30 (18.7%) gastrointestinal bleeding. No risk factor has been identified. Bleeding was associated with prolonged assistance by VA-ECMO, mechanical ventilation, hospital length of stay, use of vasoactive drugs and transfusion. Mesenteric ischemia occurred in 32 patients (20%). In multivariate analysis, dialysis was the only significant risk factor, OR 6.35 [IC95 1.76–22.9] (p = 0.005). Heart transplant seems to be protective, OR 0.11 + [IC95 0.01–0.90 (p = 0.04). Attributed mortality increases consistently from 43 to 84.4% (p < 0.0001).
Conclusion: Severe digestive complications occur in 1 3 of VA-ECMO assisted-patients after cardiac surgery. The mortality increases by 95% in this population. Renal replacement therapy is identified as risk factor of ischemic complications.
F-56 Colonoscopy in the intensive care unit: What indication for what profitability? A bicenter retrospective study
Messika Jonathan1, Issoufaly Tazime1, Duboc Henri1, Sztrymf Benjamin2, Prat Dominique2, Roux Damien1, Gaudry Stéphane1, Dreyfuss Didier1, Coffin Benoit1, Ricard Jean-Damien1
1Hôpital Louis Mourier, Colombes, France; 2Hôpital Antoine Béclère, Clamart, France
Correspondence: Messika Jonathan - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-56
Introduction: Colonoscopy is crucial for the management of lower gastro-intestinal disorders, but its profitability is discussed in critically ill patients, mainly because of the complexity of colonic preparation. As the profitability of colonoscopy in Intermediate or Intensive Care Units (CICU) has been scarcely reported (1), we investigated its indications and usefulness.
Patients and methods: Retrospective bicenter observational study (2004–2015). Main endpoint: diagnostic profitability of CICU in unselected critically ill patients. Profitability was a priori defined as “high” if CICU led to adapt ongoing therapies; allowed an endoscopic intervention; or participated in the decision to limit therapeutic effort. Secondary endpoints: describe the quality of CICU and its preparation; determine its position in diagnosis strategy; describe its morbidity.
Results: One hundred and eleven CICU were performed in 84 patients (male sex n = 50 + 60%, age 72y [63–84] + SAPSII 73 [62–84]) within 3 days [1–10] after admission. Gastro-intestinal bleeding or haemorrhagic shock was the cause of admission in 35 patients (42%). On the day of CICU, 37 patients (44%) had shock. CICU indications were—haemorrhage (n = 77) with 35% of acute anaemia (n = 39) + suspected colitis (ischemic [n = 19, 17%], infectious [n = 17, 15%], toxic [n = 5, 5%], inflammatory [n = 1, 1%]) + investigation of a Gram negative bacilli sepsis (n = 7, 6%) + sigmoid volvulus (n = 4, 4%) + and cancer diagnosis (n = 4 + 4%). CICU profitability was deemed high in 50% (n = 56), with an endoscopic intervention performed in 32% (n = 35). The CICU lead to antimicrobial adaptation (n = 9), emergent surgery (n = 10), or to limit therapeutics effort (n = 2). In 23 cases (21%) the CICU was considered normal. Patients’ preparation was rated as good in 27% (n = 30) + and the colonoscopy was complete in 33 (30%). The CICU was mainly performed as a 2nd (58%) or 3rd (40%) investigation after an abdominal CT-scan or an upper digestive endoscopy (respectively performed in first instance in 69 and 55%). Three CICU were complicated by 3 hemodynamic and 2 respiratory failures, none were fatal.
Discussion: In our series of unselected critically ill patients, CICU were mainly performed to investigate lower gastro-intestinal bleeding. Despite a low rate of good preparation, CICU is safe and its profitability is high in the majority of cases.
Conclusion: Although performed in poor conditions, CICU seems useful in the diagnostic and the therapeutic management of critically ill patients, and not only in gastro-intestinal bleeding. (1) Church, Surgical endoscopy 2014.
F-57 Correlation between non-invasive pain assessment using the analgesia nociception index and Behavioral Pain Scale in critically ill patients: a prospective observational study
Masse Juliette1, Dejonckheere Julien1, Broucqsault-Dedrie Céline1, Houard Marion1, Nseir Saad1
1CHU de Lille, France
Correspondence: Masse Juliette - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-57
Introduction: Accurate pain assessment is associated with better outcomes in intensive care unit (ICU) patients. Specific scales for non-communicative patients have been developed and validated but their routine use still remains inaccurate and subjective. Analgesia Nociception Index (ANI) is based on high-frequency heart rate variability. This study objective was to assess the correlation between the Behavioral Pain Scale (BPS) and ANI during care procedures in deeply sedated patients.
Patients and methods: We conduced a French multicentric prospective observational study with blinded continuous recording of ANI during 8 h with spotting of care procedures in patients with RASS less or equal to − 2. We compared pain assessment using BPS and ANI before (t1) and during (t2) each care procedure. The cares analyzed included prick glycaemia, turning, catheter insertion, dressing change and others. A behavioral pain reactivity (BPR) was defined by a BPS elevation of at least 1 point. We analyzed minimal ANI values and its variations with calculation of DeltaANI (ANIt1– ANIt2). Because of the analysis of several cares per patient we used a Bonferroni’s correction in comparison of BPR and no BPR groups with a significant p value < 0.025 for this comparison. For others analyses the p value considered as significant was p < 0.05. Correlation between ANI and BPS was analyzed using a Spearman correlation rank test.
Results: Nighty two cares were analyzed in 46 patients. A BPR was noted for 29 cares (32%). ANI before care procedure was comparable in BPR and no BPR groups (p = 0.19). The most frequent care was turning in the BPR group (55%) and prick glycaemia (40%) in the no BPR group. Compared to the period before care, minimal ANI decreased significantly during care procedure in BPR group (median (IQR) 53 [35–82] vs 43 [28–50] + p < 0.001), whereas it did not reach statistical significance in the no BPR group (49 [35–58] vs 44 [31–60] + p = 0.049). DeltaANI was higher in the BPR group than in the no BPR group (8 [2–33] vs 3 [− 4 to 13] + p = 0.009). A low correlation was noted between DeltaANI and BPS during care (r = 0.211, p = 0.044).
Conclusion: ANI decreases significantly during procedures where BPS raises and not during procedures with constant BPS. A correlation was founded between BPS and DeltaANI. Thus, ANI monitoring could be a helpful tool for daily assessment of pain in sedated critically ill patients.
F-58 Assessment of virtual reality as an adjunct therapy in pain management in burn patient
Mokline Amel1, Gharsallah Lazheri1, Rahmeni Imen1, Chaouch Nadia1, Messadi Amen Allah1
1CHU Ben Arous, Tunis, Tunisia
Correspondence: Mokline Amel - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-58
Introduction: The pain associated with burn was one of the most painful injuries to treat. Pain was induced by therapeutic acts such as wound debridement, dressing and other painful procedures. Burn pain caused changes in neurophysiology and pharmacokinetics that may make standard pharmacologic analgesic therapy less effective than usual.virtual reality has been explored as an adjunct therapy for the management of acute pain for a number of conditions. In our study, we attempt to assess the impact of virtual reality on management of burn pain during dressing changes.
Patients and methods: Before the therapeutic procedure (dressing changes), the concept of virtual reality therapy was explained to the patient (technology and equipment used). The video used was snow mountain. During the act, pain was assessed until the end of the procedure. The assessment of pain was based on visual analog scale (vas). For pain intensity, the scale was most commonly anchored by “no pain” (score of 0) and “very intense pain” (score of 10).
Results: During the study period, 20 patients were included. The mean age was 32 ± 17 years. 75% of our patients were adults aged over 20 years. They were 17 men and 3 women. the average burned surface area was 30 ± 13%. Pain was evaluated before the start of the therapeutic procedure. The mean initial pain severity score was 8.85 ± 0.74 (range 8 to 10). The pain assessment after virtual reality condition showed a significant decrease in the intensity of pain (p < 0.01). The mean pain decreased from 8.85 to 4.6 ± 0.84 with extremes ranging from 1 to 4.
Conclusion: Our study supports the use of virtual reality, simple non-invasive, as an adjunct therapy in the management of pain associated with dressing changes in burn patients.
F-59 Evaluation of patient comfort during abdominal drain removal using hypno-analgesia in intensive care unit
Amar Yaël1, Alves Sylvie1, Le Bec Caroline1, Puechberty Christelle1, Rousseau Isabelle1, Blot François1
1Institut Gustave Roussy, Villejuif, France
Correspondence: Amar Yaël - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-59
Introduction: Hypno-analgesia (HA) is used in the operating room and for complex pain. Before implementation of HA in our intensive care unit (ICU), most protocols for algogenic procedures included intravenous or epidural morphine and Nitrous Oxid. Since 2016, many caregivers have been trained, HA has been implemented and patient comfort is evaluated using 1) a specific analogic scale of comfort (0 to 10) before and after the procedure + 2) at the end of the procedure, a score of patient and caregiver comfort using a five item questionnaire (5 to 20 points).
Patients and methods: This pilot prospective study compares HA versus the standard protocol in the removal of abdominal drains after digestive surgery. The main objective was to evaluate the patient comfort before after the procedure using a scale of comfort + the secondary objectives were to test the patient and caregiver comfort scores and evaluate in the impact on consumption of analgesic. Between May 2016 and September 2017, two groups were obtained, according whether the procedure was performed by HA-trained or non-HA-trained professionals (depending on caregivers availability in the unit). The number of subjects required to compare scales of comfort before vs. after drain removal was 66, using a nonparametric Wilcoxon–Mann–Whitney test.
Results: Eighty-eight patients were analyzed. The mean note in the comfort scale remained unchanged after vs. before drain removal in patients without HA (n = 43, +0.04 points, ± 2.8), while it increased in patients with HA (n = 45, +2.07, ± 2.7 + p = 0.001). Using our specific five item comfort score, patients and caregivers had a comparable level of satisfaction in HA and non-HA groups (Patients 17.4 20 and 16.3 20 + caregivers—19 20 in both). A trend was observed in reduction of the consumption of morphine and Nitrous Oxid with HA, without altering their comfort.
Discussion: Despite its limitations (mainly, its open non-randomized design), this study suggests that—HA may be used for algogenic procedures and is willingly adopted in ICU by patients and professionals + specific scales scores, adapted for HA, may be useful to assess the effectiveness + finally, HA seems to be at least as efficient as classical procedures and could reduce the use of analgesic drugs.
Conclusion: HA adds value to patients and to all caregivers. Prospective randomized studies are needed to valid the comfort scores we proposed, and to prove that HA reduces the consumption of analgesic drugs.
F-60 The effects of standardized musical intervention (Music Care© type) during painful cares on vigils patients in intensive care unit
Guilbaut Victoria1, Gouteix Eliane2, Koubi Claude2, Fosse Jean Philippe2
1Annecy Le Vieux, France; 2Hôpital Les Sources, Nice, France
Correspondence: Guilbaut Victoria - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-60
Introduction: Pain has long been a focus of concern for doctors and caregivers. In intensive care unit, the inability to verbalize discomfort and pain are major stressors for patients. Music therapy has demonstrated in many international studies its effect on the blood pressure and on the respiratory frequency. In this context, we conducted a study to evaluate the effects of standardized musical intervention on pain during painful cares in vigils patients hospitalized in critical care.
Patients and methods: Design—We conduct a prospective, observational, randomised, single blind, mono center study. 140 painful cares were studied and then distributed in two groups (n = 70 with music, n = 70 without music). The patients were equiped with a Bose© helmet, and had or not music therapy during the care. Our main criteria was the pain, it has been evaluated by a numeric scale before and after the painful care. We also estimated anxiety with the COVI’s heteroevaluation scale before and after the car. We also noticed if the care were stopped because of the pain, then we used a semi quantative numeric scale in order to estimate the feeling of the caregiver and the patient on the session.
Results: Concerning pain, there is no significant difference between the two groups (p > 0.005). However, in the music group, pain decreased by 35% after the care (p < 0.001). Anxiety was way lower in the music group than in the group without music (p < 0.001). We also noticed a decrease of 50% of the anxiety in the music group. The patients and the caregivers’ feeling were the same in the two groups, with no significant difference (p > 0.05). On the other hand, caregivers tended to underestimate the difficulty of the session in comparison with the patients’ (p < 0.01) in both groups.
Conclusion: Music therapy did not improve the pain in a significant way, in the music group versus the group without but allowed a decrease of 35% of the pain after the care. Nevertheless, music reduced by two patients’anxiety.
F-61 Impact of a nurse implemented sedation and analgesia algorithm on complications of critical illness in surgical intensive care unit
1Hôpital Côte de Nacre, Caen, France
Correspondence: Pottier Véronique - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-61
Introduction: Sedation and analgesia is one of the basic themes in ICU as complications associated with excessive sedation negatively impact the morbidity and mortality of patients. The objective of this study is to show that the nurse implementation of a sedation and analgesia algorithm is beneficial to the patient in terms of sedative drugs reduction and thus overall decrease in duration of mechanical ventilation (MV) and the morbidity and mortality which is associated with it, without altering patient comfort and tolerance of the environment.
Patients and methods: A before and after prospective, observational, non-interventional study was conducted in surgical ICU in Caen University Hospital, between November 2014 and April 2017. Mechanically ventilated patients under sedation predicted to last 48 h or more were included. During the “Before” period, sedation and analgesia was managed by the physician, while during the “After” period, it was managed by the nurses according to the protocol.
Results: 1156 intubated and mechanically ventilated patients were admitted during the study period. Among the 145 eligible patients, 100 were included during “Before” period and 45 during “After” period. The duration of MV after inclusion was significantly shorter in group “After” (10.5 [7 + 18] vs 8 [5 + 11.5] days, p = 0.042), as the duration of target RASS (-2 à 0) was significantly longer (0 [0 + 2] vs 1 [0 + 3] day, p = 0.038), the duration of RASS < − 2 significantly shorter (6.5 [4 + 12] vs 3 [2 + 5] days, p < 0.001), dose of sedative drugs was significantly decreased (1330 [517.5 + 2543.8] vs 315 [15 + 720] mg, p < 0.001 for hypnotics and 1803 [1097.5 + 4290] vs 900 [450 + 1680] µg, p < 0.001 for opioids, respectively), and sedation cost (25.1 [12.7 + 67.4] vs 12.2 [7.3 + 34] euros, p = 0.004). The patients experienced less of ventilator-acquired pneumonia (VAP) and delirium during the “After” period (55 vs 24.4%, p = 0.004, and 41 vs 26.7%, p = 0.015, respectively).
Conclusion: The nurse implementation of a sedation and analgesia algorithm was associated with a trend towards reduction in duration of MV, ICU and hospital length of stay. Moreover, prevalence of VAP and delirium was reduced, in correlation to the significant decrease in sedative drugs. This type of algorithm is necessary to reduce morbidity and mortality associated with MV.
F-62 Remifentanil for analgesia in central venous catheter insertion: a randomized, controlled trial
Pichon Xavier1, Vardon Bounes Fanny1, Ducos Guillaume1, Ruiz Jean1, Samier Caroline1, Silva Stein1, Sommet Agnès1, Fourcade Olivier1, Conil Jean-Marie1, Minville Vincent1
1CHU de Toulouse, France
Correspondence: Pichon Xavier - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-62
Introduction: Central venous catheter insertion is a common practice for anesthetists and intensivsts. This invasive procedure generates pain and anxiety for patients. We aim to demonstrate that remifentanil improves the analgesia during scheduled central venous catheter insertion in mindful patients.
Patients and methods: A prospective, randomized, double-blind, controlled study in patients requiring central venous access. Patients were randomly assigned to receive 3 ng ml−1 remifentanil target controlled infusion (TCI) and local anesthesia (LA) with lidocaine or placebo and LA. All patients were monitored in intensive care or post-intervention care unit and systematically received oxygen. Patients were asked to assess verbal numeric rating pain scale (VNRPS) during the procedure. The primary outcome was the maximal VNRPS. Secondary outcomes were pain at each step, anxiety, patient satisfaction, operator ease and side effects.
Results: Ninety patients were included (45 in each group). All patients were analyzed. Remifentanil significantly reduced maximal pain—VNRPS 20 (95% confidence interval [CI] 16–40) vs 50 (95% CI 40–60) in the placebo group p = 0.0009 (Table 1). We did not observe any adverse event during this study, and there were no significant difference between the 2 groups regarding side effects.
Conclusion: TCI remifentanil is a safe procedure to reduce pain during central venous catheter insertion in awake patients. Trial Registration—clinicaltrials.gov Identifier—02206022, REMIDOLCATH.
F-63 Comparison of two sedation regimens during targeted temperature management after cardiac arrest
Paul Marine1, Bougouin Wulfran1, Cariou Alain1, Dumas Florence1, Geri Guillaume1, Guillemet Lucie1, Champigneulle Benoit2, Ben Hadj Salem Omar1, Legriel Stéphane3, Chiche Jean-Daniel1, Charpentier Julien1, Mira Jean-Paul1, Sandroni Claudio4
1Hôpital Cochin, Paris, France; 2Hôpital Européen Georges Pompidou, Paris, France; 3Hôpital Mignot, Paris, France; 4Catholic University School of Medicine, Rome, Italy
Correspondence: Paul Marine - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-63
Introduction: Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential interests of this strategy have not been clinically demonstrated.
Patients and methods: Before-after study. We compared two sedation regimens (propofol-remifentanil, period P2 vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h.
Results: 460 patients (326 in P1, 134 in P2) were included. CAHP score in P2 and P1 did not significantly differ (p = 0.93). Sixty percent of patients awoke in both periods (194 326 vs 81 134, p = 0.85). Median time to awakening was 2.5 (IQR 1–9) hours in P2 vs. 17 (IQR 7–60) hours in P1. Awakening was delayed in 6% in P2 vs. 29% of patients in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03–0.2 + p < 0.001). Patients in P2 had significantly more ventilator-free days, and lower catecholamine-free days between admission and day 28. Survival and favorable neurologic outcome at discharge did not differ across periods.
Time course for awakening according to sedation period.
These figures report the time course of patients included after discontinuation of sedation. At each time point, we report in the upper part, proportion of patients awoken after discontinuation of sedation, in the lower part, patients who died without awakening, and in the middle part (in white), patients still comatose. Red dots indicate, for each period, the last patient awakening (after 12 days in P1 and 5 days in P2).
Black dots indicate the median time to awakening (too early to appear for period 2).
Conclusion: During TTM following resuscitation from CA, sedation with propofol-remifentanil compared with midazolam-fentanyl was associated with an earlier awakening, and an increase in ventilator-free days.
F-64 Conformity of drug administration and central venous access in intensive care unit: a prospective evaluation
Perez Justine1, Lotito Adrien1, Jean Emmanuel1, Ouvrier Maryse1, Escudier Etienne1, Levrat Albrice1, Sirodot Michel1, Guerin Franck1
1CH de Metz Tessy, France
Correspondence: Perez Justine - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-64
Introduction: The new recommendations of the French society of anesthesia-intensive care (SFAR) on perfusion and medication errors were revised in 2016 to promote proper use relating to drug administration with medical devices. To advance that of inquiry, practices of our intensive care unit (ICU) were assessed in order to improve drug administration by central venous catheter (CVC).
Patients and methods: Prospective evaluation by pharmacist resident and technical nurse during seven weeks, using a standard evaluation tool, in a 16 bed ICU. Drug recommendations and SFAR documents from 2016 were used as referential of conformity. The following parameters were evaluated—1 Central venous lines mounting, 2 Drug administration and identification with a focus on narrow therapeutic index (NTI) drugs.
Results: 50 patients with CVC were analyzed between June and July 2017. 19 entered directly in the ICU. 23 were hospitalized for surgical reasons. 42 had triple-lumen CVC. Regarding the first parameter, no conformity was found due to lack of line identification (100%) or anti-return valve well positioned (96%). Perfusion ramp position was above heart level in 10%, infusion tubing had contact with floor in 6%, and absence of plug on non-used lines is found in 8% of cases. Regarding second parameter, non-conformities were due mostly to syringe label—absence of drug’s concentration (72%), preparator identification (99%), patient identification (99.7%), drug identification (3.5%, all concerning propofol), date and time of medication preparation (67%), lack of color code of labels (100%). Regarding NTI, 70% were not administrated according to the recommendations—absence of dedicated line (63%), absence of administration on the nearest insertion site of the catheter (67%).
Conclusion: The evaluation highlight some improvement axis such as complete identification on syringes, sensitizing of ICU healthcare team, or homogenization of CVC perfusion system. It calls for a second evaluation round after implementation of improvements.
F-65 Impact of a sedation protocol in patients treated with invasive mechanical ventilation: a retrospective before-after study
Piriou Pierre-Guillaume1, Brule Noelle1, Delbove Agathe1, Lascarrou Jean-Baptiste1, Martin Maelle1, Pontis Emmanuel1, Lemeur Anthony1, Garret Charlotte1, Reignier Jean1
1CHU de Nantes, Nantes, France
Correspondence: Piriou Pierre-Guillaume - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-65
Introduction: Sedation is a corner stone of the care of patients receiving mechanical ventilation in the ICU. Sedation was associated with increased comfort and adherence to care, but also with increased morbidity, including delirium, increased duration of mechanical ventilation and length of ICU stay. Previous studies reported beneficial impact of reduced doses of sedative drugs and careful monitoring of patients comfort and consciousness. Our goal was to assess the impact of the introduction of a nurses-dedicated sedation protocol in our ICU.
Patients and methods: This monocentre retrospective before-after study included all the patients admitted in our ICU, over two three-month periods, from July 2015 and January 2016, treated with invasive mechanical ventilation for more than 24 h and older than 18yrs. After the first period, all physicians and nurses were trained to a new sedation management protocol. Analysis was performed to assess the prescription and application of the protocol, its impact on the use of sedative drugs, ICU length of stay, and duration of mechanical ventilation. Major complications were also recorded.
Results: 134 patients were included—78 before and 56 after the protocol implementation. Patients in both groups had similar baseline characteristics (Men 67 vs. 50%, p = 0.08 + mean age 56 ± 18 vs. 60 ± 16 years, p = 0.1 + weight 73.2 ± 20.6 vs. 70.2 ± 15.9 kg p = 0.61 + IGS2 44 ± 17 vs. 44 ± 19, p = 0.99 + medical admission 91 vs. 88%, p = 0.51). Recordings of RASS and BPS did not differ between groups (9 ± 4 vs 10 ± 9, p = 048 + 19 ± 25 vs, 16 ± 11, p = 0.25). The duration of sedation was significantly shorter after introduction of protocol (4.1 ± 4.7 vs 1.9 ± 1.0, p < 0.0001), as was the duration of mechanical ventilation (9.3 ± 13.8 vs 4.1 ± 3.2, p = 0.001) and ICU length of stay (12.3 ± 15.8 vs 7.3 ± 5.3, p = 0.028). There was no difference in major ICU complications, nor in mortality between groups (25 and 30%).
Conclusion: Although the implantation of a sedation protocol did not translate in increased recording of RASS and BPS scores, it was associated with improved outcomes. Our data suggest that, more than the protocol by itself, beneficial effects reported after the implementation of a sedation protocol may be ascribed to increased awareness of the care givers and thus better management of sedation.
F-66 Assessing the impact of specialized clinical pharmacists on patient care in the critical care unit: a systematic review
Goyer Isabelle1, Villarbu Mathilde1, Jokic Mikael1, Brossier David1
1CHU de Caen, Caen, France
Correspondence: Goyer Isabelle - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-66
Introduction: Critically ill patients often necessitate multiple high-risk supportive pharmacologic treatments and exhibit complex and rapidly changing pharmacokinetic parameters. Their constantly evolving medical condition warrants continuous reevaluation and adjustments in pharmacotherapy. Multiple studies have shown the impact of pharmacist’s interventions on the reduction of medication prescription errors and extrapolated hypothetic cost savings. Critical care societies around the world recommend full time specialized clinical pharmacy services in the intensive care unit (ICU). Nonetheless, the full impact of specialized clinical pharmacy in the critical care unit should be appreciated in terms of meaningful direct patient outcomes such as length of ICU stay, length of mechanical ventilation (MV), risk of MV associated pneumonia or other nosocomial infections, risk of delirium, thromboembolic events or mortality and direct actual expenditure savings.
Patients and methods: Literature review (PubMed, google scholar and cross-referencing of selected articles) with selected Mesh terms (Intensive Care Units [Mesh] OR Critical Illness [Mesh] OR Resuscitation [Mesh]) AND (Pharmacists [Mesh] OR Pharmacy [Mesh]) done on August 28th, 2017. Original research studies written in English or French evaluating the impact of an ICU clinical pharmacist’s care on clinical endpoints were selected. All available articles were included without time limit, oldest article dating back to December 1991.
Results: The literature search yielded 157 references to which additional relevant references were added by cross-referencing selected articles. 26 studies evaluating the impact of clinical pharmacists on patient outcomes in the critical care setting were selected for this analysis. One hundred percent of the studies reported positive measurable clinical outcomes of the presence of a clinical pharmacist in critical care setting. Eighty-eight percent of the studies were done in the USA and 31% were prospective trials (n = 1348 patients). Six studies evaluated actual monetary expenditure and 100% of them concluded in cost-effectiveness of critical care clinical pharmacy services.
Conclusion: ICU clinical pharmacists do not only intercept medication prescription errors once they happen and decrease related hypothetic institutional costs. Their full time presence and interdisciplinary team inclusion in the ICU globally improves patient care and translates into tangible benefits in terms of patient outcomes and direct monetary savings. We can no longer ignore international recommendations warranting full time specialized clinical pharmacy services in critical care units to ensure patient care efficiency, safety and cost-effectiveness. Critical care clinical pharmacy services should be considered as an essential element of a standard ICU.
F-67 Impact of implementing a computer-based prescription system and moving in new buildings on healthcare workload—the case for acute respiratory failure (ARF) and sepsis
Dachraoui Fahmi1, Tlili Mariem1, Bouker Nouha1, Hraiech Kmar1, Nouira Wiem1, Ouni Amal1, Zorgati Hend1, Boukadida Sana1, Hammouda Zaineb1, Ouanes Islem1, Ouanes Besbes Lamia1, Abroug Fekri1
1Chu Fatouma Bourguiba, Monastir, Tunisia
Correspondence: Dachraoui Fahmi - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-67
Introduction: Workload affects the quality of care and the prognosis of critically ills patients. Measuring workload in intensive care units (ICU) has thus become essential for allowing a better matching between the activities required and the management of resources. In March 2016, the medical ICU of the university hospital of Monastir (Tunisia) moved into new buildings (more space and beds, computer-based prescriptions and monitoring, etc.). The aim of the present study is to compare the level of workload before and after the change of the ICU buildings.
Patients and methods: During the two study periods (period 1- July–September 2015 and period 2- July–September 2017) adult patients consecutively admitted, for more than 24 h, in the medical ICU for ARF and or sepsis were included in the analysis. Data collected were the demographic characteristics (age, sex, Body Mass Index (BMI), comorbidities, Simplified Acute Physiology Score (SAPS) III), the nursing workload measured using the Therapeutic Intervention Scoring System (TISS-28) and hospital survival.
Results: Thirty-six patients (22 male) were included in the study (14 during Period 1 and 22 during the second period). The medians of age, SAPS III and BMI were respectively 65 (IQR = 21) years, 46 (IQR = 12) and 27.7 (IQR = 9.4). The main comorbidities were hypertension, COPD and neurological disease respectively in 36, 25 and 20%. The demographic characteristics were similar during the two periods. Nurse workload was characterized by m TISS-28 = 18 (IQR = 7) and Time of nurse’s care of 190 min (IQR = 74). These two workload indicators were significantly higher during the second period (Table 1). During the second period, “standard monitoring” and “frequent dressing changes” (> 3 time day) were the activities with significant increase from, respectively 81 to 91% (p < 0.0001) and from 41 to 88% (p < 0.0001).
Conclusion: The relocation of our ICU in in new buildings was associated with a significant increase of the nurse workload with regard to patients with ARF and or sepsis.
F-68 Creating a high resolution electronic database in the pediatric intensive care unit: validation phase
Mathieu Audrey1, Brossier David2, Sauthier Michael1, El Taani Redha1, Goyer Isabelle1, Emeriaud Guillaume1, Jouvet Philippe1
1CHU Sainte Justine, Montréal, Québec, Canada; 2CHU de Caen, France
Correspondence: Mathieu Audrey - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-68
Introduction: The HSJ-PICU database is a high resolution electronic database automatically collected in the pediatric intensive care unit (PICU) of the Montreal Sainte Justine hospital (HSJ). Every 5 to 30 s, this database collects all physiological, therapeutic and clinical data from medical devices at bedside of all children admitted in the PICU. To ensure that these data are accurately collected in the HSJ-PICU database, we conducted a real time data validation study.
Patients and methods: The prospective validation study was performed from June 23rd to July 11th 2017. Every day, each monitor (IntelliVue MP60 and MP70, Koninklijke Philips Electronics) of all hospitalized children in the PICU was video recorded during 30 s. The videotaped data were compared to the simultaneously collected data in the HSJ PICU database using a Bland–Altman analysis.
Results: Data from 95 patients’ days were recorded. Overall 3279 data were video recorded and compared to the corresponding data collected in the HSJ-PICU database (1104 heart rates, 1079 respiratory rates, 975 pulse oximetries, 43 central venous pressures, 12 end tidal PCO2, 66 mean arterial pressures). Bland–Altman analysis showed excellent accuracy and precision between recorded and collected data for all tested variables within clinically significant pre-defined limits of agreement. However, 82 (2.5%) data were missing and a delay was observed between videotaped and collected times. This delay was less than 28 s and remained stable through all data for each patient. We identified that the missing data were due to a limit in the number of data being processed in the database at the same time and the delay between data presentation and data collection in the database was due to different server time settings. Both technical issues were corrected.
Conclusion: Our study identified two issues in the data collection process that slightly limited the accuracy of our high resolution electronic database. We recommend the performance of such validation study before using a high resolution database for clinical or research purposes.
F-69 Association between bodyweight variation and survival and other adverse events in critically ill patients with shock: a multicenter cohort study of the OUTCOMEREA network
Dupuis Claire1, Gros Antoine1, Ruckly Stéphane1, Lautrette Alexandre1, Garrouste-Orgeas Maité1, Gainnier Marc1, Forel Jean-Marie1, Marcotte Guillaume1, Azoulay Elie1, Cohen Yves1, Schwebel Carole1, Argaud Laurent1, De Montmollin Etienne1, Siami Shidasp1, Goldgran-Toledano Dany1, Darmon Michael1, Timsit Jean-François1
1Hôpital André Mignot, Paris, France
Correspondence: Dupuis Claire - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-69
Introduction: Fluid overload, and also its variations, is known to jeopardize the outcome of ICU patients. However, fluid balance remains difficult to assess accurately. In that context, our study aims to assess the prognostic value of body weight variations (BWV) from Day 3 to Day 7 on the 30-day mortality, length of stay (LOS) and the occurrence of ventilator-associated pneumonia (VAP) and bedsore in critically ill patients with shock.
Patients and methods: Adult patients admitted in ICU with shock between 2002 and 2012, and requiring mechanical ventilation during the first 48 h, were extracted from a prospective multicenter cohort for a retrospective analysis. BWV was defined as the difference between the body weight of the day of interest and the body weight on admission. Case mix, severity on admission, and outcomes were collected. Fine and Gray sub-distribution survival models were used, with ICU discharge as competing event, adjusted on comorbidity and illness severity at admission at each landmark, from Day 3 to Day 7. The impact of BWV on ICU stay duration was estimated through a multivariate negative binomial regression model.
Results: The median age and SAPS 2 score of the 2 374 included patients were 67 (IQR, 55–77) years and 53 (IQR, 41–65), respectively. The BWV increased from 0.4 kg (IQR, 0–4.8) on Day 3 to 3 kg (IQR, − 0.4 to 8.2) on Day 7. The 30 day in-hospital mortality, the ICU occurrence of bedsore and VAP were 27, 3 and 19.6%, respectively. Four categories of BWV were defined according to BWV interquartiles: weight loss, stable weight, moderate and severe weight gain. Categories of BWV were independently associated with death on Day 5 and Day 6 (Day 5 : sHR 1.27; 95% 0.99–1.63 p = 0.06; Day 6: sHR 1.43; 95% CI 1.08–1.89, p = 0.01) (Fig. 1). A weight loss tended to be associated with increased occurrence of bedsore, and weight gain with increased occurrence of VAP. The extent of BWV increased the duration of ICU stay independently of other severity factors.
Discussion: BWV may be another clinically relevant tool to assess the risk of death, mostly after Day 4. The increased risk of bedsore in case of weight loss deserved to be confirmed.
Conclusion: Body weight should be daily monitored for better prognostication. BWV-based restrictive strategies should be further evaluated.
F-70 The clinical effectiveness of multi-layer silicone dressings in preventing ICU acquired pressure ulcers: a randomised controlled trial
1University de Melbourne, Melbourne, Australia
Correspondence: Santamaria Nick - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-70
Introduction: The development of pressure ulcers (PU) in critically ill ICU patients result in additional morbidity and may contribute to mortality in some cases. The minimisation of ICU acquired PU remain an international challenge. This paper describes Australian research that used multi-layer soft silicone sacral and heel dressings to prevent PU in critically ill patients.
Patients and methods: A total of 440 critically ill patients were enrolled into an 18-month randomised controlled trial in one of Melbourne’s trauma centres. Patients were randomised on admission to the Emergency Department and either had standard PU prevention or standard care plus the application of prophylactic sacral and heel dressings. Patients were observed daily for PU development for the duration of their ICU stay.
Results: Patients in the dressing group has significantly reduced incidence rate of PU development compared to patients receiving standard PU prevention alone (3.1 vs 13.1%, p < 0.03). Patients in the dressings group had a relative risk reduction of 80% and a 10% absolute risk reduction for developing a PU regardless of their critical illness. Results indicate the number needed to treat to prevent one PU was 10. Additionally, we calculated the cost–benefit of this intervention and found the patients treated with prophylactic dressings cost 3.6 time less than the standard care group for wound care.
Discussion: The use of prophylactic dressings to prevent PU at our hospital have proved to be very effective in ICU and subsequent studies have confirmed our results. It appears that the main mechanism of PU protection provided by these dressings is the reduction of pressure and shear forces leading to tissue distortion and cell death rather than the previously accepted ischaemic model of PU development. Our current policy is now to use these dressings on all patients with a high risk of developing PU.
Conclusion: The use of prophylactic multi-layer silicone dressings to prevent PU in critically ill patients is effective but it does not replace standard PU prevention methods. The use of these dressings sould be considered complimentary to best practice in PU prevention.
F-71 Iatrogenic events in intensive care unit: incidence, risk factors and impact on outcome
Ayed Samia1, Merhebene Takoua1, Jamoussi Amira1, Ben Khelil Jalila1, Besbes Mohamed1
1Hôpital Memmi, Ariana, Tunisia
Correspondence: Ayed Samia - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-71
Introduction: Iatrogenic events (IEs) are defined as harm resulting from medical intervention and health care, and not explained by underlying disease. Mortality is reported to be as high as 13.6% in cohorts of hospitalized patients experiencing IE. Both length of stay and cost of hospitalization are increased by IEs occurrence. We perform this study to determine the incidence, risk factors, and impact on outcome of IEs in intensive care unit (ICU).
Patients and methods: All patients admitted more than 24 h to the 22-bed ICU of a teaching hospital were prospectively screened. Patients were monitored daily for adverse clinical occurrences. Time and data about each IE were collected and they were considered as preventable or life-threatening events. For each patient, the followings were recorded—basic demographic data, indication for admission, severity scores on admission (SAPSII and APACHEII), need and duration of mechanical ventilation (MV), length of stay (LOS) in ICU, intensive care work load score (OMEGA), global mortality and IEs related mortality.
Results: During the 6 months period, 167 patients were included and 65 (38.9%) were judged to have developed an IE while hospitalized. We recorded 282 IEs over 2004 days in ICU so a density incidence of 14 IE for 100 patient-day. IEs were considered preventable in 34% of cases and life-threatening in 22% of cases. IEs occurred in a mean delay of 6 ± 6 days. Global mortality rate was 36.5% and IEs related mortality rate was 13.7%. Patients with IEs were significantly severe on admission, with a longer duration of MV and LOS in ICU. OMEGA score was significantly higher. Multivariate analysis showed that OMEGA score was the independent risk factor of IEs occurrence (OR 1.031 IC 95% [1.015–1.047], p < 10–3). Dead patients were significantly severe on admission and experienced more IEs than survivors. OMEGA score, duration of MV and LOS were significantly higher. In multivariate analysis, IEs and life-threatening IEs were independent factors of mortality (OR 6.171 IC 95% [3.087–12.339], p < 10–3 and OR 21.482 IC 95% [5.077–90.889], p < 10–3 respectively).
Conclusion: IEs in ICU are common and frequent but one-third is preventable. Work load ICU score is the independent risk factor of their occurrence. IEs impact largely the outcome especially the life-threatening ones. Efforts must be focused on preventing programs to reduce IEs and improve the outcome.
F-72 Determinants of initial hyperlactatemia and early clearance of lactate in septic shock
Llitjos Jean-François1, De Roquetaillade Charles1, Jamme Matthieu1, Charpentier Julien1, Cariou Alain1, Chiche Jean-Daniel1, Mira Jean-Paul1, Pene Frederic1
1Hôpital Cochin, Paris, France
Correspondence: Llitjos Jean-François - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-72
Introduction: Based on the recent SEPSIS-3 definitions, septic shock is defined by the combination of vasopressor requirement and serum lactate level > 2 mmol/L. However hyperlactatemia and lactate kinetics may result from both increased production and impaired clearance in the critically ill, and may therefore not only rely on the severity of circulatory failure. We herein addressed the determinants of hyperlactatemia (> 2 mmol/L) and the factors likely to impact on early lactate clearance in septic shock.
Patients and methods: This was a 9-year (2008–2016) monocentric retrospective study. All adult patients diagnosed for septic shock within the first 48 h were included. Septic shock was defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors. The first lactate value (L1) was measured at the time of ICU admission. Hyperlactatemia was defined as a first lactate level > 2 mmol/L. The second value (L2) was measured within 12 h following the first measurement. Lactate clearance was calculated as (L1-L2) L1 time between L1 and L2 measurements) and expressed in mmol hour. Parameters associated with initial hyperlactatemia and lactate clearance were investigated using multivariate logistic regression analysis.
Results: Among 938 patients admitted for septic shock, 438 (46%) patients exhibited hyperlactatemia > 2 mmol/L at ICU admission. Patients with initial hyperlactatemia had a higher in-ICU mortality rate (41.3% versus 32.6%, p = 0.007). In multivariate analysis, hyperlactatemia was independently associated with bacteremia (OR 1.64, CI 95% [1.19–2.27], p = 0.002) and prior beta-2 adrenergic agonist therapy (OR 0.32, CI 95% [0.15–0.67], p = 0.003). In multivariate analysis adjusted with severity, early lactate clearance (i.e. decrease in lactate levels within the first 12 h) was independently associated with the following variables—leucopenia at admission (OR 0.53, CI 95% [0.32–0.89], p = 0.016), initial lactate value (OR 1.28, CI 95% [1.20–1.36], p < 0.001), arterial oxygen content (OR 1.05, CI 95% [1.01–1.10], p = 0.009), concurrent fluid balance (per liter) (OR 0.91, CI 95% [0.85–0.97], p = 0.005).
Conclusion: Optimisation of the arterial oxygen content to improve tissue oxygenation represents a major therapeutic goal in septic shock. Whether the amount of fluid infusion may have harmful effects on lactate clearance by itself or is a surrogate marker of severity deserves further investigation.
F-73 Neutrophil function is not defective after cardiopulmonary bypass
Lesouhaitier Mathieu1, Gregoire Murielle1, Uhel Fabrice1, Gacouin Arnaud1, Le Tulzo Yves1, Flecher Erwan1, Tarte Karin1, Tadie Jean-Marc1
1CHU Rennes, Rennes, France
Correspondence: Lesouhaitier Mathieu - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-73
Introduction: Cardiac surgery with cardiopulmonary bypass (CPB) induces immunosuppression which has considerable implications for patients. CPB induces a significant increase in circulating neutrophils. Neutrophil activation, associated with production of antibacterial peptides, reactive oxygen species (ROS), cytokines, and other inflammatory mediators, as well as release of DNA into the extracellular milieu (Neutrophil extracellular traps (NETs)), plays a central role in innate host defense and modulation of inflammation. However, it has been shown that, in septic shock or systemic inflammation as major surgery, immature circulating neutrophils can induce immunosuppression and increase the risk of secondary infections. Staphylococcus aureus (SA) is one of the most commonly encountered bacterial pathogen responsible for poststernotomy mediastinitis, and neutrophils alterations may favor postoperative infections. The main objectives of this study were to evaluate the direct effects of CBP on neutrophils functions and to study the impact of different strains of SA on neutrophils bactericidal functions.
Patients and methods: Blood samples were collected before and 24 h after cardiac surgery with CPB and bone marrow samples were harvested directly after sternotomy, before initiation of CPB, and at the end of CPB, before sternal closure. Septic patients were included as controls. Circulating neutrophils analysis was performed using flow cytometry. We also studied NETosis, ROS production and bactericidal activity in isolated neutrophils before and after surgery using two strains of SA—one responsible of postoperative mediastinitis and one isolated from nasal carriage.
Results: Blood cell count with differential demonstrated a significant increase in neutrophils 24 h after surgery. Flow cytometry analysis of blood samples indicated neutrophils were matures with a significant increase in degranulation marker (CD66b). Neutrophils life span was also increased after CBP. Flow cytometry analysis of bone marrow samples showed no difference in cell composition and maturation before and after CBP. The neutrophil production of ROS was significantly higher after CBP. However, CBP did not impact NETs formation, phagocytosis and bactericidial function. Moreover, there was no difference regarding the phagocytosis and the bactericidial activity when exposed to the two strain of SA. As expected, immature neutrophils count was significantly increased in septic patients compared to cardiac surgery patients.
Conclusion: These results indicate that CBP promotes the recruitment of matures neutrophils via a demargination process. CBP does not induce neutrophil dysfunction. Neutrophils should not be targeted to decrease postoperative infection after CPB.
F-74 A study of the correlation between Protein Tyrosin Phosphatase-1B gene expression and organ failure during septic shock
Beuzelin Marion1, Grangé Steven1, Clavier Thomas1, Girault Christophe1, Beduneau Gaëtan1, Carpentier Dorothée1, Artaud-Macari Elise1, Hobeika Sinad1, Lemaitre Caroline1, Enguerrand Pauline1, Tamion Fabienne1
1CHU Charles Nicolle, Rouen, France
Correspondence: Beuzelin Marion - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-74
Introduction: Protein Tyrosine Phosphatase 1B (PTP1B) is a negative regulator of both NO production and insulin signaling and has been shown to be an aggravating factor in septic shock. Stress hyperglycemia frequently occurs in critically ill patients and is associated with poor outcome. Experimental studies on transgenic mice have shown that PTP1B deletion resulted in a reduced insulin resistance and in a better survival during experimental model of sepsis. The main objective was to study the correlation between the PTP1B gene expression and organ failure (through the delta SOFA score between day 1 and day 5) or insulin resistance.
Patients and methods: Preliminary monocentric study including patients admitted for septic shock. Patient’s characteristics, medical history, blood tests, etiology of ICU admission and number of organ dysfunction were collected and the blood samples were taken between D1 and D5 to analyse PTP1B ARN’s expression.
Results: Forty-seven patients were included. No link was found between PTP1B expression and the delta SOFA score between day 1 and 5 (Spearman correlation: − 0.088 [− 0.40 + 0.41]; p = 0.60). Level of PTP1B gene significantly decreased during the 5 first days (1.4 [0.90–1.70] versus 0.81 [0.71–1.00], p < 0.0001). Patients with higher expression of PTP1B gene did not show more insulin resistance. The PTP1B gene expression was linked to the cumulated doses of Norepinephrine given at day 1 (Spearman correlation—0.33 [0.036 + 0.58]; p = 0.025) and during the 5 first days (Spearman correlation—0.32 [0.028 + 0.56] + p = 0.028), and to the lactate level at day 1 (Spearman correlation—0.47 [0.20 + 0.88] p = 0.0012).
Conclusion: No correlation was found between PTP1B gene expression and organ failure (through the day 1 and day 5 delta SOFA score) or insulin resistance in septic shock patients. PTP1B gene expression seems to be linked to septic endothelial dysfunction and further studies are necessary to explain more the role of PTP1B expression in sepsis
F-75 Characterization of the safety and pharmacokinetic profile of a novel TREM-1 pathway regulating peptide (MOTREM) during a phase I, randomised, placebo controlled, first in human clinical trial
Salcedo Margarita1, Cuvier Valerie1, Lorch Ulrike2, Witte Stephan1, Olivier Aurélie1, Gibot Sebastien1, Delor Isabelle1, Garaud Jean-Jacques1, Derive Marc1
1INOTREM SA, Paris, France; 2Richmond Pharmacology, London, UK
Correspondence: Salcedo Margarita - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-75
Introduction: MOTREM is the clinically formulated synthetic peptide (LR12) that is currently being developed for the treatment of sepsis and for the prevention of sequelae after acute myocardial infarction. Preclinical experiments have demonstrated that LR12 is able to modulate inflammatory responses and prevent their deleterious consequences in various animal models at a pharmacologically active dose of 1 mg kg h. Its pharmacological action occurs via the Triggering Receptor Expressed on Myeloid Cells-1 (TREM-1) signalling pathway. MOTREM was safe and well tolerated in GLP toxicology studies.
Patients and methods: Twenty-seven healthy male volunteers have been included in this clinical trial. The product was administered by continuous intravenous infusion (CIV). A single ascending dose design with 8 dose levels was used. Cohorts 1 and 2 received a 15-min single dose of MOTREM (1 and 10 mg and one and two volunteers respectively). Then, cohorts 3 to 8 received either a 15-min loading dose (from 0.5 mg kg to 5 mg kg) followed by 7.75-hours maintenance dose (from 0.03 mg kg h to 6 mg kg h) of MOTREM or a matching placebo (3–1 ratio). All volunteers were carefully monitored. Before escalation to the next dose level, safety and PK data of the previous dose level were reviewed by a safety review committee. Since immune system is at rest in normal individuals and thus TREM-1 pathway is not activated, no pharmacodynamics parameters were analyzed. The main objectives of this trial was then to study the safety and pharmacokinetic profile of MOTREM.
Results: No product related changes in vital signs, clinical nor laboratory parameters were observed. No product-related adverse events were reported. The PK of MOTREM was linear; The main clearance was estimated at 463L/h/70 kg which is higher than the hepatic blood flow in human (i.e., 90L/h/70 kg) and is therefore indicative of an extensive enzymatic metabolism in blood + effective half-life was calculated to be about 3 min.
Conclusion: MOTREM was found to be safe and well tolerated up to the highest dose tested (5mg/kg for a 15-min loading dose and 6 mg kg h for a 7.75-hours maintenance dose). Safety and pharmacokinetics of MOTREM is currently being studied in septic shock patients in a phase IIa randomised, double-blind, two-stage, placebo controlled, international, multicenter clinical trial (www.clinicaltrials.gov NCT03158948).
F-76 Targeted endothelial Trem-1 deletion protects mice during septic shock
Jolly Lucie1, Carrasco Kévin1, Derive Marc1, Boufenzer Amir1, Gibot Sébastien2
1INOTREM, Vandoeuvres Les Nancy, France; 2CHU Nancy, Nancy, France
Correspondence: Jolly Lucie - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-76
Introduction: TREM-1 (Triggering Receptor Expressed on Myeloid cells-1) is an immunoreceptor expressed on neutrophils and monocytes macrophages whose role is to amplify the inflammatory response driven by Toll-Like Receptors engagement. The pharmacological inhibition of TREM-1 confers protection in several pre-clinical models of acute inflammation. In this study, we aimed to decipher the role of TREM-1 on the endothelium.
Patients and methods: We evaluated the expression of Trem-1 in vessels and isolated endothelial cells by flow cytometry, qRT-PCR and confocal microscopy. We generated an endothelium-conditional Trem-1 ko mice and submitted them to polymicrobial sepsis through CLP. Organs and blood were harvested at different time points and analyzed for cellular content, cytokine chemokine concentrations, and vasoreactivity. Survival was monitored for 1 week.
Results: Trem-1 was expressed in aorta and pulmonary vessels from animals, and inducible after LPS stimulation or during sepsis. These results were confirmed in human pulmonary microvascular endothelial cells. The pharmacological inhibition of TREM-1, using the synthetic inhibitory peptide LR12, decreased the LPS-induced Trem-1 expression. Sepsis induced a profound vascular hyporeactivity in WT animals, both in terms of contractility and endothelium-dependent relaxation. Although contractility was still impaired in EndoTREM-1—mice, vasorelaxation was completely restored. Soluble TREM-1 concentrations, a marker of TREM-1 activation, were markedly increased in the plasma, the peritoneal lavage fluid and the lungs from WT septic mice compared to control. In EndoTREM-1—mice, sTREM-1 level was reduced. Plasma concentrations of soluble VCAM-1 and IL-6 were also reduced in EndoTREM-1—animals. We observed an accumulation of neutrophils and inflammatory Ly6Chigh monocytes in the lung of WT septic mice. This accumulation was dampened in EndoTrem-1—mice. By contrast, endothelial Trem-1 deletion favored the accumulation of reparative cells (Ly6Clow monocytes). Finally, survival was clearly improved in the EndoTrem-1—group as compared to the WT group.
Conclusion: We reported that TREM-1 is expressed and inducible in endothelial cells and plays a direct role in vascular inflammation and dysfunction. The targeted deletion of endothelial Trem-1 conferred protection during septic shock in modulating inflammatory cells mobilization and activation, restoring vasoreactivity and improving survival. The effect of TREM-1 on vascular tone, while impressive, deserves further investigations including the design of endothelium specific TREM-1 inhibitors.
F-77 Thiamine status and lactate concentration in sepsis
Heming Nicholas1, Salah Amor1, Meng Paris1, Sivanandamoorthy Sivanthiny1, Annane Djillali1
1Hôpital Raymond Poincaré, Garches, France
Correspondence: Heming Nicholas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-77
Introduction: Thiamine is an essential co-factor for aerobic metabolism. Both sepsis and thiamine deficiency are associated with lactic acidosis and hypotension. We assessed in a single center observational study the relationship between thiamine and lactate concentrations as well as clinical outcomes in a cohort of sepsis patients.
Patients and methods: 28 patients, median age 60 [44–77.3] years, of which 15 (53.6%) were male, SAPS II 40 [27–50.5]. 14 patients suffered from pneumonia, 6 from intra-abdominal sepsis. We measured serum levels of total and free thiamine, thiamine mono di and triphosphate (TMP, TDP and TTP respectively), as well as the erythrocyte transketolase activity and arterial lactate at the time of admission. We also recorded the vital status at the end of the ICU stay.
Results: 50% of our subjects exhibited particularly low levels of free thiamine (< 7 nmol/L). There was no correlation between free (r = − 0.4; p = 0.85), or total (r = − 0.19; p = 0.34) thiamine concentration and lactate levels. There was no correlation between TMP (r = 0.02; p = 0.91), TDP (r = − 0.19; p = 0.34), TTP (r = − 0.15; p = 0.46) and lactate levels in the whole population. No correlation was found between the concentration of thiamine derivatives and arterial lactate levels in the subgroup of patients exhibiting the highest levels of lactate (> 2 and > 4 mmol/L). Total thiamine and TDP concentration at the time of admission were significantly higher in ICU survivors than in non-survivors (p = 0.031 and p = 0.028).
Conclusion: During sepsis, we did not find any correlation between thiamine and lactate concentration. Lower thiamine diphosphate concentration may be associated with ICU-mortality.
F-78 Impact of sodium lactate perfusion in fluid balance and capillary leak in a rat model of endotoxin shock
Boyer Déborah1, Besnier Emmanuel1, Duburcq Thibault2, Favory Raphael2, Henry Jean-Paul1, Richard Vincent1, Tamion Fabienne1
1Rouen, France; 2Lille, France
Correspondence: Boyer Déborah - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-78
Introduction: A positive fluid balance in sepsis is a determining factor for mortality. In previous experimental studies, sodium lactate has been shown to improve hemodynamic and avoid fluid overload (1). To understand these beneficial effects, we investigated the impact of sodium lactate on capillary leakage, in comparaison to saline on capillary leak in a rat model.
Patients and methods: The sixteen sedated, mechanically ventilated rats were challenged with intravenous infusion of E.coli lipopolysaccharide (10 mg/kg). Two groups of eight animals were randomised to receive a continous perfusion (5 mL/kg/h) of sodium lactate 11.2% (treatment group) or 0.9% NaCl (control group). In order to inject the same caloric load in the two groups, a 4.35 mL/kg/h of either water of 10% dextrose solution were perfused. Mean arterial pressure, heart rate, urine ouput were measured over a 210 min period. An echocardiography was then performed and Evans Blue (1%, 30 mg/kg) was intravenously injected 30 min before sacrifice. Organs were withdrawn and organs wet dry ratio and Evans blue dye extravasation were measured.
Results: Fluid balance, organs wet dry ratio and Evans blue dye extravasation were not significantly improved in sodium lactate group. Hemodynamics parameters were not significantly enhanced after sodium lactate infusion.
Discussion: Previously, lactate administration has improves renal perfusion. In our study, the volume of urine output was decreased in the 2 groups reflecting the severity of our model. and the vascular filling (9.35 ml/kg/h) higher than in the literature could impact our results.
Conclusion: In our endotoxinic model, capillary leakage was not improved by sodium lactate infusion. Further studies are under way to evaluate the impact of lactate sodium in a less severe model (LPS 5 mg/kg), with a decreased vascular filling and in a polymicrobial model of sepsis by caecal ligature and puncture.
Duburcq T, Durand A, Dessein A-F, Vamecq J, Vienne J-C, Dobbelaere D, et al. Comparison of fluid balance and hemodynamic and metabolic effects of sodium lactate versus sodium bicarbonate versus 0.9% NaCl in porcine endotoxic shock: a randomized, open-label, controlled study. Crit Care. 2017 + 21(1).
F-79 Photoplethysmographic determination of the respiratory rate in acutely ill patients
L’Her Erwan1, Bodenes Laetitia1, N’Guyen Quang-Thang2, Lellouche François3
1CHU de la Cavale Blanche, Brest, France; 2Oxynov France, Plouzané, France; 3Centre de Recherche de l’IUCPQ, Québec, Canada
Correspondence: L’Her Erwan - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-79
Introduction: Respiratory rate (RR) is among the first vital signs to change in deteriorating patients. Intermittent RR measurement via visual observation is routine and it is usually estimated by visual counts of the chest wall movements. This approach has several inherent limitations that diminish its clinical applicability. The pulse oximetry photoplethysmographic (PPG) signal monitoring is routine since the early 1980’. The PPG signal includes respiratory synchronous components, seen as frequency modulation of the heart rate, amplitude modulation of the cardiac pulse, and respiratory induced intensity variations in the PPG baseline. Several studies have attempted to extract RR from PPG recordings, however their majority have been undertaken in controlled settings, on small groups of healthy subjects, and or have included waveforms without artefacts. The main purpose of our study is to assess the validity of a new RR extraction algorithm.
Patients and methods: This study is derived from a datawharehousing project (ReaSTOC study, ClinicalTrials.gov identifier—NCT02893462), including all consecutive patients admitted to our ICU. Physiological tracings were recorded from the standard monitoring system (Intelliview MP70 Philips), using a dedicated network and extraction software (Synapse v1, LTSI INSERM U1099) that enables photoplethysmographic recordings at a native resolution of 125 Hz. All consecutive patients were recorded for a 2-hours period during the first 24-hours following admission. Physiological recordings were associated with metadata collection. The proposed method for RR estimation relies on analyzing frequency components of a PPG signal via its spectrum, and enhancing respiration-induced modulations by advanced statistical signal processing techniques.
Results: 202 patients were analyzed (140 male + age 60 ± 11 yr., SAPSII 51.5 ± 15.7). 26.2% had a history of chronic respiratory disorder + They were admitted for acute respiratory failure (41.6%), hemodynamic failure (28.2%), neurological failure (18.3%). 128 patients were under invasive mechanical ventilation (63.4%) and 72 patients were spontaneously breathing (35.6%). Due to a bad PPG signal and or artefacts, RR calculation was not possible in 9 patients (4.5%). Correlation of the algorithm RR values and RR gold standard are provided within the Fig. 1. Error was null and bias was low (− 3.3 and + 3.5 b min).
Conclusion: The proposed method for RR estimation is accurate and has a low error and bias, either during invasive mechanical ventilation and in spontaneously breathing patients. The versatility of pulse oximetry monitoring in various types of clinical settings offers new issues for RR monitoring.
F-80 Muscular pressure under NAVA using the PEI index during weaning after acute respiratory failure
Maxime Denis1, Benjamin Repusseau1, Ouattara Alexandre1, Roze Hadrien1
1CHU de Bordeaux, Bordeaux, France
Correspondence: Maxime Denis - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-80
Introduction: With NAVA assist is proportional and synchronized to diaphragmatic electrical activity (EAdi). EAdi represent the diaphragmatic neural drive. We titrate NAVA according the EAdi max recorded during a failed spontaneous breathing trial (SBT). After a failed SBT NAVA is started and we increase NAVA level in order to reduce the respiratory load until EAdi = 40% EAdi max. (1) Recently, the pressure Electricy index—Pmus Eadi index (PEI) has been described. (2) The purpose of this study was to assess muscular pressure (Pmus) using PEI with our NAVA protocol.
Patients and methods: Observational study, patients recovering from pneumonitis and acute respiratory failure. SBT was Pressure Support Ventilation with 7cmH20 of assist and no PEP. PEI was calculated under NAVA and during SBT from airway pressure drop during end-expiratory occlusions, muscular pressure (Pmus) was estimated from PEI (2). Another index, patient ventilator contribution index (PVBC) was also measured using the inspiratory peak of EAdi and Vt (inspiratory) during assisted and non-assisted breaths. We calculated PVBC-squared because it has been shown that it is more correlated to Pmus Ptot.
Results: Results are summarized in the Table. No patient had respiratory distress under NAVA. NAVA VT was higher than SBT VT—6.2 [4.7–6.7] vs 5.4 [4.8–6.7] ml.kg-1 PBW, p = 0.02. After the failed SBT the reduction of 40% of EAdi with NAVA reduced Pmus by 53%. Pmus, EAdi and Paw-PEP were not correlated and PEI during SBT was 22% higher than under NAVA, p = 0.013. The ratio Pmus (Pmus +Paw-PEP) under NAVA was 33% and PVBC-squared was 31%.
Conclusion: The reduction of 40% of the diaphragmatic neural drive according to our protocol reduced significantly the respiratory load within acceptable range of Pmus. Moreover PEI can increase when the load is too high, probably by accessory muscles recruitment.
Intensive Care Med. 2011 + 37–1087–94.
Crit Care Med. 2013 + 41–1483–91.
F-81 What is the best patient position for intubation in intensive care unit: an ancillary study of the MACMAN trial
Lascarrou Jean-Baptiste1, Bailly Arthur2, Le Thuaut Aurelie3, Champigneulle Benoit4, Toufik Kamel5, Mercier Emmanuelle6, Ricard Jean-Damien7, Lemiale Virginie8, Colin Gwenhael2, Martin Maelle3, Helms Julie9, Reignier Jean3
1CHU de Nantes, France; 2CHD Vendee, Nantes, France; 3CHU Nantes, France; 4HEGP, France; 5CHR Orleans, France; 6CHU Tours, France; 7Hopital Colombes, France; 8Hopital Saint Louis, France; 9CHU Strasbourg, Strasbourg, France
Correspondence: Lascarrou Jean-Baptiste - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-81
Introduction: In ICU, intubation is a high risk procedure associated with high morbidity. Despite procedure’s improvement with systematic application of fluid loading, early use of vasopressors and checklist use, morbidity remains high. First pass success is strongly correlated with adverse event occurrence. A recent study by Semler et al. concluded than “sniffing” position is better than “ramped” position to increase first pass success even the primary outcome prespecified—pulse pressure saturation was not different between the two groups. We conducted a post hoc analysis of the randomized clinical trial MacGrath Mac video laryngoscope or Macintosh laryngoscope for intubation in the intensive care unit (MACMAN) to determine the best position for intubation in the ICU.
Patients and methods: MACMAN was a multicentre, open-label, randomized controlled superiority trial. Consecutive patients requiring intubation were randomly allocated to either the McGRATH MAC videolaryngoscope or the Macintosh laryngoscope, with stratification by centre and operator experience. An only inclusion criterion was—“Patients must be admitted to an ICU and require mechanical ventilation through an endotracheal tube”. Patients were excluded if—contraindication to orotracheal intubation (e.g., unstable spinal lesion); insufficient time to include and randomize the patient (e.g., because of cardiac arrest); age < 18 years; pregnant or breastfeeding woman + correctional facility inmate; patient under guardianship + patient without health insurance; refusal of the patient or next of kin to participate in the study; previous enrolment in a clinical randomized trial with intubation as the primary end point (including previous inclusion in the present trial). Post-hoc analysis was performed to assess association between patient position (sniffing or supine) and first pass success. Between-groups baseline difference was adjusted for baseline covariates significantly associated with the group membership (p < 0.2).
|OR [IC 95%]||AUC||Se||Sp|
|Failure of first pass||1.18 [0.43–3.22] p = 0.75||0.52 [0.40–0.63]||33.3 [13.3–59.0]||70.2 [64.9–75.1]|
|Bougie use at first pass||1.41 [0.31–6.47] p = 0.66||0.51 [0.44–0.59]||11.1 [1.4–34.7]||91.9 [88.4–94.6]|
|Duration of intubation > 3 min||1.01 [0.37–2.76] p = 0.99||0.50 [0.39–0.62]||33.3 [13.3–59.0]||66.9 [61.5–71.9]|
|DASH1-A||32.51 [4.27–247.39] p = 0.001||0.80 [0.74–0.86]||94.4 [72.7–99.9]||65.7 [60.3–70.8]|
Conclusion: In the MACMAN study, sniffing position is not associate with better intubation metric success as compare to supine position. Further studies are warranted to determine the best patient position for intubation in the ICU.
F-82 Automated oxygen titration (FreeO2) during acute exacerbation of COPD
Lellouche Francois1, Bouchard Pierre-Alexandre1, Morissette Martin2, L’Her Erwan3
1IUCPQ, Québec, Canada; 2Oxynov, Québec, Canada; 3CHU la Cavale Blanche, Brest, France
Correspondence: Lellouche Francois - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-82
Introduction: During acute exacerbation of COPD oxygen should be titrated to avoid both hypoxemia and hyperoxia. The recommendations are not followed and automated oxygen titration may be useful in this population. The aim of this study was to evaluate a new device developed to automatically titrate oxygen based on SpO2 target (FreeO2, Oxynov, Canada) and to compare oxygenation parameters with usual administration (manual flowmeter).
Patients and methods: The study is an observational monocentric study. We prospectively included patients hospitalized for acute exacerbation of COPD receiving oxygen. Written informed consent was obtained from all patient. In the first part of the study, we evaluated oxygen flowrate and SpO2 during 30 min at baseline based on management of the physicians in charge. The oxygenation parameters were compared with automated titration (FreeO2 during 1 h). In the second part of the study, oxygen was delivered with FreeO2 until oxygen weaning or a maximum of 72 h. We evaluated the oxygenation parameters during prolonged utilization, the duration of oxygen administration, a new Bluetooth SpO2 connection compared to wire SpO2 connection (evaluated by Visual Analog Scale 0–10).
Results: We present preliminary data of 23 COPD patients (sex ratio M F = 9 14). Mean age (± SD) was 72 ± 11 years, mean FEV1 (± SD) was 0.9 ± 0.3L. Oxygenation data in both parts of the study are displayed in the Table 1. Time in the SpO2 target was significantly increased with FreeO2 in comparison with manual titration and oxygen flowrate was reduced by half. In the second part of the study, the % of time in the SpO2 target with automated oxygen titration was above 80% and time with hypoxemia and with hyperoxia were low. In 11 patients, we compared comfort with wire SpO2 connection to Bluetooth wireless SpO2 connection. The comfort was significantly increased with wireless connection (7.0 ± 2.9 vs. 9.7 ± 0.6, p < 0.001). Duration of oxygen administration after inclusion (2.3 ± 4.3 days) and hospital length of stay after inclusion (5.7 ± 5.3 days).
Conclusion: Automated oxygen titration maintains the patients within predetermined SpO2 target more than 80% of the time and reduces oxygen flowrate in comparison with manual oxygen titration. The second part of the study demonstrates the feasibility to use automated oxygen titration during several days with similar outcomes as previously reported in similar population. There are several limitations of the study and additional evaluations of this device are required.
F-83 Continuous control of arterial oxygenation in mechanical ventilated patients
1CH Sainte Musse, Toulon, France
Correspondence: Mechati Malika - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-83
Introduction: Hyperoxemia occurs up to 50% of mechanical ventilation days in the ICU  and is associated with increased mortality as compared to patients ventilated in normoxemia . INTELLiVENT-ASV is a full closed loop ventilation mode adjusting automatically oxygenation’s settings FiO2 and PEEP according to SpO2 for passive and spontaneously breathing mechanically ventilated patients. This post hoc analysis of a monocentric randomized controlled parallel group study compared frequency of hyperoxemia (PaO2 > 120 mmHg and or SpO2 > 96%) and hypoxemia (PaO2 < 60 mmHg and or SpO2 < 90%) and the percentage of ventilation time with SpO2 > 96% and the percentage of ventilation time with SpO2 < 88% between INTELLiVENT-ASV and conventional ventilation mode in mechanically ventilated ICU patients.
Patients and methods: The randomized controlled trial was performed in the general ICU of Hôpital Sainte Musse, Toulon, France. Eligible participants were adult aged 18 or over, invasively ventilated for less than 24 h at the time of inclusion with an expected duration of mechanical ventilation of more than 48 h. Exclusion criteria were broncho-pleural fistula, ventilation drive disorder and moribund patients. Patients were allocated to INTELLiVENT-ASV group or to conventional ventilation group (volume assist control and pressure support modes) using blocked randomization. The post hoc analysis was performed by the comparison of all arterial blood gases (ABG) performed during the study period—the number of ABG with hyperoxemia and hypoxemia, the median PaO2 and SpO2 for these arterial blood gases and FiO2 associated were compared according to group.
Results: 60 patients were included, 30 patients in each group. The total number od ABG was 333 (mode conventional) vs 316 (mode INTELLiVENT-ASV) (p = ns). The number of ABG with PaO2 > 120 mmHg was respectively 54 versus 33 (p = 0.032) with SaO2 > 96% was 203 vs 153 (p = 0.001) with PaO2 < 60 mmHg was 57 vs 56 (p = 0.121) + with Sao2 < 90% was 88 vs 86 (p = 0.951). The percentage of time of ventilation spent with Spo2 > 96% was 32% vs 29 (p = 0.438), and with Sao2 < 88% was 0.6 vs 0.5 (p = 0.615).
Conclusion: The continuous control of oxygenation settings provided by INTELLiVENT-ASV decreases significantly the number of blood gas with hyperoxemia as compared to manual oxygenation setting without increasing the risk of hypoxemia.
Suzuki et al. J Crit Care 28(5)—647–654.
Girardis et al. JAMA 316(15)—1583 to 1589.
F-84 The Mechanical Ventilation: Respiratory Distress Observation Scale (MV-RDOS) as a surrogate of self-reported dyspnea in intubated patients
Decavèle Maxens1, Gay Frédérick1, Persichini Romain1, Morélot-Panzini Capucine1, Similowski Thomas1, Demoule Alexandre1
1Hôpital Pitié-Salpêtrière, Paris, France
Correspondence: Decavèle Maxens - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-84
Introduction: In invasively mechanically ventilated patient, dyspnea is frequent and severe. Relying on self-report, its measurement remains challenging in patients unable to communicate. A 5-item observation scale, namely the intensive care—respiratory distress observation scale (IC-RDOS), has been proposed as a surrogate of dyspnea-visual analogic scale (D-VAS) self-report in intensive care unit (ICU) patients . However this scale has been validated among non-intubated patients and included one item “supplemental oxygen” not thoroughly adapted for intubated population. We sought to develop a dyspnea observation scale more suitable for intubated patients and to evaluate its performance to detect dyspnea.
Patients and methods: Ancillary analysis of data prospectively collected from 220 ICU communicative patients enrolled for the validation of the IC-RDOS. Factorial principal component analysis was first performed to select variables that mostly contributed to the principal axes, among a set of 21 observable variables with possible clinical relevance. To identify the best correlation between these variables and D-VAS, were performed an iterative partial least square regression process (PLS).
Results: Iterative PLS procedure identified five variables, of which the combination and weighting allowed optimal correlation with D-VAS (r = 0.61; 95% CI 0.50 to 0.72; p value < 0.0001), which constitute the IC-RDOS . In a first step, we removed “supplemental oxygen”, not relevant in intubated patients. We obtained a 4-items IC-RDOS (r = 0.47, 95% CI [0.32 + 0.60], p < 0.0001) of which a value of 2.2 predicted a D-VAS > 3 with 48.1% sensitivity and a 93.9% specificity (areas under receiver operating characteristic curves (AUC = 0.763; 95% CI [0.679 + 0.848]). In a second step, to improve these performances, we added the item “respiratory rate”. Further iterations, led to a new 5-item optimized correlate of D-VAS (r = 0.47, 95% CI [0.36 + 0.57], p < 0.0001) with the algorithm described in Fig. 1b, which constitute the mechanical ventilation—respiratory distress observation scale (MV-RDOS). The Fig. 1a shows the AUC for the 4-items IC-RDOS and the MV-RDOS according to the D-VAS thresholds. A MV-RDOS of 2.3 predicted a D-VAS > 3 with 72% sensitivity and a 74% specificity (AUC = 0.766, 95% CI [0.679 + 0.852]).
Conclusion: These results suggest that MV-RDOS could be of value to identify dyspnea in intubated ICU patients.
Persichini R, Gay F, Schmidt M, Mayaux J, Demoule A, Morélot-Panzini C, Similowski T. Diagnostic Accuracy of Respiratory Distress Observation Scales as Surrogates of Dyspnea Self-report in Intensive Care Unit Patients. Anesthesiology. 2015 Oct; 123(4):830–7.
F-85 Lung ultrasound in the diagnosis of Ventilator-associated pneumonia in intensive care medicine. Study LUVAP
Rezig Sofiane1, Marc Julien1, Brault Clement1, Zerbib Yoann1, Caplin Cecile1, Mercier Romain1, Verrier Nathalie1, Richecoeur Jack1, Slama Michel1, Maizel Julien1
1CHU d’Amiens, France
Correspondence: Rezig Sofiane - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-85
Introduction: Lung ultrasound (LUS) has emerged in different clinical settings, such as in intensive care medicine (ICM). Early diagnosis of ventilator-associated pneumonia (VAP) remains a challenge to the intensivist. However, scientific evidence is little available on whether LUS reliably improves the diagnosis of VAP. The aim of this prospective study was to assess whether LUS could be an alternative to pulmonary computerized Tomography (CT) for assessing diagnosis of VAP in ICM.
Patients and methods: Twenty-one patients ventilated for duration more than 5 days suspected of VAP were included. LUS was performed by a well-trained operator who was blinded of the VAP diagnosis. The diagnostic gold standard of VAP was on the basis of pulmonary CT and positive culture pulmonary. All clinical criteria for the diagnosis were collected the same day of LUS and pulmonary CT. The ultrasound exam included anterior, lateral and posterior views from both sides of the chest with superior and inferior views. We classed patient in 4 groups according diagnosis of VAP with pulmonary CT (VAP + or VAP-) and LUS (LUS + or LUS-). LUS characteristics of VAP diagnosis included 9 profils—asymetric line B (profil A B), without sliding (profil B’), sub pleural consolidation (profil C), consolidation with punctiforme bronchogram (PB), linear air bronchograms (LB) or dynamic bronchograms (LBD), posteror lateral alveolar pleural suffusion (PLAPS), pleural effusion pathological (PEP), shred sign (SS).
Results: Of 21 patients prospectively included, 17 (81%) were diagnosed VAP + . Of the 17 patients VAP + , 16 were VAP + LUS + (95%) and 1 was VAP + LUS—(5%). The positive rates for LUS + of the profil A B, profil B’, profil C, PB, LB, LBD, PLAPS, PEP and SS were respectively 34, 23, 14, 34, 25, 32, 21, 9, 45%. The overall accuracy, sensitivity and negative predictive value of LUS for VAP diagnosis were 85.8, 95.7 and 80.4% respectively. Specificity and positive predictive value of LUS for VAP diagnosis were 82 and 95.3% respectively. The area-under-the-ROC curve of the LUS for VAP diagnosis was 0.89 (95% IC 0.76–0.92), p = 0.0055.
Conclusion: LUS is a sensitive diagnostic tool with which to identify VAP in critical ill patient. We suggest that LUS is a complementary tool to pulmonary CT in the diagnosis of VAP and that the follow up of VAP by LUS can reduce the need for accessing of pulmonary CT.
F-86 Impact of onset time of acute kidney injury on outcomes in patients under veno-venous ECMO support: a prospective observational study
Zapetskaia Tatiana1, Conil Jean Marie2, Georges Bernard2, Bounes Fanny2, Seguin Thierry2, Crognier Laure2, Brouchet Laurent1, Silva Stein2, Minville Vincent2, Delmas Clement2
1CHU de Tours, France; 2CHU de Toulouse, France
Correspondence: Zapetskaia Tatiana - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-86
Introduction: VV-ECMO is increasingly used for critically ill patients, such as those with life-threatening but reversible respiratory failure. In this context, acute kidney injury (AKI) is a major and frequent complication which seems associated with poor outcome. As far as risk factors for occurrence of AKI in patients under VV-ECMO, are poorly studied, we aimed to identify characteristics associated with severe AKI stage 3 KDIGO and the impact on 3 months’ outcome.
Patients and methods: We conducted a prospective, observational cohort study in our tertiary university hospital ICU (Toulouse, France) from May 2009 to April 2016. All adult patients undergoing VV-ECMO were included. Clinical and biological data were collected prior to ECMO implantation and during the hospitalization.
Results: Among 60 included patients, AKI occurred in 45 patients (75%)—31 patients (51%) developed AKI stage 3 and 26 patients (43%) required CRRT. Most of patients developed AKI stage 3 prior to ECMO insertion (41.4%). Instable hemodynamics, lower pH, higher lactate level, higher SOFA and modified SOFA scores, prior cardiopulmonary resuscitation or hemorrhagic shock were associated with AKI stage 3 occurrence. The rate of successful weaning from mechanical ventilation was initiatively lower in patients with AKI stage 3 (24 vs 68%; p = 0.0009). 23 (85%) patients had normal renal function at discharge. The 90-day mortality rate was significantly higher in patients with AKI stage 3 (72 vs 32%, p = 0.0023). Kaplan–Meier curves differed significantly for patients with AKI stage 3 versus patients without AKI (p = 0.012) (Fig. 1a) and for patients with AKI stage 3 prior to ECMO insertion versus patients without AKI (p = 0.004) (Fig. 1b). Multivariate logistic regression suggests, that AKI stage 3 prior to ECMO insertion was an independent risk for 90-days mortality.
Conclusion: Incidence of severe AKI is correlated with global severity at admission and prior to ECMO insertion. In our cohort, AKI stage 3 KDIGO prior to ECMO insertion was negatively associated with survival.
F-87 Vascular Access for Renal Replacement Therapy Among 459 Critically Ill Patients A pragmatic analysis of the randomized AKIKI trial
Gaudry Stéphane1, Benichou Nicolas1, Lebbah Saïd2, Hajage David2, Martin-Lefèvre Laurent2, Pons Bertrand2, Boulet Eric2, Boyer Alexandre2, Chevrel Guillaume2, Lerolle Nicolas2, Carpentier Dorothée2, De Prost Nicolas2, Lautrette Alexandre2, Anne Bretagnol2, Mayaux Julien2, Saad Nseir2, Frederique Schortgen2, Tubach Florence2, Ricard Jean-Damien1, Dreyfuss Didier1
1Hôpital Louis Mourier, Colombes, France; 2Hôpital Henri Mondor, Paris, France
Correspondence: Gaudry Stéphane - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-87
Introduction: Vascular access for acute renal replacement therapy (RRT) is routine question in the intensive care unit. Randomized trials comparing jugular and femoral sites have shown similar rate of nosocomial events and catheter dysfunction. Recent prospective observational data on RRT catheters use are scarce. We analyzed, in a large population of critically ill patients enrolled on a randomized trial on RRT initiation strategies, RRT catheter site, cause of catheters changes and complications according to insertion site. The advantage of this method is that it gives a pragmatic view of the real clinical situation.
Patients and methods: Ancillary study of the AKIKI trial, an open pragmatic randomized controlled trial published in 2016, in which patients with severe acute kidney injury were randomly assigned to either an early or a delayed RRT initiation strategy. The present study involved all patients who underwent at least one RRT session. Number of RRT catheters, insertion sites, factors potentially associated with the choice of insertion site, duration of catheter use, reason for catheter replacement, and complications were prospectively collected.
Results: Among the 619 patients included in AKIKI, 462 received RRT at least once and 459 patients were finally included in the analysis (3 missing data), leading to a total of 598 RRT catheters. Femoral site was chosen preferentially (n = 319, 53%), followed by jugular site (n = 256, 43%) and subclavian site (n = 23, 4%). Investigating center was the sole factor significantly associated with the choice of insertion site in multivariate analysis (p = 0.01). Higher weight did not affect choice of insertion site. Mean duration of catheter use was 6.6 (+-5.0) days without difference according to site. Catheter dysfunction was the main reason for replacement (n = 61, 49%). Suspicion of infection led to replacement of many catheters (n = 40, 32%) but was actually seldom proven (n = 4, 3%). No mechanical complication (pneumothorax or hemothorax) occurred.
Conclusion: Femoral site was preferentially used in this observational study of RRT catheters in 31 French intensive care units. The choice of insertion site depended on investigating center habits. A high incidence of catheter infection suspicions that were eventually ruled out led to many undue replacement.
F-88 Model based meta-analysis of vancomycin during renal replacement therapy: application to vancomycin pharmacokinetic during SLED in ICU patients
Claisse Guillaume1, Ollier Edouard2, Maillard Nicolas1, Mariat Christophe1
1Saint-Priest En Jarez, France; 2INSERM, U1059, Saint-Priest En Jarez, France
Correspondence: Claisse Guillaume - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-88
Introduction: Sustained low-efficiency dialysis (SLED) has become a frequent renal replacement therapy (RRT) technique used in instable critically ill patients hospitalised in ICU. However, little is known about the effect of SLED on antibiotics clearance. Despite recent new antibiotics, vancomycin remains an important drug used to treat cocci-gram positive severe infections in ICU. Many studies have reported data regarding clearance of vancomycin during continuous and or intermittent RRT. However, only few data are available regarding vancomycin pharmacokinetic (PK) on SLED. Here, we realised a meta-analysis of vancomycin clearance during continuous and intermittent RRT to model vancomycin PK during SLED.
Patients and methods: We conducted a systematic review of published article on PK of vancomycin during RRT with high flux filters. The literature search was conducted from the PubMed database from its inception to August 2017. Studies were included if they were providing an estimation of RRT vancomycin clearance. A model based meta-analysis of RRT vancomycin clearance in function of RRT settings (blood, dialysate and ultrafiltration flow rate) was performed using a non-linear mixed effect model. To guide the choice of the dosing regiment, we used previously published population PK data to simulate the PK of vancomycin in ICU patient undergoing SLED. Vancomycin clearance was splited in two parts—(1) the residual body clearance and (2) the clearance due to SLED obtain from the model constructed by meta-analysis.
Results: A total of 28 articles were included in the study corresponding to 69 measurements of RRT vancomycin clearance (47 with Haemodialisys, 14 with Haemofiltration, 8 with Haemodiafiltration). The model described adequately the measurements with no apparent bias between observed and predicted clearance. Based on population PK simulations, following a 1.75 g vancomycin bolus (25 mg kg for a 70 kg patient), time to pass below a threshold of 15 µg l was estimated to 5.87 h [2.83–12.7] (mean, 90%CI) for patient undergoing SLED (started 1 h after first administration) and to 19.21 h [4.37–120 +] for whose who not. At the end of SLED, only 4.5% of patients would have a vancomycin concentration above 15 µg L whereas 76% of them would be above this threshold with a second bolus administrated 6 h after the first one (Fig. 1).
Conclusion: Vancomycin is clearly eliminated by SLED and an administration of a standard unique dose (25 mg kg) may not allowed to stay above the therapeutic threshold.
F-89 Relative blood volume monitoring predicts the variation of mean arterial pressure during long standing dialysis in ICU
Chraka Hayate1, Claisse Guillaume1, Alamartine Eric1, Mariat Christophe1, Maillard Nicolas1
1CHU Saint etienne, Saint Etienne, France
Correspondence: Chraka Hayate - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-89
Introduction: Long standing dialysis (SLED or CRRT) allows a better hemodynamic tolerance as well as a greater performance to achieve a negative fluid balance in intensive care unit. Dialysis alter hemodynamics mainly by short term variation of blood volume. In this study we took advantage of a continuous monitoring of blood volume during dialysis session to decipher the relationship between the variation of relative blood volume (RBV) with mean arterial pressure (MAP).
Patients and methods: This study is observational prospective, including all prolonged (> 8 h) dialysis sessions in Saint Etienne nephrology intensive care unit between January and June 2017. Exclusion criteria were ongoing blood transfusion and blood volume controled ultrafiltration. Medical records were compiled along with cardiac ultrasonography at the beginning when available. The statistical analysis was perfomed in two parts. The first part studied the performances of the first hour deltaRBV (defined by RBV before minus RBV after 1 h of dialysis) to predict a drop of MAP below 65 mmHg (hypotension). This analysis excluded sessions with hypotension and intervention during the first hour. The second study was the modelization of the relationship between deltaRBV and deltaMAP for every hour of dialysis without any intervention on blood pressure. Both analyses were performed using mixed effects linear and generalized models.
Results: A total of 82 sessions on 23 different patients were performed during the period. The characteristics of patients were as follows—sex ratio at 1, age (SD) 64.3 (9.0), weight 83.3 kg (17.2), SAPSII score 48.3 (13.6). 20 patients on 23 were taken in charge for fluid overload. In the first set of analyses (per sessions), 27 sessions were excluded for intervention in the first hour. The adjusted DeltaRBV did not predict hypotension during the session (generalized mixed effect model, session and patients set as random effects, estimate 0.14, p = 0.71). In the second set of analyses (per hour without any intervention), 535 h were analyzed. Adjusted DeltaRBV correlated strongly and inversly with deltaMAP (linear mixed effect model, random effects were sessions, patients and hour order in the session, estimate 1.42, p < 0.0001).
Conclusion: In our mostly fluid overloaded patients, the drop of RBV correlated with an increase of MAP.
F-90 Renal and immunological outcomes in kidney-transplant recipients admitted in intensive care units
Guinault Damien1, Lavayssiere Laurence1, Nogier Marie-Béatrice1, Cointault Olivier1, Del Bello Arnaud1, Esposito Laure1, Hebral Anne-Laure1, Kamar Nassim1, Faguer Stanislas2
1CHU de Toulouse, Toulouse, France, 2Hôpital Rangueil, 1 avenue Jean Poulhes, Toulouse, France
Correspondence: Guinault Damien - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-90
Introduction: Kidney transplant recipients (KTR) are at risk of ICU admission because of prolonged immunosuppressive therapy and a higher risk of cardiovascular events, severe infections or drug-related toxicities. Several retrospectives studies reported the short-term outcome of KTR admitted to the ICU, but data concerning the risk of chronic kidney disease and anti-HLA immunization are scarce.
Patients and methods: In this retrospective study, we addressed the in-hospital and long-term mortalities of the 200 KTR admitted in a French ICU (10 beds) between January 2010 and June 2016. Predictive factors for death, long-term renal function and HLA immunization were identified.
Results: The main causes for admission were acute respiratory failure (27.5%), sepsis (26.5%), post-operative period (peritonitis, hemorrhage + 23%). At the admission, mean age, SAPS2 and SOFA score were 58 ± 13 years, 52 ± 19 and 6.7 ± 3.3, respectively. Renal replacement therapy, mechanical ventilation and vasopressors were required in 103 (51.5%), 107 (53.5%) and 97 (48.5%) patients. Immunosuppressive regimen was modified in 155 patients (76.1% + steroids increase 68%, calcineurin inhibitors or antimetabolites withdrawal 25 and 37%, respectively). In-hospital mortality was 20% (30.1 and 38.2% at months 12 and 36). By multivariate analysis, EBV blood proliferation in the 6 months preceding the admission in the ICU, and the SAPS2 gravity score at admission independently predicted the in-hospital and long-term mortalities. Among the 113 patients alive at month 6 after the admission in the ICU and with available data, 34 (30.1%) and 51 (45.1%) progressed to a more severe CKD stage at months 1 and 6, respectively. Both, the severity of the AKI and the preexisting CKD predicted the risk of progression of the CKD. Last, de novo anti-HLA immunization at month 6 was identified in 18 119 patients (15.1%, donor specific antibodies 11 18 (61.1%)) and was significantly associated with the occurrence of acute transplant rejection (p = 0.002). In five patients who developed anti-HLA antibodies, RBC transfusion during the ICU stay was the only immunological trigger identified.
Discussion: Outcome of KTR is closed to the general population admitted in ICU and better than other immunocompromised patient, like patients from oncohematology.
Conclusion: Worsening of the renal function and HLA immunization are frequent and may impact mid to long-term prognosis because of the high risk of transplant rejection, end-stage renal disease and further transplantation contraindication.
F-91 Frequency and prognostic impact of acute kidney injury in patients with pulmonary embolism, data from the RIETE registry—results of a retrospective study performed on a prospective multicenter multinational database
Murgier Martin1, Bertoletti Laurent1, Darmon Michael1, Reina Valle2, Del Toro Jorge2, Llamas Pilar4, Monreal Bosch Manuel1
1Saint-Priest-En-Jarez, France; 2Hospital Sierrallana, Santender, Spain; 3Hospital General Universitario Gregorio Marañón, Madrid, Spain; 4Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
Correspondence: Murgier Martin - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-91
Introduction: Acute kidney injury (AKI) is associated with a poor prognosis. Although pulmonary embolism (PE) may promote AKI through renal congestion or hemodynamic instability, its frequency as its impact on the prognosis of patients with acute PE have been poorly studied.
Patients and methods: Using data from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry, we assessed the frequency of AKI at baseline, and its influence on the 30-day mortality rate of patients with objectively confirmed PE. AKI was defined according to the “Kidney Disease—Improving Global Outcomes” definition. We used multivariate analysis to assess whether or not the presence of AKI independently influenced the risk for 30-day death.
Results: The study included 21,131 patients with acute PE, of whom 6222 (29.5%) had AKI at baseline. Of these, 4385 patients (21%) were in stage 1, 1385 (6.5%) in stage 2 and 452 (2%) in stage 3. The proportion of patients with high-risk PE in those with no AKI, AKI stage 1, AKI stage 2 and AKI stage 3 was—2.8, 5.3, 8.8 and 12%, respectively (p < 0.001). After 30 days, 1236 patients (5.85%) had died. Overall mortality was—4% in patients with no AKI, 8.4% in AKI stage 1, 14% in AKI stage 2, 17% in AKI stage 3, all p < 0.001). On multivariable analysis, AKI was independently associated with an increased risk of death at 30 days (odds ratio = 1.25 + 95% CI 1.02–1.54), after adjusting for the initial severity of PE, age > 65 years, chronic heart failure or chronic lung disease, cancer, anemia and liver cirrhosis.
Conclusion: One in every 3–4 patients with acute PE had AKI. Moreover AKI was an independent predictor of poor outcome in PE patients. This study suggests that PE (and its severity) should be considered as a risk factor for AKI and AKI may deserve to be evaluated as a prognostic factor in patients with acute PE.
F-92 Severe metabolic acidosis after out-of-hospital cardiac arrest: risk factors and relationship with outcome
Jamme Matthieu1, Ben Hadj Salem Omar1, Guillemet Lucie1, Dupland Pierre1, Bougouin Wulfran1, Charpentier Julien1, Mira Jean-Paul1, Pène Frédéric1, Dumas Florence1, Cariou Alain1, Géri Guillaume2
1Hôpital Cochin (APHP), Paris, France; 2Hôpital Ambroise Paré (APHP), Boulogne Billancourt, France
Correspondence: Jamme Matthieu - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-92
Introduction: Metabolic acidosis is frequently observed as a consequence of global ischemia–reperfusion after out-of-hospital cardiac arrest (OHCA). We aimed to identify risk factors and assessing the impact of metabolic acidosis on outcome after OHCA.
Patients and methods: We included all consecutive OHCA patients admitted between 2007 and 2012. Using admission data, metabolic acidosis was defined by a positive base deficit and was categorized by quartiles. Main outcome was survival at ICU discharge. Factors associated with acidosis severity and with main outcome were evaluated by linear and logistic regression, respectively.
Results: 826 patients (68.3% male, median age 61 years) were included in the analysis. Median base deficit was 8.8 [5.3, 13.2] mEq/l. Male gender (p = 0.002), resuscitation duration (p < 0.001), initial shockable rhythm (p < 0.001) and post-resuscitation shock (p < 0.001) were associated with a deeper acidosis. ICU mortality rate increased across base deficit quartiles (39.1, 59.2, 76.3 and 88.3%, p for trend < 0.001) and base deficit was independently associated with ICU mortality (p < 0.001). The proportion of CPC 1 patients among ICU survivors was similar across base deficit quartiles (72.8, 67.1, 70.5 and 62.5%, p = 0.21) and 11.7% of patients with a base deficit higher than 13.2 mEq l survived to ICU discharge with a good neurological recovery.
Conclusion: Severe metabolic acidosis is frequent in OHCA patients and is associated with poorer outcome, in particular due to refractory shock. However, we observed that about 10% of patients with a very severe metabolic acidosis survived to ICU discharge with a good neurological recovery.
F-93 Influence of socio-economic status on initial severity and prognosis of patients admitted to intensive care: the IVOIRE study
Quenot Jean-Pierre1, Meziani Ferhat2, Meunier-Beillard Nicolas1, Capellier Gilles3, Bollaert Pierre-Edouard4, Louis Guillaume5, Dargent Auguste1, Levy Bruno4, Bein Christophe6, Ecarnot Fiona3, Rigaud Jean-Philippe7, Helms2, Julie, Fournel Isabelle1
1Centre Hospitalier Universitaire, Dijon, France; 2Centre Hospitalier Universitaire, Strasbourg, France; 3Centre Hospitalier Universitaire, Besançon, France; 4Centre Hospitalier Universitaire, Nancy, France; 5Centre Hospitalier, Metz, France; 6Centre Hospitalier, Vesoul, France; 7Centre Hospitalier, Dieppe, France
Correspondence: Quenot Jean-Pierre - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-93
Introduction: Precarious socio-economic status can directly influence health, need for hospitalisation and mortality, according to a previous study performed in 22 European countries. Similar findings have been reported from Anglo-Saxon countries in the setting of intensive care. Due to the different structure of the healthcare system in France, we aimed to investigate whether socio-economic status influences initial severity of disease and 3 months mortality in patients admitted to intensive care in France.
Patients and methods: Prospective, multicentre, cohort study including 1396 adult patients admitted to one of 8 participating intensive care units (ICUs) between 2012 and 2016, and presenting failure of one or more major organs. Patients were considered to have a precarious socio-economic status if they presented at least one criterion of social vulnerability or a high EPICES deprivation score.
Results: Data on social vulnerability were available for 1281 patients, of whom 54.3% were considered to be socially vulnerable. Compared to non-vulnerable patients, socially vulnerable patients were younger (64.8 vs 67.2 years, p = 0.006), more frequently had chronic disease (18.0 vs 12.0%, p = 0.003 respectively for congestive heart failure and 26.8%vs 18.1%, p = 0.0002 for chronic respiratory disease), had higher levels of physical dependency (9.2 vs 4.7%, p = 0.002), and were more often classed as having long-term health conditions (67.1 vs 62.1%, p < 0.0001). Conversely, non-vulnerable patients had greater severity of disease at admission to the ICU than those classed as vulnerable, both in terms of SAPS II and SOFA scores (respectively 53.16 vs 50.09 (p = 0.001) and 8.35 vs 7.77(p = 0.002)). Findings were similar after adjusting for major confounders (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) [0.48–0.81], p = 0.0005). Mortality at 3 months was not significantly different between socially vulnerable patients and those not considered vulnerable, respectively 34.6 vs 36.10% (p = 0.62), even after adjustment for initial severity.
Conclusion: Despite less severe disease at admission to the ICU among patients considered socially vulnerable, 3-month mortality did not differ significantly between those who were socially vulnerable and those who were not. These findings suggest that the French healthcare system provides good protection for the most disadvantaged members of society, particularly when they are admitted to the ICU.
F-94 Anonymous and continuous evaluation of the satisfaction of the critically ill patients’ proxies: the OpinionFamily tool
Labbe Vincent1, Marie Cécile De Crémiers1, Taconet Clémentine1, Pham Tài1, Djibre Michel1, Blayau Clarisse1, Voiriot Guillaume1, Garnier Marc1, Fulgencio Jean-Pierre1, Gounane Cherifa1, Gibelin Aude1, Flechel Anita1, Fartoukh Muriel1
1Hôpital Tenon, Paris, France
Correspondence: Labbe Vincent - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-94
Introduction: An approach of the quality of care may involve assessing the patients’ satisfaction. However, the extended caregiver—patient and family relationship, specific to the critically ill patients, may also require to assess the proxies’ satisfaction. The OpinionFamily tool was developed to assess the satisfaction of the critically ill patients’ proxies, in an anonymous and continuous fashion.
Patients and methods: We conducted a study in the ICU of Tenon hospital (Paris, France) between Mars and August 2017. The OpinionFamily questionnaire, built with 6 categories (4 items each), aimed to measure the proxies’ satisfaction regarding their perception of the quality of care. All the proxies were invited to express voluntarily and anonymously his her degree of agreement as a response to a statement by the selection of the corresponding stars (strongly disagree—1 star, disagree—2 stars, neither agree nor disagree—3 stars, agree—4 stars, strongly agree—5 stars) using a secure touch screen disposed 24 7 in the waiting room of the ICU.
Results: Altogether, 456 patients were hospitalised during the study period, and 148 proxies completed the questionnaire. All the responders spoke French. Only 12 responders (9%) answered more than one time. Of the responders, 105 (71%) were the referring person, 47 (32%) were children and 26 (17%) were spouses. During the study period, 50 (34%), 59 (40%), and 38 (26%) responders had visited their relative 1 to 3 times, 4 to 10 times, and more than 10 times, respectively. The different categories assessed by the OpinionFamily tool were related to «the family and the patient» (Fig. 1A), «the family and the environment» (Fig. 1B), and «the family and the caregivers–availability, trust, support, and information» (Fig. 1C). The corresponding levels of satisfaction (responses of at least 4 stars) were respectively 67, 78, 65, 77, 78, and 79%. Some items were associated with a poor satisfaction (participation to the care, identification and availability of the caregivers).
Conclusion: The implementation of the OpinionFamily tool allowed a continuous evaluation of the satisfaction of the critically ill patients’ proxies. A systematic implementation of this tool in the ICUs may be useful to the caregivers for a better understanding of the needs of the proxies. In addition, this tool may allow rapid changes in ICU organizations and behaviours to improve the proxies’ satisfaction, which may ultimately, improve the care of patients.
F-95 Ethical decisions in patients with severe acute respiratory failure: determining factors, time of decision and impact on outcome: the eDecide project—an ancillary analysis of LungSafe study
Berleur Marie1, Pham Tai2, Ricard Jean-Damien1, Uchida Masatoshi3, Thomson Taylor4, Messika Jonathan1, Dreyfuss Didier1, Roux Damien1
1Hôpital Louis Mourier, Colombes, France; 2Hôpital St Michael, Toronto, Canada; 3Dokkyo Medical University, JAPAN; 4Boston, USA
Correspondence: Berleur Marie - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-95
Introduction: Withholding and withdrawing life-sustaining therapy (LST) are complex ethical decisions made in many critically ill patients. Many factors influence end-of-life decisions (EOL). We describe EOL decisions in patients with acute respiratory failure and their impact on patients’ prognosis.
Patients and methods: An international observational study included all patients with acute respiratory distress over a 1-month period. 459 ICU in 50 countries were involved. Demographic, clinical and biological data were compared between patients with and without decision of LST limitation. We also compared surviving patients after LST limitation decision to those who eventually died.
Results: Among the 4041 patients, mortality was 37.2%. A decision of LST limitation was reported in 948 patients (23.4%). In univariate analysis, patients with LST limitation decision were older and more frequently hospitalized for a medical condition, had a lower body weight, a higher SOFA score, and presented active neoplasia immunosuppression or chronic liver failure more frequently (p < 0.001 for all). Patients admitted after trauma, drug overdose or pulmonary contusion were less subject to have an LST limitation decision (p < 0.001). In contrast, patients with non-cardiogenic shock were more subject to these decisions (p = 0.018). EOL decisions were less frequent in lower-middle income countries as compared to high and middle-high income countries (p < 0.001). Multivariate analysis will be presented. Among 948 patients with an LST limitation decision, 148 survived (15.6%). Mortality was higher in this group than in the whole study population (p = 0.001). In univariate analysis, death after decision of LST limitation was associated with admission for a medical condition (p = 0.02), severe ARDS, higher inspiratory pressure, non-cardiogenic shock, higher SOFA score with or without respiratory component and chronic liver failure (p < = 0.001 for all). On the contrary, admission for trauma was associated with survival (p = 0.001). Regarding the 1503 patients who died during their hospital stay, 703 did not receive a decision of LST limitation (46.8%). Decision of LST limitation was more frequent in older patients (p < 0.001) and in high-income countries.
Conclusion: Decisions of LST limitation are frequent in the ICU, and are associated with increased age and medical severity. However, a significant percentage of these patients survived. Interestingly, almost half of the patients who eventually died during their hospital stay had not been subject of a decision of LST limitation.
F-96 Evaluation of the decision-making process leading to a decision not to readmit a patient to the intensive care unit during a same hospital stay
Guido Olivia1, Meunier-Beillard Nicolas1, Meziani Ferhat2, Delmas Emmanuel1, Dargent Auguste1, Rigaud Jean-Philippe3, Ecarnot Fiona4, Fournel Isabelle1, Quenot Jean-Pierre1
1CHU de Dijon, France; 2CHRU de Strasbourg, France; 3Centre Hospitalier, Dieppe, France; 4Centre Hospitalier Universitaire, Besançon, France
Correspondence: Guido Olivia - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-96
Introduction: The risk–benefit ratio of (re-)admission to the intensive care unit (ICU) has been widely discussed in the literature. However, the ethics of non-readmission during a single hospital stay have not been widely addressed. A decision not to re-admit a patient to the ICU could be seen as a limitation of therapy, thus falling within the scope of the law dated 22 April 2005, by denying the patient access to potentially-available healthcare resources. In this context, we aimed to—(1) investigate whether decisions not to re-admit patients to the ICU are taken in accordance with French legislation + and (2) identify the characteristics of patients concerned by this type of decision.
Patients and methods: This study was based on data from the prospective, multicentre IVOIRE cohort (Influence of socio-economic vulnerability on initial severity and prognosis of patients admitted to the ICU + PHRC-IR 2012). We identified patients included in two large regional university hospitals in the East of France for whom a decision not to re-admit was taken during a single hospital stay. The decision-making process was evaluated based on a questionnaire comprising 13 items developed by a sociologist from semi-directive interviews with clinicians.
Results: Among 857 patients discharged from the ICU alive, a decision not to re-admit to the ICU during a same hospital stay was noted in the medical file of 63 patients (7.3%). This decision was primarily made on the day of discharge (42.6%), and those involved in the decision included—the family, an outside consultant, and the patient themselves in 54, 31.7 and 15.9% of cases respectively. The decision was justified in medical terms in 92.1% of cases, and the main reasons cited were—(1) therapeutic impasse (52.4%) + (2) comorbidities (44.4%) + (3) degree of dependence of the patient (34.9%). Patients concerned by decisions of this type were generally older (75 vs 65.6 years, p < 0.0001), with more comorbidities (median 4 vs 2, p = 0.001), greater loss of dependence according to Katz’s activities of daily living (5 vs 6, p < 0.0001), and longer duration of life-sustaining therapies (7.5 vs 5 days, p = 0.028).
Conclusion: Although the profile of the patients identified in this study likely justified the decision not to re-admit the patient to the ICU, there is room for improvement in the decision-making process.
F-97 Evolution between 1993 and 2013 of 4 triage criteria for admission to a French ICU
Mentec Hervé1, Mouhtatine Youssef1
1CH Victor Dupouy, Argenteuil, France
Correspondence: Mentec Hervé - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-97
Introduction: Nowadays, opposite to ancient times, the feeling of caring only for patients accumulating frailty factors wins ICU physicians. We assessed the evolution of the prevalence of 4 patients’ characteristics, deemed frailty markers, on ICU admission over 20 years.
Patients and methods: Retrospective study of reports of all patients admitted to the same ICU in 1993 and 2013. During that period, the medical team evolved only slowly + therefore the same medical philosophy prevailed. We recorded the prevalence of 3 characteristics on 2 levels—age > = 80 years with or without cognitive impairment, smoking with or without COPD, alcoholism with or without cirrhosis, and of a forth characteristic—metastatic cancer or malignant hemopathy (MCMH). We recorded SAPS II, vital supports, withholding and withdrawing of cares and ICU mortality.
Results: 589 patients were admitted in 1993, 597 in 2013. Median age was 59.8 years in 1993, 66.3 years in 2013 (p < 0.0001). The proportion of patients > = 80 years increased between 1993 and 2013 (10.2 to 17.3%, p = 0.0004). The prevalence of cognitive impairment also increased (0.4 to 4.0%, p < 0.0001). The prevalence of smoking decreased (36.2 to 32.3%, p = 0.001) and prevalences of COPD (15.6 to 19.3%, p = 0.63), alcoholism (26.0 to 29.5%, p = 0.80), cirrhosis (5.9 to 7.0%, p = 0.92) and MCMH (11.0 to 11.4%, p = 0.68) remained stable. Median number of the 4 characteristics per patient was similar in 1993 and 2013 (1[0–2] and 1[0–1], p = 0.86). Median SAPS II was higher in 2013 (45.0) compared to 1993 (32.1) (p = 0.0001). Compared to 1993, vital supports and withholding or withdrawing of cares were more frequent in 2013. ICU mortality was higher in 2013 (29%) than in 1993 (20%) (p = 0.001). ICU mortality increased with accumulation of the 4 characteristics. In multivariate analysis, factors positively associated with ICU mortality were age > = 80 years, alcoholism-cirrhosis combination, SAPS II, catecholamine infusion and mechanical ventilation, whereas admission for drug intoxication had a protective effect.
Conclusion: The intensivists’ feeling that patients admitted to ICU changed over time is confirmed. However, among the 4 characteristics we studied, only age > = 80 years and cognitive impairment were more prevalent in 2013 and only age > = 80 years and alcoholism-cirrhosis combination were independently associated with ICU mortality.
F-98 Non-therapeutic ventilation for organ donation. National survey of practice
Si Larbi Anne-Gaëlle1, Soummer Alexis1, Lapergue Bertrand1, Gaudin Virginie1, Bonnin France1, Cerf Charles1
1Hôpital Foch, Suresnes, France
Correspondence: Si Larbi Anne-Gaëlle - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-98
Introduction: Most of organ donors are brain dead patients. In some cases, patients are identified as potential donors before brain death and will undergo intubation and mechanical ventilation for the sole purpose of awaiting brain death. The aim of this study is to evaluate the practices of professionals in charge of potential donors.
Patients and methods: In 2014, a questionnaire was sent by e-mail to 1800 French health professionals working in departments in charge of potential donors (ICU, neurology, emergency room), 183 responded with a response rate of 10%. Qualitative variables are expressed in percent and compared by Chi2 test.
Results: 169 questionnaires are usable. 117 respondents (69%) are ICU physicians (ICUp), 36 (21%) are non-ICU physicians (non-ICUp) and 16 (10%) are non-medical caregivers. Among the non-ICUp, 19 (53%) are neurologists, 7 (19%) are emergency physicians and 8 (22%) work in another department. 47% work in a university hospital and 57% in Paris area. Experience of the physicians—112 ICUp (97%) have already pursued mechanical ventilation with the sole purpose of waiting for brain death, and 68% of all physicians have already intubated a patient for this sole purpose (Table 1). In this case, the issue of organ donation was addressed to the relatives before intubation by 42% of ICUp and 68% of non ICUp (p = 0.03). 29% of participants never addressed organ donation before the brain death. For the 71% who have done so at least once, organ harvesting never happened in 20% of cases. Legitimacy and difficulties (Table 1)—21% of respondents felt that when a decision of treatment withdrawal or withholding is taken, the patient should not go to ICU for any reason and 29% think that these patients should be allowed to die “quietly”. The prospect of an extubation if brain death does not occur or in case of organ donation refusal is a problem for 24% of ICUp and 38% of non ICUp (p = 0.08). 88% of ICUp and 93% of non ICUp think they would need to receive training.
Conclusion: This study shows that pursuing mechanical ventilation for the sole purpose of awaiting brain death and organ harvesting is a common practice, and that intubating a patient for this purpose alone is done in most of cases but could still be more generalized. On the other hand, information to the relatives should be improved.
F-99 Effect of low tidal volume on absolute humidity delivered by heated humidifiers in ICU ventilators: a bench study
Guerin Claude1, Moro Barbara1, Baboi Loredana1, Yonis Hodane1, Lissonde Floriane1, Aublanc Mylène1, Louf-Durier Aurore1, Riad Zakaria1, Richard Jean-Christophe1
1Hôpital de la Croix Rousse, Lyon, France
Correspondence: Guerin Claude - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-99
Introduction: In ARDS patients under ECMO common ventilator strategy aims at resting the lung by lowering tidal volume (VT). We were wondering whether such low VT can impact the efficacy of heated humidifiers (HH) in ICU ventilators to achieve the recommended target of 33 mg L−1 absolute humidity (AH).
Patients and methods: Pneumatic test lung with 20 ml cm H2O compliance and 20 cm H2O L s resistance was attached to any of 5 ICU ventilators (V 500 (Drager), Carescape R 860 (GE Healthcare), Servo U (Maquet), G5 (Nihon-Kohden) and PB980 (Medtronic)) equipped with Fisher-Paykel MR 850 HH and double wired limb ventilator circuit. PEEP was set to 12 cm H2O and FIO2 0.21. HH was set in manual mode and targeted 37 °C into the chamber and 40 °C at the Y piece. AH was assessed by using the psychrometric method and probes temperature continuously monitored. HH was run during 45 min at VT 500 ml then 100 ml, at respiratory rate (RR) 30 breaths min. Once probes temperatures leveled off at VT 100 ml, 10 cycles were counted then 120 ml VT was delivered til next plateau temperature and so on by 20 ml-increment in VT up to 280 ml. Then VT was lowered to 100 ml and RR to 15 breaths min. At the time of plateau temperature same VT increment as above was performed. Experiment was performed by using adult (RT 380 EVAQUA Fisher Paykel) and repeated with neonate (RT 266 EVAQUA Fisher-Paykel) ventilator circuit. The relationship of VT to AH were analyzed by using linear model for each circuit-RR combination.
Results: With adult RR15, adult RR30, neonate RR15 and neonate RR30 the median intercept and slope of the relation ship of VT to AH were 28 and 0.017 °C ml, 31 and 0.017, 25 and 0.023, 28 and 0.019, respectively. There were significant différences across ICU ventilators from this mean effect (Fig. 1).
Conclusion: AH increased with increasing VT with differences across ventilators and circuit RR combinations. Recommended 33 mg L−1 AH was never reached in some ventilatorsBest setting is adult circuit and RR 30 min for reaching 33 mg L−1 AH.
F-100 Continuous prolonged monitoring with EIT in supine and prone position: feasibility and first results
Mezidi Mehdi1, Riad Zakaria1, Yonis Hodane1, Louf-Durier Aurore1, Tapponnier Romain1, Lissonde Floriane1, Aublanc Mylène1, Baboi Loredana1, Richard Jean-Christophe1, Guérin Claude1
1Hospices Civils de Lyon, France
Correspondence: Mezidi Mehdi - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-100
Introduction: Electric impedance tomography (EIT) is a non-invasive tool allowing a continuous monitoring of regional lung ventilation. Prone position (PP) for long sessions in association with low tidal volume and cisatracurium infusion has been shown survival benefit in moderate to severe ARDS patients. The goal of the present study was to report on the feasibility of continuous EIT monitoring and to describe time course of EIT-derived indexes during a 16-hour PP session.
Patients and methods: This is a secondary study of patients included in a prospective interventional physiologic study performed in patients with moderate to severe ARDS (PaO2 FIO2 < 150 mmHg), intubated, sedated and paralyzed, requiring PP. The study was evaluating 2 different PEEP strategies. Notably, PEEP and other settings was kept constant during the last 14 h of the 16 h PP session. EIT was performed with Swisstom BB2 device. Patients were assessed in SP at 30° and in PP at 0°or 15° from the horizontal plane. EIT belt was placed around the chest according to manufacturer’s specifications. To prevent pressure sores in the PP dressing was placed between EIT belt and mattress and around the EIT wire. We analyzed the the center of ventilation (CoV), which describes the well-ventilated areas of the lung with 0% for ventilation occurring only in the ventral region and 100% for a ventilation only in the dorsal region. We report the time course of CoV in supine position (SP) 30 min before PP, 30 min after the beginning of PP (H0.5) and every hour (H1, H2… H16) till PP end. Results are expressed in median [1st-3rd quartiles] and count (percentage).
Results: Continuous EIT was recorded in 19 patients of who 15 patients (79%) had usable records and 10 (67%) enough time points for present purpose. One patient presented an erythema on the sternum despite the protective dressing. In the SP, CoV was greater than 50% in every patient indicating that the ventilation took place predominantly in the dorsal (spine) lung regions. With PP, CoV did not vary significantly (p = 0.53) between SP and H0.5. However, some patients experienced clinically significant drop or rise of CoV (Fig. 1). CoV reached a plateau after 5 [3–6] h.
Conclusion: Continuous and prolonged EIT monitoring is feasible and safe in PP. Main issue is to keep a stable signal. The ventilation redistribution may take a long time for some patients.
F-101 How long should the patient be left in prone position?
Jochmans Sebastien1, Mazerand Sandie1, Sy Oumar1, Chelly Jonathan1, Vong Ly Van1, Ellrodt Olivier1, Mercier Des Rochettes Emmanuelle1, Abdallah Razach1, Rolin Nathalie1, Serbource-Goguel Jean1, Vinsonneau Christophe2, Monchi Mehran1
1GH Sud Ile-de-France, Hôpital de Melun, Melun, France; 2CH Bethune, Melun, France
Correspondence: Jochmans Sebastien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-101
Introduction: The optimal duration of a prone position session (PP) is not yet known.
Patients and methods: All ARDS patients treated with PP were included. We recorded before the session and every 30 min (during the session) up to 24 h—dynamic compliance (Cdyn), PetCO2, dead space (Vd Vt) and phase 3 slope of volumetric capnography. We evaluated for each session whether there was a positive response for each parameter—decrease in PetCO2, Phase 3 slope, Vd Vt and increase in Cdyn.
Results: 57 patients and 114 sessions were analysed. PaO2 FiO2 was 124 [87–163] with PEEP 16 [14–18], RR 25 [20–30] and VT 6.5 mL kg IBW [6.1–7.3]. The effect of PP on the monitored parameters varies significantly between each patient but also between each session for the same patient. In positive responders, the effect continues statistically for 7 to 20 h depending on the parameter studied—10.5 h for Vd Vt, 19.5 for Phase 3 slope, 7 for PetCO2 and 9 for Cdyn.
Conclusion: The maximum effect of prone positioning on selected parameters seems to be obtained after 20 h of therapy.
F-102 Respiratory mechanic, transpulmonary pressure and oxygenation during PEEP titration with the Express protocol in ARDS patients
Bergez Marie1, Tranvan David1, Saghi Tahar2, Gentile Ariane1, Ouattara Alexandre3, Labadie Philippe4, Fontaine Bruno1, Roze Hadrien4
1Hopital des Armées Robert Piquet, Bordeaux, France; 2Polyclinique Bordeaux nord, Bordeaux, France; 3SAR2, CHU de Bordeaux, Bordeaux, France; 4CHU de Bordeaux, France
Correspondence: Bergez Marie - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-102
Introduction: Some protocols use individual respiratory mechanics to titrate PEEP in ARDS (1, 2). Respiratory mechanics with transpulmonary pressure and oxygenation during individual PEEP titration using the Express protocol in ARDS patients is unknown. This study measured and compared transpulmonary pressures with the Express protocol.
Patients and methods: Prospective data collection. Oesophageal pressure (Pes) was measured with Nutrivent™ catheter. Patients under myorelaxant received randomly 2 methods of PEEP titration, alternatively based on plateau pressure (Express group) or PEEP 5–8 cm H2O (Mini distension group). We used the following equations– Relative inspiratory transpulmonary pressure (PL rel) = Plateau pressure x (lung elastance respiratory system elastance). Transpulmonary expiratory Pressure (Ptp expi) = End expiratory airway pressure—End expiratory oesophageal pressure − 5 cm H2O (2)—Driving Pressure (DP) = plateau pressure—total PEEP—Transpulmonary Driving Pressure (DPtp) = DP—deltaPoeso—Respiratory system elastance (ERS) = DP VT.—Lung elastance (EL) = DPtp VT—PEEP volume = expired VT from PEEP to ZEEP-VT.
Results: 17 patients were included in 2016. With the Express protocol, PEEP increased from 7[5–8] to 15[12–16] cm H2O p < 0.0001 + PaO2 FiO2 increased from 87[70–121] to 94[84–185], p = 0.02, and DP remained unchanged 13[10–15] vs 13[11–16] cm H2O. With Express protocol Plateau pressure, relative transpulmonary inspiratory pressure (PLrel) and expiratory transpulmonary pressures were 28 [28–30], 20 [18–23.5] and 6 [4–10] cm H2O, respectively. Transpulmonary driving pressure (DPtp) was 13 [11–16.5] cm H2O and was highly correlated to DP (R2 = 0.97, p < 0.001), whereas lung (EL) and chest wall elastance (ECW) were 25[20–34] and 9.4[7.0–11.0] cm H2O litre, respectively. Patients with PLrel below 20cmH20 had higher ECW and lower DPtp. PEEP volume was significantly lower in the group with PLrel below 20cmH20 with 360[272–571] vs 621[438–856] ml, respectively, p = 0.04. PEEP corresponding Ptp expi matched FiO2 according to the Talmor protocol (2) for 3 patients.
Conclusion: Those results indicate the effect of the Express protocol on different index derived from oesophageal pressure at the bedside in ARDS patients. It shows that individual PEEP level were different from those proposed by the Talmor protocol. Further protocols based on inspiratory relative transpulmonary pressure in patients with higher chest wall elastance are required. 1. JAMA 2008 + 299–646. 2. N Engl J Med 2008 + 359–2095–2104.
F-103 Neutrophil extracellular traps in the lungs of patients with pneumonia and the acute respiratory distress syndrome
De Prost Nicolas1, Bendib Inès1, De Chaisemartin Luc1, Granger Vanessa1, Schlemmer Frédéric1, Maitre Bernard1, Carteaux Guillaume1, Razazi Keyvan1, Mekontso Dessap Armand1, Martin Sylvie1
1Hôpital Henri Mondor Créteil, Créteil, France
Correspondence: De Prost Nicolas - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-103
Introduction: The acute respiratory distress syndrome (ARDS) is characterized by lung infiltration with activated neutrophils. Neutrophil extracellular traps (NETs) are antimicrobial structures released by neutrophils. NETs have also been associated with tissue damage in experimental models of acute lung injury. Whether NETs are involved in the pathogenesis of human ARDS and could be a potential therapeutic target is unknown. We aimed to quantify alveolar NETs production in patients with pneumonia and ARDS and assess its relationship with outcomes.
Patients and methods: Prospective monocentric study. Patients admitted in the ICU in 2014 2015 with pneumonia and moderate severe ARDS were included. Immunosuppressed patients were excluded. NETs (DNA-myeloperoxidase) levels were measured by ELISA in broncho-alveolar lavage (BAL) fluid and serum samples of ARDS patients and in those of control patients (n = 4). Patients with higher and lower BAL fluid NETs levels were compared using the median as a cutoff value.
Results: Thirty-five patients with bacterial (n = 18), viral (n = 11) or non-microbiologically documented (n = 6) pneumonia and ARDS were included. NETs levels were significantly higher in BAL fluid than in blood of ARDS but not of control patients (Fig. 1). Patients with higher BAL NETs levels did not differ from others regarding baseline characteristics (age—55 ± 17 vs 52 ± 17 years, p = 0.63 + SAPS II—42 ± 18 vs 39 ± 14, p = 0.66 + SOFA—8 ± 4 vs 8 ± 3, p = 0.99). PaO2 FiO2 ratios did not differ upon admission (130 [69–186] vs 99 [81–160] mmHg, p = 0.65) but were higher in patients with higher BAL NETs levels on the day BAL was performed (242 [149–350] vs 142 [103–193] mmHg, p = 0.006) together with a trend towards higher blood neutrophil counts (13.6 ± 7.4 vs 9.3 ± 6.6 × 103 mm3, p = 0.09). Patients with higher BAL NETs levels did not have a significantly different hospital mortality (17.6 vs 16.7%, p > 0.99) but exhibited a shorter mechanical ventilation duration in survivors (6 [3–13] vs 11 [6–24] days, p = 0.026) and a trend towards more ventilator-free days at day 28 (22 [14–25] vs 14 [0–21] days, p = 0.066).
Conclusion: In this cohort of patients with pneumonia and ARDS, we observed a lung production of NETs-MPO. Patients with a higher lung production of NETs showed shorter MV duration than others. Our results do not support targeting NETs for adjuvant therapy in ARDS patients with pneumonia.
F-104 PaO2 FiO2 ratio estimation from SpO2 FiO2 rati: a planned companion study of the SPECTRUM study
Michel Philippe1, Boissier Florence2, Aissaoui Nadia3, Barbar Saber Davide4, Brouard Florence5, Grimaldi David6, Hraiech Sami7, Lacherade Jean-Claude8, Lascarrou Jean-Baptiste9, Muller Grégoire10, Piton Gaël11, Youssoufa Atik Cerc (on Behalf Of The Srlf Trial Group)7,12
1CH de Pontoise, France; 2CHU Poitiers, Poitiers, France; 3Hôpital Européen George Popidou, France; 4CHU de Nîmes, France; 5CH de Périgueux, France; 6Hôpital Erasme, Bruxelles, Belgique; 7Hôpital Nord, Marseille, France; 8CHD Vendée, La Roche-Sur-Yon, France; 9CHU de Nantes, France; 10Hôpital de la Source, Orléans, France; 11CHU de Besançon, France; 12Srlf Trial Group, France
Correspondence: Michel Philippe - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-104
Introduction: The ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2 FiO2 or P F) is daily used to assess patients’ evolution under ventilatory support. Some studies reported the reliability of percutaneous oxygen saturation (SpO2) to appreciate PaO2 easy to get on bedside. Thus two equations have been proposed—Rice equation and Ellis equation. However, no large prospective study assessed the reliability of such equations to estimate the P F at the bedside in real conditions. Using the SPECTRUM (Severe hyPoxemia—prevalEnCe, TReatment and oUtcoMe) study, we aimed to evaluate the reliability of SpO2 obtained by Rice and Ellis equation.
Patients and methods: This study is a planned companion of SPECTRUM study, a recent prevalence-point-day conducted by the SRLF Trial group in 117 french-speaking ICU aiming to report the patterns and outcomes of hypoxemic patients (defined by P F < 300 mmHg). We included in the analysis all patients under mechanical ventilation with SpO2 < 98% (according to limit of the Rice study). SpO2 and FiO2 were measured simultaneously to arterial blood gas were drawn.
Results: Among 1656 Patients of the SPECTRUM study, 421 were on mechanical ventilation and had undergone arterial blood gas with simultaneously recorded SpO2 and FiO2. Of note, P F was < 100 mmHg for 132 + between 100 and 200 for 191 + and between 200 and 300 for 29. Pairwise correlations of truth P F with estimated P F was good (Rice—Spearman’s rho = 0.84, p < 0.001–Ellis—rho = .85 p < 0.001). Bland–Altmann test showed an important variability of results (P F vs Rice (Figure)—0.02 ± 57.8–P F vs Ellis—14.3 ± 45.5). The variability decreased with lower P F. Caution may be used to interpret our results because we did not reported the quality of SpO2 signal at the bedside.
Conclusion: Regarding the variability of the results, whatever the used equation, caution may be used to predict the P F by the SpO2 FiO2 ratio in patients under mechanical ventilation.
F-105 Transpulmonary pressures measurements as a mean to optimize mechanical ventilation in a unique series of patients combining ARDS and very severe morbid obesity
Vimpere Damien1, Aissaoui Nadia2, Couteau-Chardon Amélie3, Lancelot Aymeric3, Commereuc Morganne3, Guerot Emmanuel3, Diehl Jean-Luc4
1Hopital Georges Pompidou, Paris, France; 2Centre de Recherche Cardiovasculaire, Paris, France; 3Hôpital Européen Georges Pompidou, AP-HP, Paris, France; 4Université Paris Descartes, Paris, France
Correspondence: Vimpere Damien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-105
Introduction: Morbid obesity and ARDS both affect respiratory mechanics mainly through their respective impacts on chest wall and lung elastances. We present a unique series of patients combining very severe morbid obesity and moderate to severe Acute Respiratory Distress Syndrome (ARDS). We describe the use of trans-pulmonary pressures (TPP) measurements for optimization of external PEEP setting.
Patients and methods: The monocentric observational study was performed in 8 morbidly obese patients admitted for moderate to severe ARDS. We performed an incremental PEEP trial (5 cm H2O steps) with TPP measurement (NutriVent probe, Sidam, Italy) in a semi-recumbent position as previously described. A decremental PEEP trial after a recruitment maneuver was not performed since the safety of such a maneuver in this specific population is largely unknown. We defined two ways for determination of external PEEP setting—(1) PEEP necessary to obtain a positive expiratory TPP and (2) PEEP necessary to obtain a plateau pressure between 28 and 30 cm H2O (maximal alveolar recruitment Express strategy). Data are expressed as numbers (%) and medians (interquartile range). Statistical analysis was made using the XLSTAT software.
Results: We enrolled during 5 years 8 morbidly obese patients (BMI 63 (IR 59–69)) admitted for a moderate to severe ARDS. Clinical characteristics are displayed in Table 1. The Express strategy indicated a PEEP setting of 15 cm H2O (IR 15–20) whereas TPP-guided PEEP was 30 cm H2O (IR 25–32), p = 0.03. Driving pressure was higher in the Express strategy PEEP setting (10.7 cm H20 (IR 9–12)) than in the TPP-guided PEEP (10.2 cm H20 (IR 9.5–13)), p = 0.92. TPP-guided PEEP setting was higher than indicated by the Express strategy in all but one patient. One patient suffered from transient hypotension when external PEEP was set at 25 cm H2O, while no patient displayed an inspiratory TPP higher than 25 cm H2O. Additional data will be provided during the meeting—pressure–volume curve at ZEEP (6 patients), CRF measurements (4 patients) and ABG and capnometry values at each PEEP level (3 patients).
Conclusion: In our ARDS patients with extremely severe obesity, an incremental PEEP trial with TPP measurements appeared to be safe and indicated a PEEP setting significantly higher than for the commonly-used ARDS strategies. Such an approach deserves further comparisons with other modalities of monitoring, such as CRF measurements, EIT studies, etc.
F-106 Severe poisoning by cardiotoxic drugs and circulatory assistance: 5-year experience at French university hospital
Tardif Elsa1, Conil Jean-Marie1, Georges Bernard1, Marcheix Bertrand1, Crognier Laure1, Bounes Fanny1, Delmas Clement1
1CHU Rangueil, Toulouse, France
Correspondence: Tardif Elsa - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-106
Introduction: Toxicity from cardiac drugs is associated with a large number of fatalities, significant morbidity and healthcare consequences. Severity of these poisonings can be explained by a refractory cardiogenic shock not responding to optimal conventional treatment. Criteria of circulatory assistance indications remain unclear. The aim of the study was to describe and to compare patients intoxicated by cardiotoxic drug treated with or without veno-arterial ExtraCorporeal Membrane Oxygenation (VA ECMO).
Patients and methods: Retrospective cohort study conducted at French university hospital. All patients intoxicated with cardiotoxic drugs between January 2012 and March 2017 were included. Patients were divided into 2 groups—with and without VA ECMO.
Results: Among the 105 patients included in the study, 18 patients were treated with VA ECMO (17%) and 87 patients with conventional therapies. ECMO was respectively employed for refractory shock and cardiac arrest in 13 and 5 cases, all patient required vasopressor support. In-hospital mortality was 10.5% and was significantly higher in the ECMO group (44.4%). Beta-blockers with membrane stabilizing activity and non-dihydropyridine calcium channel blockers poisoning were the most commonly reported in the ECMO group. Mean time from hospital admission to initiation of ECMO was 11 h [1–53] and the average ECMO duration was 2.6 days [1–8]. No serious adverse reaction was reported during this period.
n = 87
n = 18
|Clinical data at admission|
|Glasgow Coma Scale, score||15 [14 to 15]||14 [6 to 15]||0.13|
|Temperature, degree||36.3 [36 to 36.5]||36.1 [35.2 to 36.8]||0.54|
|Mean arterial pressure, mmHg||70 [67 to 74]||51 [45 to 63.6]||0.006|
|Heart rate, beats/min||70 [63 to 78]||70 [59 to 91]||0.93|
|PaO2/FiO2 ratio||392,9 [361 to 433]||238,8 [93.8 to 429]||0.02|
|Paraclinical exams at admission|
|Minimal Left Ventricular Ejection Fraction, %||55 [50 to 55]||20 [10 to 48]||< 0.0001|
|Sinus rhythm, n (%)||77 (90.6)||10 (55.6)||0.001|
|QRS, ms||80 [80 to 80]||120 [98 to 200]||0.02|
|Corrected QT interval, ms||441 [425 to 458]||495 [436 to 555]||0.03|
|PR, ms||180 [180 to 200]||120 [110 to 200]||0.06|
|Biological data at admission|
|pH||7.385 [7.38 to 7.41]||7.36 [7.24 to 7.43]||0.14|
|Lactate levels, mmol/l||2.05 [1.4 to 2.54]||4.3 [1.8 to 7.99]||0.006|
|Bicarbonate, mmol/l||22.65 [21.3 to 23.5]||20.15 [16 to 23.2]||0.19|
|Base excess, mEq/l||− 2.8 [(− 3.6) to (− 1.4)]||− 6 [(− 9.3) to (− 0.6)]||0.19|
|pCO2, mmHg||36.75 [35 to 39]||40.1 [35.5 to 50]||0.09|
|Troponin, ng/l||7 [7 to 7.1]||7 [3.5 to 25.3]||0.77|
|Blood glucose level, g/l||1.2 [1.1 to 1.3]||1.5 [1.16 to 2.4]||0.05|
|Serum sodium levels, mmol/l||140 [139 to 141]||142.5 [139.4 to 146]||0.02|
|Serum potassium levels, mmol/l||3.9 [3.8 to 4]||3.35 [2.9 to 4.1]||0.01|
|Creatinine, µmol/l||78.5 [70.4 to 87]||89.5 [63.8 to 151.6]||0.45|
|Prothrombin time, %||91 [88 to 94]||80 [64 to 88.8]||0.01|
|Factor V, %||109 [71 to 125]||58.5 [38.7 to 72.8]||0.007|
|SGOT, UI/l||23 [21 to 25]||30.5 [21 to 65.2]||0.05|
|SGPT, UI/l||23 [18 to 25]||28 [17 to 71]||0.07|
|Biological data at day 1|
|pH||7.4 [7.38 to 7.4]||7.4 [7.38 to 7.48]||0.39|
|Lactate levels, mmol/l||1.3 [1 to 1.47]||2.1 [1.6 to 4]||0.02|
|Bicarbonate, mmol/l||23.2 [22 to 24]||19.7 [17.1 to 21.8]||0.006|
|Base excess, mEq/l||− 1.7 [(− 1.9) to (− 0.8)]||− 3.9 [(− 8.2) to (− 0.4)]||0.03|
|pCO2, mmHg||37.4 [35 to 40]||29.3 [28 to 33.7]||0.0001|
|Serum sodium level, mmol/l||139 [139 to 141]||145 [140 to 150]||0.0007|
|SGOT, UI/l||30 [22.3 to 45]||93 [49.6 to 1063]||0.0005|
|SGPT, UI/l||26 [19 to 35.6]||77 [36 to 722.9]||0.003|
|Prothrombin time, %||74.5 [68 to 79.5]||58 [43.6 to 68.7]||0.001|
|Factor V, %||78 [58.4 to 95.3]||46 [19.4 to 59.3]||0.002|
|Treatment in intensive care unit|
|Norepinephrine, n (%)||31 (35.6)||16 (89)||< 0.0001|
|Dobutamine, n (%)||10 (12)||6 (33)||0.03|
|Epinephrine, n (%)||13 (15)||14 (78)||< 0.0001|
|Isoprenaline, n (%)||14 (16)||7 (38.9)||0.05|
|Crystalloids/24 h, ml||2000 [1500 to 2198]||3605 [2500 to 5000]||0.0001|
|Renal replacement therapy, n (%)||2 (2.3)||7 (38.9)||< 0.0001|
|Death, n (%)||3 (3.4)||8 (44.4)||< 0.0001|
Conclusion: Refractory cardiogenic shock following cardiotoxic drug poisoning requiring circulatory assistance is associated with significant mortality. Even if its use seems justified by the literature, the implantation criteria must be specified and this after an optimal conventional treatment to prevent multiple organ failure.
F-107 Outcome of poisoned patients with cardiovascular failure requiring massive catecholamine doses: back from irreversibility?
Megarbane Bruno1, Bouchet Amandine1, Peron Nicolas1, Nuzzo Alexandre1, Kerdjana Lamia1, Malissin Isabelle1, Voicu Sebastian1, Deye Nicolas1
1Hôpital Lariboisière, Paris, France
Correspondence: Megarbane Bruno - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-107
Introduction: Maximal dosage thresholds for catecholamine infusion were associated with almost 100%-fatality rate in patients presenting cardiovascular failure of non-toxic causes and mainly in case of sepsis. In contrast, little is known regarding such thresholds in poisoning while survivors were reported despite receiving massive catecholamine doses. Our objectives were to test the validity in poisoning of the thresholds determined in non-poisoned patients and evaluate the survival rate, the catecholamine-attributed complications and the predictive factors of death in the poisoned patients receiving massive catecholamine doses.
Patients and methods: We performed a retrospective study including all poisoned patients admitted to our intensive care unit (ICU) during a 13-year period (2003–2016) and who received massive catecholamine doses (i.e. epinephrine > 5 mg h + norepinephrine > 10 mg h and or isoprenaline > 5 mg h) to treat cardiovascular failure. The usual demographic, clinical and outcome data were collected. Univariate analysis was performed with Mann–Whitney and Chi-2 tests.
Results: Two hundred forty-six poisoned patients (representing 25% of the poisoned patients admitted in the ICU and receiving catecholamine infusion during this period) were included in the study. The patients (56% females 44% males, age—47 years [36 + 57] (median [percentiles 25 + 75]) were poisoned in relation to self—(88%) or accidental overdose (12%). One-hundred and seventeen patients (48%) survived. The involved toxicants were calcium-channel inhibitors (), beta-blockers (), sodium-channel blocker (), vasodilatators (). The mortality rate was significantly correlated with the epinephrine (p = 0.0001) and norepinephrine (p < 0.0002) infusion rate. The maximal infusion rates associated with survival were 50 mg h epinephrine, 140 mg h norepinephrine and 25 mg h isoprenaline. Catecholamine-attributed complications (11%) were mesenteric () and limb ischemia (). Based on univariate analysis, the other predictive factors of death were the onset of cardiovascular arrest (p < 0.0001), the female sex (p = 0.03), decreased Glasgow coma score (p = 0.0001), the cardiogenic shock (p = 0.004), ECMO requirement (p = 0.003), mechanical ventilation (p = 0.01), lactate elevation (p < 0.0001), plasma creatinine (p = 0.009), transaminases (p < 0.0001) and CPK (p < 0.0001) as well as prothrombine time (p < 0.0001), platelets (p < 0.0001), arterial pH (p < 0.0001) and PaO2 FiO2 ratio (p = 0.008).
Conclusion: Surviving to drug-related cardiovascular failure requiring major catecholamine doses overwhelming the usual thresholds associated with irreversibility (i.e. fatality rates of 100%) in non-toxic situations.
F-108 Assessment of inferior vena cava size as a static parameter to predict fluid responsiveness in ventilated patients with circulatory failure
Repessé Xavier1, Evrard Bruno2, Charron Cyril2, Gonzalez Céline2, Jacob Christophe2, Bouferrache Koceila2, Maizel Julien2, Prat Gwenaël2, Goudelin Marine2, Daix Thomas2, François Bruno2, SlamaMichel2, Vieillard-Baron Antoine2, Géri Guillaume2, Vignon Philippe2
1CHU Ambroise Paré, Boulogne-Billancourt, France; 2HU Dupuytren, Limoges, France
Correspondence: Repessé Xavier - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-108
Introduction: As a static parameter, end-expiratory IVC diameter (IVCEE) has been disregarded to accurately predict fluid responsiveness (FR) in small study samples. Nevertheless, IVCEE is easy and rapid to measure in most critically ill patients by the frontline intensivist with competence in basic critical care echocardiography (CCE).
Patients and methods: Ancillary study of a multicenter cohort of ventilated ICU patients who were prospectively assessed using CCE for an acute circulatory failure of any origin in 5 ICUs. In each patient, the following parameters were measured—IVCEE in the subcostal longitudinal view of the vessel, left ventricular (LV) stroke volume using the Doppler method before and after a 90°-PLR, and bladder pressure as a surrogate of intra-abdominal pressure (IAP). FR was defined by an increase of LV stroke volume > 10% after 1 min of PLR, when compared to baseline.
Results: Among the 540 patients of the initial cohort, IVCEE was not available in 117 patients (22%) due to a poor subcostal view, and finally 423 patients were included in the present study (median age—65 years [56–76] + 281 men + median SOFA—10 [8–12]), 172 of them exhibiting FR (58%). Acute circulatory failure was related to sepsis in 237 patients (56%) and ICU mortality reached 41%. To predict FR, the optimal IVCEE threshold values were lower than 8 (n = 16 patients), 10 (n = 31) and 13 mm (n = 62) to reach a 95, 90 and 85% specificity, respectively. Conversely, optimal IVCEE threshold values were higher than 28 (n = 17), 27(n = 28) and 25 mm (n = 61) to reach a 95, 90 and 80% specificity in predicting the absence of FR. In multivariable analysis, IVCEE was independently associated with FR and interacted significantly with IAP. A strong and adjusted relationship between IVCEE and FR in the subgroup of patients with an IAP < 12 cm H2O was observed while this relationship was significantly less pronounced in patients with IAP > = 12 cm H2O (Fig. 1).
Conclusion: Measurement of IVCEE is moderately feasible in ventilated patients with acute circulatory failure of various origins and appears as a specific indicator of FR in the presence of markedly low or high values, although many patients are in a large “grey” zone. This static index should be used with caution in patients with elevated IAP.
F-109 Vasopressor cumulative dose requirement and risk of early death during septic shock: an analysis from the EPISS cohort
Dargent Auguste1, Nguyen Maxime1, Fournel Isabelle1, Bourredjem Abderrahmane1, Charles Pierre-Emmanuel1, Quenot Jean-Pierre1
1CHU Dijon, Dijon, France
Correspondence: Dargent Auguste - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-109
Introduction: Septic shock is the primary cause of death in intensive care units, with about 20% of patients dying in the first 3 days in a state of multi-organ failure. To design future trials focused on early mortality, we require knowledge of early indicators that can detect patients at high risk of early death from refractory septic shock. It was recently demonstrated that vasopressor dependency and refractory shock could be predicted by a MAP-phenylephrine dose–response curve. The aim of this study was to assess whether the cumulative dose of vasopressors (CDV) is a predictor of early death (within 72 h) attributable to septic shock (EDASS).
Patients and methods: This substudy of the EPISS trial was based on 370 patients admitted to a French ICU for septic shock between 2009 and 2011. CDV was calculated as the cumulative dose of epinephrine + norepinephrine. EDASS was defined as defined as fulfillment of the following criteria—death within the first 72 h following vasopressor initiation, ongoing vasopressor therapy at time of death, exclusion of a cause of death other than sepsis. The area under the receiving operating characteristic (ROC) curve was calculated for the CDV at 6, 12, 24, 36, and 48 h after vasopressor initiation. A strategy in two steps was designed in order to assess the feasibility of real-time, early detection of EDASS risk with CDV, based on selected times and thresholds.
Results: Among the 370 patients included, 51 (14%) died within the first 72 h with 40 (11%) EDASS. The CDV of patients in the EDASS group was significantly higher (p < 0.0001) at all-time points after the introduction of catecholamines than among those without EDASS, as early as 6 h from catecholamine initiation (Fig. 1). A strategy in two steps (CDV > 800 µg kg at 6 h and or CDV > 2600 µg kg at 24 h) was able to predict EDASS with sensitivity of 45%, specificity 97%, positive predictive value 78% and negative predictive value 94%. Overall, this two-step strategy identified 18 high-risk patients at 6 h, of whom 15 presented EDASS.
Conclusion: Overall, our results confirm that early death directly attributable to septic shock could be effectively predicted by the CDV in the first hours of treatment. These results will help to select patients eligible for innovative therapies aimed at improving early mortality in septic shock.
F-110 CO2 interpretation during cardiopulmonary resuscitation: a bench and clinical study
Savary Dominique1, Drouet Adrien2, Grieco Domenico Luca3, Rigollot Marceau4, Badat Bilal4, Delisle Stephane4, Charbonney Emmanuel5, Ouellet Paul5, Ricard Cecile2, Mancebo Jordi5, Mercat Alain6, Brochard7, Laurent, Richard Jean-Christophe2
1CH Annecy Genevois, Metz-Tessy, France; 2CHU Metz-Tessy, France; 3Université du Sacré coeur, Rome, Italy; 4Air Liquide, Paris, France; 5Université de Montréal, Canada; 6CHU d’Angers, France; 7Hôpital Saint Michael, Toronto, Canada
Correspondence: Savary Dominique - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-110
Introduction: In patients with cardiac arrest, end-tidal CO2 (EtCO2) has been proposed to monitor the efficacy of cardiopulmonary resuscitation (CPR) but uncertainty persists on its interpretation. We hypothesized that exhaled CO2 may also by affected by occurrence of “lung airways” collapse previously noticed during CPR. Because this closure may possibly also limit oxygenation + analysis of the entire exhaled CO2 time waveform—may give information of high clinical value to manage CPR. We report preliminary results from a clinical and bench study aimed at describing the pattern of the capnogram during CPR.
Patients and methods: Clinical study: Capnograms were recorded prospectively during CPR in patients with out-of-hospital cardiac arrest and enrolled in a French registry and later analysed. EtCO2 was recorded at each breath and we calculated a coefficient of transmission (CTCO2) describing the CO2 swings induced by CPR: ratio of the change in exhaled CO2 value induced by compression to the EtCO2 value.
Bench study: A constant CO2 flow, simulating CO2 production, was added in the aveoli in a bench model including a simulation of airway closure. Same methodology was applied in a Thiel cadaver model (ethic committee approval CER-14–201–08–03.17) from the Anatomy Department of a University of Canada. We obtained CO2/time waveforms on the lung model and in cadavers similar to patients’ recordings under different ventilator settings.
Results: The capnograms from 54 patients were analysed age 71[57–79] years, female 13 (24%), survivors after hospital admission 7 (13%). Qualitative assessment exhibited mainly 3 patterns that correlated with CTCO2. CTCO2 was independent from EtCO2 (Fig. 1). In bench and cadaver models, PEEP increase resulted in significant CTCO2 increase.
Discussion: These observations suggest that CO2 pattern during CPR depends not only on circulation but also on the status of airways opening. Examination of the CO2 pattern and measuring CTCO2 could permit to adjust ventilator settings during CPR without impairing circulation.
Conclusion: During CPR, the capnogram provides information reflecting airway patency, and unrelated to EtCO2. This can contribute to assess tidal ventilation generated by chest compressions and diffusion of oxygen to the alveoli.
F-111 Extracorporeal life support for refractory out-of-hospital cardiac arrest: outcome analysis according to a modified institutional protocol
Lavigne Flavie1, Pozzi Matteo2, Armoiry Xavier3, Jacquet Lagreze Matthias3, Schweizer Remi3, Portran Philippe3, Fellahi Jean-Luc3
1Bron, France; 2Hôpital Louis Pradel, Bron, France; 3University of Warwick, ROYAUME UNI
Correspondence: Lavigne Flavie - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-111
Introduction: Refractory out-of-hospital cardiac arrest (OHCA) is a catastrophic condition with a dismal survival under conventional cardiopulmonary resuscitation (CPR). In this setting extracorporeal life support (ECLS) could be suggested as a rescue therapeutic option. However, the results of ECLS for refractory OHCA are disappointing. Moreover, the underlying cardiac rhythm is a matter of debate as previous reports found shockable rhythms as independent predictors of survival. The aim of this report was to analyse the outcomes of ECLS for refractory OHCA in our single-center experience according to the modification of our institutional protocol.
Patients and methods: Patients who received an ECLS for witnessed, refractory, OHCA from January 2010 to December 2016 were included in this analysis. The criteria for ECLS implantation were—(1) no-flow time ≤ 5 min + (2) low-flow time ≤ 75 min (≤ 100 min from January 2010 to July 2012) + (3) end-tidal carbon dioxide (ETCO2) ≥ 10 mmHg. Patients were divided into 2 groups according to the study period and cardiac rhythm at ECLS implantation—(1) Period 1 = from January 2010 to December 2014, shockable and non-shockable rhythms + (2) Period 2 = from January 2015 to December 2016, only shockable rhythms. We excluded from our analysis patients—(1) referred for ECLS support for refractory cardiogenic shock + (2) experiencing severe hypothermia (body temperature < 32 °C) before CPR + (3) with pre-existing, known major comorbidities compromising short-term (< 1 year) life expectancy + (4) aged < 18 years.
Results: Over the 7-year study period, we used ECLS in 81 patients with refractory OHCA. Baseline characteristics, cardiac arrest etiology, no-flow and low-flow duration were comparable between the 2 groups (Table 1). The survival to hospital discharge was not statistically different between the 2 groups (Period 1 = 8.8% [n = 6 patients] vs. Period 2 = 7.7% [n = 1 patient], p = 0.69). In the Period 1 group, all the survivors to hospital discharge (n = 6 patients) presented a shockable rhythm at ECLS implantation.
Conclusion: The introduction of a restrictive protocol based on the underlying cardiac rhythm in the setting of refractory OHCA has dramatically reduced the number of ECLS implantation. Nonetheless, the survival to hospital discharge is still poor even for refractory OHCA with a shockable rhythm. Further investigations are needed in order to best define those patients who could benefit from this potential life-saving procedure.
F-112 Decreased prevalence, but persisting hazard of cardiogenic shock at the acute stage of myocardial infarction: a 20-year perspective
Aissaoui Nadia1, Puymirat Etienne2, Delmas Clément3, Bonello Laurent4, Henry Patrick5, Bonnefoy Eric6, Schiele François7, Ferrieres Jean3, Simon Tabassome8, Danchin Nicolas2
1Hôpital Européen Georges Pompidou, Paris, France; 2Université Paris-Descartes, Paris, France; 3CHU Rangueil, Toulouse, France; 4Hôpital Nord, Marseille, France; 5Hôpital Lariboisière, Paris, France; 6Hôpital cardiologique Louis Pradel, Lyon, France; 7CHU Jean Minjoz, Besancon, France; 8Hôpital Saint Antoine, Paris, France
Correspondence: Aissaoui Nadia - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-112
Introduction: Cardiogenic shock (CS) is one of the most severe complications of acute myocardial infarction (AMI). Little information is available on trends in prevalence, management and outcomes in recent years.
Patients and methods: We used data from the FAST-MI programme, consisting of 5 one-month nationwide French surveys of patients admitted for AMI in intensive care units of cardiology, carried out 5 years apart since 1995, to assess the characteristics of CS. Data on timing of CS were recorded since 2000.
Results: From 1995 to 2015, prevalence of CS consistently decreased from 6.9% in 1995 to 2.8% in 2015. Prevalence decreased both for CS on admission (from 2.7% in 2000 to 1.1% in 2015) and CS developing at a later stage (from 4.4 to 1.7%). In CS patients, baseline demographic characteristics did not change markedly over time (mean age 74 years in 1995, 72 years in 2015 + female sex 44% in 1995, 28% in 2015, p = 0.11). Diabetes mellitus remained unchanged while hypertension increased from 52 to 66% and hypercholesterolemia from 24 to 42%. History of AMI (28 to 15%), stroke (13 to 4%) and heart failure (20 to 6%) decreased over time. In contrast, cardiac arrest increased from 9% in 2005 to 16% in 2015. In parallel, invasive ventilation increased from 16 to 40% and circulatory assist devices from 0.4 to 9%. Use of PCI increased from 20% in 1995 to 74% in 2015, while Coronary Artery Bypass Graft Surgery during the initial hospital stay increased from 2 to 4.8%. Six-month mortality was 73% in 1995, decreased to 62% in 2005 and remained as high as 58% in 2015. At each time point, mortality was lower in patients who underwent PCI + trends in 6-month mortality showed little difference from 1995 to 2015 in patients without PCI (76 to 74%), and only a slight decrease in those undergoing PCI (60 to 53%). Using Cox multivariate analysis both the period (2015 vs 1995 HR 0.65, 95% CI 0.47–0.91) and in-hospital PCI (HR 0.66, 95% CI 0.53–0.81) were independent predictors of death.
Conclusion: Prevalence of CS in AMI patients has notably decreased over the past 20 years. Mortality of CS patients in the most recent period remains high, and the gain in mortality over time is correlated with a greater use of PCI.
F-113 ECLS induces changes in immune cells that may promote nosocomial infection
Frerou Aurelien1, Lesouhaitier Mathieu1, Gregoire Murielle1, Uhel Fabrice1, Gacouin Arnaud1, Maamar Adel1, Le Tulzo Yves1, Flecher Erwan1, Tarte Karin1, Tadie Jean-Marc1
1CHU de Rennes, France
Correspondence: Frerou Aurelien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-113
Introduction: Although major advances in management of Extra Corporeal Life Support (ECLS) patients have been made in the last decade, the short-term mortality remains important. The high incidence of nosocomial infections during ECLS largely contributes to this poor outcome. Cardiopulmonary bypass (CBP) during cardiac surgery induces a systemic inflammatory response associated with an immune dysregulation and a significant pulmonary dysfunction which has been well characterized. Surprisingly, there are only a few data available on immunological changes induced by ECLS. We believe that ECLS leads to immune dysfunction that could expose patients to nosocomial infections.
Patients and methods: A two-phase study was lead. First we analyzed blood cell count with differential (including lymphocyte, neutrophils and monocyte counts) in all patients who received ECLS in our institution from 2014 to 2017 within the first week following ECLS initiation. Secondly, Monocytes, granulocytes, dendritic cells and lymphocytes function were assessed at day 0, day 1 and day 3 using flow cytometry and functional tests in patients receiving ECLS and compared to patients with cardiogenic shock without ECLS.
Results: Among 159 patients with ELCS we found an early and persistent lymphopenia and a late neutrophilia (found to be associated with poor outcome in critically ill patients). Compared to control (n = 7), we found in patients who received ECLS (n = 6) a significant increase in immature granulocytes (104.107 ± 47.106 on day one versus 95.105 ± 96 ± 105, p = 0.01) and lymphocytes apoptosis. ECLS induced changes in Myeloid derived suppressors cells proportion (3.69% ± 3.5 on day three versus 0.58% ± 0.49 before ECLS, p = 0.05), which has been recently associated with a higher incidence of nosocomial infections and seems to be major actors of sepsis-induced immune suppression. Complement component 5a receptor (C5aR) from the neutrophil cell surface, was also decreased after ECLS initiation (ratio of mean fluorescence index 0.73 ± 0.22 on day one, p = 0.03) which is a sign of complement-induced neutrophil dysfunction in septic patients.
Conclusion: ECLS induces quantitative and qualitative leukocytes dysfunctions that can lead to a greater susceptibility to nosocomial infections which contribute to the poor outcome observed in several studies.
F-114 Interest of microbiological documentation in aspiration pneumonia in a cardiac arrest population admitted in an intensive care unit—a retrospective monocentric study
Diehl Jean-Luc1, Vimpere Damien1, Guerot Emmanuel1, Couteau-Chardon Amélie1, Lancelot Aymeric1, Commereuc Morganne1, Aissaoui Nadia1
1Hôpital Européen Georges Pompidou, Paris, France
Correspondence: Diehl Jean-Luc - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-114
Introduction: Aspiration pneumonia is a common complication of cardiac arrest. Although its real incidence remains undetermined, probabilist antibiotherapy is frequently or even systematically prescribed in these cases. We assessed the incidence of out-of-hospital cardiac arrest-related aspiration pneumonia and the impact of a microbiological documentation in regard to antibiotherapy course.
Patients and methods: All patients admitted for out-of-hospital cardiac arrest from 1 1 2014 to 1 8 2017 were studied. In our ICU, aspiration pneumonia is suspected when a clinical syndrome (fever, per resuscitation constatation) and or chest radiography infiltrates were present. In case of suspected aspiration pneumonia, a microbiological documentation was performed before initiation of probabilist treatment with amoxicillin-clavulanate. We retrospectively defined if patients have aspiration pneumonia using the following criteria—per resuscitation constatation, chest radiography infiltrates, fever. The number of microbiological documentation leading to an antibiotherapy modification was recorded as well as pathogens types. Data are expressed as numbers (%) and medians (interquartile range). Statistical analysis was made as appropriate using the XLSTAT software.
Results: 176 patients were studied. Clinical characteristics are displayed in Table 1. 80 (45) received a probabilist antibiotherapy and 79 (45) were retrospectively considered with aspiration pneumonitia. Results of microbiological documentation were 94 (53) positive microbiological sample and 68 (38) with a positive threshold whose 6 (3) were considered colonized (i.e. no clinico-radiological sign). On the entire positive culture sample, 51 (54) were positive with oropharyngeal flora as unique pathogen, 14 (15) with Streptococcus pneumonia, 11 (12) with Haemophilus influenza, 10 (11) with Staphylococcus aureus (no meticilin-resistant) and 3 (3) with Pseudomonas aeruginosa. No anaerobic pathogens were isolated. In 18 cases (20) the documentation lead to a modification of the probabilist antibiotherapy—10 downgrade, 4 upgrade, 3 arrest and 1 introduction. Pathogens associated with modifications are oropharyngeal flora (arrest), Staphyloccus aureus (downgrade) and Pseudomonas aeruginosa (upgrade). Haemophilus influenzae is equally associated with downgrade and upgrade.
Conclusion: Aspiration pneumonia occurs in less than half of patients with out-of-hospital cardiac arrest. Microbiological documentation leads to antibiotherapy modification in almost a quarter of treated patients. These results don’t support systematic undocumented antibiotics prescription.
F-115 Association between augmented renal clearance, pharmacological dosing and clinical outcomes in patients receiving piperacillin-tazobactam administered by continuous infusion
Petit Laurent1, Carrié Cédric1, Sauvage Noemie1, D’Houdain Nicolas1, Cottenceau Vincent1, Lafitte Mélanie1, Legeron Rachel1, Breilh Dominique1, Sztark François1
1CHU BORDEAUX, Bordeaux, France
Correspondence: Petit Laurent - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-115
Introduction: This study aimed to assess whether augmented renal clearance (ARC) impacts negatively on piperacillin-tazobactam pharmacokinetic pharmacodynamics (PK PD) target attainment in critically ill patients receiving 16 g day by continuous infusion.
Patients and methods: Over an 8-month period, all critically ill patients treated by piperacillin-tazobactam for a suspected or documented sepsis without renal impairment were eligible. During the first three days of antimicrobial therapy, every patient underwent 24-hour creatinine clearance (CrCL) measurements and therapeutic drug monitoring at steady state. The main PK PD outcome investigated in this study was the rate of empirical target non-attainment using a theoretical target MIC of 16 mg L−1 for piperacillin and 2 mg L−1 for tazobactam. The secondary clinical outcome was the rate of therapeutic failure in microbiologically documented infections, defined as an impaired clinical response with a need for escalating antibiotics during treatment and or within 15 days after end-of-treatment.
Results: Over the study period, 60 patients were included in the primary pharmacological analysis and 45 in the secondary clinical analysis. Using a MIC of 16 mg L−1 for piperacillin, the rate of empirical target non-attainment in the overall population was 17%, with a strong association with CrCL (Fig. 1). Mean CrCL values ≥ 200 ml min over the three first days of antimicrobial therapy were statistically associated with empirical target non-attainment (OR 9.2 [2.2–38.5], p = 0.001). In microbiologically documented infections, mean CrCL values ≥ 200 ml min over the three first days of antimicrobial therapy were statistically associated with under-exposure < 4.MIC (OR 9.0 [2.0–40.6], p = 0.003). Under-exposure < 4.MIC was significantly associated with therapeutic failure (OR 10.7 [2.1–53.7], p = 0.003).
Conclusion: Empirical administration of piperacillin-tazobactam 16 g day by continuous infusion should be appropriate for most critically ill patients without renal impairment, although patients with very high CrCL ≥ 200 ml min remain at risk of empirical or documented target non-attainment. These data emphasize the need of therapeutic drug monitoring in patients with ARC, especially when targeting less susceptible pathogens or surgical infections with limited penetration of antimicrobial agents.
F-116 Targeting antifungal prophylaxis in liver transplantation: results of a retrospective cohort study
Terzi Nicolas1, Truche Anne-Sophie1, Ruping Florian1, Le Gall Fanny1, Bonadona Agnes1, Hamidfar Rebecca1, Minet Clémence1, Ara Somohano Claire1, Moustapha Ibrahim1, Schwebel Carole1
1CHU Grenoble Alpes, La Tronche, France
Correspondence: Abid Sonia - NTerzi@chu-grenoble.fr
Annals of Intensive Care 2018, 8(Suppl 1):F-116
Introduction: Invasive fungal infections are a major burden in solid organ transplantation, especially in patients receiving liver graft. However, their incidence has decreased thanks to the development of an antifungal prophylaxis in the post-transplantation period. In patients at high risk of invasive fungal infection (IFI), this strategy is recommended, whereas its benefit remains controversial in low-risk patients. However, there is no clear definition of these two patients groups. Our aim was to provide recent data on epidemiology, mortality and IFI risk factors in the early post-operative course in a population without any antifungal prophylaxis.
Patients and methods: This was a retrospective observational single center analysis of all consecutive patients receiving a liver transplantation between January 2010 and August 2016. The primary outcome was the occurrence of an IFI in the 90-day following transplantation. Qualitative variables were described as frequency (percentage) and quantitative variables as mean (standard deviation) when normality hypothesis was satisfied otherwise as median [interquartile range]. A multivariate logistic regression was conducted in order to identify IFI risk factors.
Results: 232 consecutive patients were included, with a median MELD score of 12 [5–21] and SAPS II score of 45 ± 14. Median numbers of transfusion during surgery was 5 units [1–9] and cold ischemia time was 399 min [339–472]. Biliary complications were the most frequent and occurred in 68 patients (29.3%). Seventeen patients (7.3%) developed a proven IFI during the considered period (Fig. 1). Candida spp. was the only pathogen identified. There was no significant difference in mortality between the two groups (1 17 with IFI vs. 2 215 without IFI, p = 0.13), and no death could be imputed to IFI occurrence. Multivariate analysis showed that biliary complications was the only factor associated with a significant higher IFI risk (OR 8.27, 95% CI [2.8–28.1], p = 0.003). The only factor associated with such a complication was transplantation in super urgent conditions.
Conclusion: IFI occur during post-operative course of liver transplantation in low risk patients not receiving antifungal prophylaxis. In a targeted preventive strategy, patients developing biliary complications appear eligible candidates for early post-operative antifungal prophylaxis.
F-117 Early surgery and functional outcomes of critically ill patients with Staphylococcus aureus infective endocarditis
Abid Sonia1, Papin Grégory1, Mourvillier Bruno1, Lebut Jordane1, Smonig Roland1, Magalahes Eric1, Andremont Olivier1, Dupuis Claire1, Juguet William1, Neuville Mathilde1, Mariotte Eric2, Bouadma Lila1, Timsit Jean-François1, Sonneville Romain1
1Hôpital Bichat, Paris, France; 2Hôpital Saint Louis, Paris, France
Correspondence: Abid Sonia - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-117
Introduction: Staphylococcus aureus is the most common cause of infective endocarditis (IE) and is associated with a severe prognosis. Patients frequently require ICU admission because of acute circulatory failure or neurological complications, or the need for emergent valvular surgery. The benefit of early surgery on functional outcomes remains uncertain. We aimed to identify risk factors for poor functional outcomes in critically ill patients with Staphylococcus aureus IE.
Patients and methods: We conducted a retrospective analysis of consecutive patients admitted to the medical ICU with acute left-sided defined Staphylococcus aureus IE according to the DUKE criteria, from January 2007 to December 2016. Factors associated with a poor functional outcome, defined by a score > 3 on the modified Rankin scale (i.e., severe disability or death) at 90 days, were identified by multivariate analysis. The model was built using clinically relevant variables associated with outcome by univariate logistic regression analysis (p < 0.2). Organ failures were defined by a score > 2 on each component of the SOFA score. Data are presented as median (interquartile) or numbers (percentage).
Results: A total of 110 consecutive patients were studied (age—62 [52–70] years, SOFA score—9 [5–13], GCS—15 [13–15]), of whom 78 (71%) patients underwent early valve replacement surgery, 2 [1–5] days after admission. Mechanical ventilation, renal replacement therapy, catecholamines were needed in 56 (51%), 22 (20%), 59 (65%) respectively. At 90 days, 73 (66%) patients had a poor functional outcome (i.e. 60 (55%) deaths and 13 (12%) severe disabilities). The only independent factor positively associated with a poor outcome was renal failure at ICU admission, (Odds ratio (OR) = 5.52, 95% confidence interval (95% CI), 1.56–19.56). By contrast, early surgery, performed within 48 h after admission, had a protective effect (OR 0.08, 95% CI 0.02–0.34) (Table 1). Septic shock, neurological complications and IE characteristics were not independently associated with functional outcome.
Conclusion: Our study suggests that about one-third of patients admitted to the ICU for Staphylococcus aureus IE have good functional outcomes at 90 days. The main factor at admission associated with poor neurological outcome is renal failure. Our study confirms the benefit of early valve replacement surgery on functional outcomes, even in the most severe patients.
F-118 Retrospective study of the neurotoxicity induced by piperacillin and amoxicillin administration in critically ill patients
Grangé Steven1, Lagoutte Jennifer1, Grall Maximillien1, Lebouar Gurvan1, Lagache Laurie1, Lemaitre Caroline1, Surlemont Elisabeth1, Carpentier Dorothée1, Béduneau Gaétan1, Girault Christophe1, Misset Benoit1, LamoureuxFabien1, Tamion Fabienne1
1CHU de Rouen, France
Correspondence: Grangé Steven - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-118
Introduction: Central nervous system toxicity following administration of beta-lactam antibiotics is a potential cause of morbidity and mortality. Ensuring a reliable and safe drug dosing in critically ill patients can be difficult, due to variable and dynamic organ function. Indeed, overexposure to piperacillin and amoxicillin can lead to neurological disorders. Pharmacological therapeutic monitoring (PTM) of beta-lactams ensures the efficacy and safety of the treatment by measuring the residual serum concentration. There are currently no clear guidelines on a threshold for toxic concentrations for all beta-lactams and therapeutic drug monitoring in critically ill patients may be a useful intervention to avoid antibiotic-related toxicities. The aim of this study was to determine the therapeutic concentration values of the beta-lactam antibiotics as well as threshold values associated with toxicity.
Patients and methods: This study was carried out retrospectively during the period 01.01.2015 to 08.02.2017, in patients hospitalized in the medical ICU-CHU Rouen with PTM. The dosages of piperacillin and amoxicillin were performed in the Department of Pharmcology and Toxicology using a high performance liquid chromatography technique coupled with tandem mass spectrometry (HPLC MS).
Results: The number of beta-lactam antibiotics was 119. Of these 119 requests, half were for piperacillin (49.6%), and one-third were for amoxicillin (30.3%). The other dosages were mainly for cloxacillin, cefepime, cefotaxime and ceftriaxone. The results confirmed that serum concentrations of piperacillin (21.6 ± 4.0 vs 98.2 ± 16.8 mg L−1 < 0.0001) and amoxicillin (35.8 ± 13.0 vs 157 ± 72 mg L−1 < 0.0001) significantly were higher in patients with neurological disorders or wakefulness delays. The ROC curves allowed the predictive values associated with the presence of neurological disorders attributable to antibiotic treatment, corresponding to residual serum concentrations of piperacillin of 66 mg L−1 and amoxicillin of 160 mg L−1. A predictive value for neurological disorders of these concentrations is proposed for residual serum concentrations greater than 40 mg L−1 for both antibiotics (80% specificity and sensitivity).
Conclusion: Our results suggest that there is an association between a residual concentration of piperacillin and amoxicillin greater than 40 mg L−1 and the occurrence of neurological disorders. Pharmacological therapeutic monitoring of beta-lactams in critically ill patients may be a useful intervention to optimize the antibiotic regimens and to avoid antibiotic-related toxicities.
F-119 Prognosis of severe infectious endocarditis, impact of preoperative neurological complications and evaluation of surgical tolerance: retrospective multicenter study
Gros Alexandre1, Séguy Benjamin2, Toussaint Aurélia3, Préau Sébastien2, Durocher Alain3, Coupez Elisabeth4, Souweine Bertrand1, Marest Delphine5, Reignier Jean5, Robin Guillaume6, Porte Lydie6, Lavie-BadieYoan6, Galinier Michel6, Coudroy Remi7, Robert René7, Urien Jean-Marie8, Martins Raphaël8, Leclercq Christophe8, Boyer Alexandre2
1CH de la Côte Basque, Bayonne, France; 2CHU de Bordeaux, France; 3CHU de Lille, France; 4CHU Clermont-Ferrand, France; 5CHU de Nantes, France; 6CHU de Toulouse, France; 7CHU de Poitiers, France; 8CHU de Rennes, France
Correspondence: Gros Alexandre - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):F-119
Introduction: Neurological complications during severe infectious endocarditis (IE) interfere with surgeon’s decisions and IE prognosis by the risk of haemorrhagic transformation or increase in cerebral haemorrhage during extracorporeal circulation. The objective is to determine the factors associated with the IE 1 year survival.
Patients and methods: Observational, multicenter, retrospective cohort study performed in 6 French University Hospitals from 2010 to 2016. Severe (SOFA score > = 3) left-sided endocarditis defined by modified Duke criteria in patients admitted in cardiac or medical ICU, complicated by at least one neurological event (MRI or CT-scan diagnosis) were included. Factors associated with the risk of 1 year mortality were assessed by uni and multivariate analysis.
Results: Among the 152 patients, 124 experienced strokes, 57 cerebral haemorrhages, 28 mycotic aneurysms, 22 meningitis. 76 (50%) underwent valvular surgery (13 emergency, 43 urgent, 19 elective, and 1 unknown), with a mortality rate of 39% compared with 74% without surgery (OR 0.23–95CI 0.12–0.46–p < 0.0001). Factors associated with 1 year mortality in univariate analysis were—male gender (OR 2.43–95CI 1.24–4.76—p 0.01), chronic renal insufficiency (OR 3.96–95CI 1.85–8.49—p 0.0003), immunosuppression (OR 4.44–95CI 1.33–14.85–p 0.02), higher Euroscore 2 and SOFA (respectively p 0.02 and p 0.003), lower systolic ejection fraction (p 0.0003) and antibiotics duration (p < 0.0001). Protective factors were oral streptococcal infection (OR 0.17–95CI 0.05–0.57—p 0.0047), mycotic aneurysms (OR 0.42–95CI 0.19–0.97—p 0.04), valvular surgery (OR 0.23–95CI 0.12–0.46—p < 0.0001) and β-lactams-aminoglycosides combination (OR 0.48–95CI 0.24–0.93—p 0.03). In multivariate analysis, 1 year mortality independent factors were chronic renal insufficiency (OR 3.6–95CI 1.1–12.1–p 0.03) and antibiotics duration (p 0.002). In subgroup analysis 87% (41 47) of patients undergoing surgery did not present neurological worsening.
Conclusion: Chronic renal insufficiency and antibiotics duration are the only factors associated with 1 year prognosis of severe IE with neurological complications. Surgery, despite its low complications rate, did not impact their prognosis. A future propensity-matched cohort study will be needed to reduce confusion bias due to influence of neurological complications on surgeon’s decisions.
F-120 Impact of resistant ICU-acquired Gram negative bacilli bloodstream infection on patient prognosis -Analysis of a large French ICU network
Bailly Sebastien1, Murris Juliette2, Lucet Jean-Christophe3, Lepape Alain4, L’Hériteau François5, Aupee Martine6, Bervas Caroline7, Boussat Sandrine8, Berger-Carbonne Anne9, Machut Anaïs4, Savey Anne4, Timist Jean-François3
1CHU, Grenoble, France; 2INSERM IAME, Paris, France; 3CHU BICHAT, Paris, France; 4HCL Lyon, Lyon, France; 5AP HP, Paris, France; 6CHU Rennes, Rennes, France; 7CHU Bordeaux, Bordeaux, France; 8CHU Nancy, Nancy, France; 9Santé Publique, Paris, France
Correspondence: Bailly Sebastien - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):F-120
Introduction: Gram negative bacilli (GNB) bloodstream infection (BSI) is the main source of ICU-acquired bacteremia. The incidence of multidrug resistant GNB (R-GNB) isolates has increased significantly in France from 2005 to 2015. The impact of R strain on the prognosis of GNB-BSI patients has not been assessed.
Patients and methods: Data from a large French national ICU network were explored during a 5-year period (2011–2015). Patients with a GNB-BSI were included and were divided into two groups according to the resistance (R) profile (BSI due to a R isolate or not). The following resistances were considered—all GNB-BSI including Pseudomonas spp., Acinetobacter spp., Stenotrophomonas spp. and Enterobacteriacae (Eb) for which the following antimicrobial resistances were considered—ticarcillin and ceftazidime (cefta) (Pseudomonas (PA)), third generation cephalosporin (3GC) (Eb) and imipenem (all GNB). After variable selection using random forest and univariable mixed logistic regression models, a multivariable analyses using a mixed model with a random effect (center). Sub-group analyses were performed according to species (PA and Eb) and resistance for Eb.
Results: From 189,020 patients admitted in an annual median of 198 French ICUs, 6837 experienced an ICU-acquired (> 48 h.) BSI, 3462 (51%) BSI due to GNB, including 1345 (41%) BSI due to R isolates. PA was identified in 828 (24%) (MDR-PA BSIs 248 (30%)) and Eb in 2933 (86%) (MDR-Eb BSIs (1126 (38%)). The raw mortality rate was 18% in the overall population and 38% in the patient with GNB BSI. It was significantly higher for R GNB BSI (41 vs 36% for susceptible GNB BSI, p < 0.01). After adequate adjustment in a multivariate analysis, we showed that R-GNB BSI was significantly associated with mortality compared to susceptible strains (Fig. 1). By considering species sub-group, the effect was not significant for resistant Pseudomonas aeruginosa (p = 0.54) but remained significant when considering only Eb. Considering Eb resistance, the impact of 3GC R showed a trend to an increased mortality risk whatever there was no effect of IMI R (N = 45 (2%)) on prognosis. Limitation—The absence of information about antibiotic consumption may partly explain the remaining significant center random effect in the final models.
Conclusion: in a large French database, after adequate adjustment on prognostic factors, Resistant BGN-BSI was associated with a higher ICU mortality than susceptible one. The effect was mainly due to Eb 3GC R.
P-01 Polytrauma: incidence and prognostic factors in 120 cases
Ferjani Wassim1, Romdhane Hayfa1, Ben Jdidia Bilel1, Azri Ines1, Saoudi Fedi1, Zaidi Bacem2, Barhoumi Mohamed Hafed2
1CHU Habib Bourhuiba Sfax, Sfax, Tunisia; 2Kairouan, Tunisia
Correspondence: Ferjani Wassim - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-01
Introduction: The polytrauma is by definition a life-threatening wounded in the short term. More than half of the preventable post-traumatic deaths are related to errors in the management strategy, lack of organization, or inexperience in the initial hospital structure. It is a rapidly evolving patient for whom the time factor is one of the pejorative components of its management. The objective of the study is to specify the socio-demographic characteristics of polytrauma patients and to identify the factors predictive of poor prognosis.
Patients and methods: This is a retrospective study of 120 polytrauma patients in the Anesthesia Reanimation department of the Ibn El Jazzar hospital in Kairouan during the year 2016.
Results: The average age of patients was 38 years. The majority of patients are male. In 80%, road accidents are the cause of polytrauma. The main lesions were—lesions of the musculoskeletal system in 92%, thoracic trauma in 90%, head trauma in 89%, maxillofacial trauma in 52.5%, trauma of the pelvis in 31%, abdominal trauma in 30.8% and spinal lesions in 19.1%. Gravity scores averaged 5.92 for RTS, 34 for ISS and 42 for IGSII. Surgical treatment was reported in 80% of patients. These were mainly orthopedic surgery in 47.5% and neurological surgery in 21.7% of cases. The use of intubation and ventilatory assistance was required in 57.5%. A secondary tracheotomy was performed in 16 patients. Mean duration of mechanical ventilation was 15 days. The length of stay in intensive care units was on average 10 days. The use of vasoactive drugs was necessary in 37% of patients. Complications were dominated by trophic disorders in 89% and mechanical complications of ventilation in 33% of cases. The mortality rate was 51.7%. On the balance of the multivariate study, the factors potentially influencing the mortality of polytrauma are + - the presence of severe head trauma (p = 0.001)—inhalation at intake (p = 0.037)—the presence of a state of shock at admission (p = 0.003)—the presence of initial hypoxemia (p = 0.042)—an initial hemoglobin level of less than 10 g (p = 0.036)—ISS score > 40 (p < 0.01) and IGSII > 45 (p = 0.034).
Conclusion: The management of polytrauma can not be improvised. The medical teams must be coordinated in pre-hospitalization. stabilizing this type of patient as quickly as possible, can improve the morbidity and mortality associated with early post-traumatic shock.
P-02 Management of non-vital polytrauma patients in the Emergency Department: a single-center, retrospective study
Le Borgne Pierrick1, Bilger Luc2, Dascalu Elena2, Ugé Sarah2, Renfer Céline2, Kauffmann Philippe2, Quoirin Etienne2, Bilbault Pascal2
1Hôpital de la Hautepierre, Strasbourg, France; 2CHU Strasbourg, Strasbourg, France
Correspondence: Le Borgne Pierrick - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-02
Introduction: Severe trauma remains a major issue worldwide. Management of these patients is mostly performed in ICUs. The radiological evaluation is essentialy based on performing a whole-body computed tomography (WBCT). However, less attention has been paid to the management of non-vital polytrauma patients in the Emergency Departments. The aim of this study was to evaluate the management of non-vital polytrauma patients who had a WBCT in our ED and to find predicting factors of severity at admission.
Patients and methods: Retrospective and monocentric study. We reviewed the chart of all patients who had a WBCT in 2014. We collected epidemiological, clinical and biological parameters and all therapeutic measures during the stay. A long-term survival follow-up was also performed. All patients admitted to the ICU were excluded.
Results: A total of 210 patients were included for statistical analysis and 64% (CI 95% [57.8–70.8]) of them had one or more lesion(s) in the WBCT. The mean ISS score was 10.1 ± 8.8. 42 severely injured patients (20% + CI 95% [14.6–25.4]) underwent urgent surgical procedures or were admitted to the ICU. The mean ISS score for these patients was 16.1 ± 10.8 compared to others 8.5 ± 7.5 in the remaining cohort (p < 0.0001). The mortality rate predicted by the TRISS model was 3.1% compared to 1.5% in the whole cohort (p < 0.0001). The average length of stay in the ED was 5.4 ± 2.9 h for the severely injured trauma patients versus 7.2 ± 4.6 h for the other patients of the study (p = 0.003), the average lenght of stay was 16.2 ± 18.9 days for the severely injured group versus 3.1 ± 6.4 days for the non-severely injured patients (p < 0.0001). In multivariate analysis, heart rate (> 100 min) and Vittel score (≥ 2 criterias) were related to the probability of belonging to the severely injured group (p = 0.03). The 24-hour mortality rate was 0.5% in the ED and the 30-day mortality rate was 1.5%.
Conclusion: The development of a network in the ED hosting non vital polytraumas remains crucial. Its primary goal will be to meet technical and time requirements and establish in-hospital triage algorithms based on clinical variables, in order to detect these patients at an early stage and offer them priority care in our overcrowded EDs.
P-03 Epidemiology and prognosis of isolated cranial trauma caused by traffic accidents in ICU
Turki Olfa1, Chelly Hedi1, Regaieg Kais1, Bahloul Mabrouk1, Braidai Sabrine1, Ben Hmida Chokri1, Bouaziz Mounir1
1CHU Habib Bourguiba, Sfax, Tunisia
Correspondence: Turki Olfa - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-03
Introduction: The trauma of traffic accidents and particularly cranial trauma are, due to their frequency and severe consequences in both the short and long term, a real public health scourge on a global scale. Studies of the epidemiology of cranial trauma by traffic accidents and their prognosis are rare at least in underdeveloped or developing countries. In addition, the impact of extracranial lesions on cranial trauma prognosis has long been discussed. The purposes of our study were to examine the epidemiological aspects and to determine the factors correlated to the immediate and distant prognosis of isolated cranial trauma.
Patients and methods: Retrospective cohort spread over 4 years (from 2009 to 2012) and including 242 patients with isolated Cranial trauma by traffic accidents (mean age 30.9 years, sex ratio—7). We proposed to study the factors correlated with a poor prognosis in terms of death in hospital and Glasgow Outcome Scale (GOS) at 6 months unfavorable in dual analysis (univariate and then multivariate). For the GOS study, patients were divided into 2 groups—GOS favorable for patients with good recovery (GOS = 5), recovery with a light handicap (GOS = 4), GOS unfavorable for those having survived with a severe disability (GOS = 3), a vegetative or pauci-relational state (GOS = 2) and those who died (GOS class 1).
Results: Hospital mortality was 26% and the GOS at 6 months was distributed as follows: death (27.3%), vegetative state (2.9%), severe disability (11.2%), mild disability (28%) and good recovery (30.6%). The 6-month GOS was deemed unfavorable in 41.4% of the cases.
Various after effects were observed in survivors: physical (42%) dominated by headache (24.4%), sleep disorders (14.2%) and epilepsy (7.2%); memory disorders (27.8%) or concentration (16.5%) and finally emotional after effects (32.4%) with irritability (30.7%) and aggressiveness (9.7%).
In multivariate statistical analysis, independent predictors of mortality were arterial hypotension, hypoxia extradural hematoma (EDH),, acute subdural hematomas (SDH), diffuse axonal injury and ventilator associated pneumonia. Those correlated with an unfavorable GOS were an age ≥ 38 years, hypotension, cerebral edema, coma duration ≥ 5.5 days, EDH and H24 glucose ≥ 7.15 mmol/l.
Conclusion: Although the short-term prognosis of head trauma seems to be improved at present, the long-term consequences of cranial trauma remain fairly frequent, and often underestimated, which underlines the importance of their screening and their proper care.
P-04 Prognostic factors in the polytrauma in the emergency Department of CHU Oran
Djebli Houria1, Benbernou Soumia2, Ghomari Nabil1, Azza Abdelkader1, Benterki Zoubir1
1Laboratoire de recherche AVC, Oran, Algeria; 2Boulevard benzerjeb, Oran, Algeria
Correspondence: Djebli Houria - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-04
Introduction: Multiple trauma patients are mainly caused by road accidents (RA), which become the leading cause of death for men under the age of 40 in industrialized countries. This condition is common in Algeria because of the large number of RA. it is in this perspective that we wanted to carry out a study with the aim of knowing the clinical radiological characteristics of polytrauma patients and of knowing the risk factors for the occurrence of death.
Patients and methods: This is a retrospective and descriptive study of the observations of polytrauma patients admitted to the multifunctional intensive care unit of UMC CHU Oran between January 2014 and July 2016. Inclusion criteria: All injured patients presenting at least two lesions, one of which involves the vital prognosis. Exclusion Criteria: Patient with less than one hospitalized lesion in CHUOran Emergency Resuscitation Department. Data were entered, coded and analyzed using the statistical analysis software Epi Info ™ 188.8.131.52 version 27/06/2016 in English. A general description of the population was made (average age, distribution by sex, origin). The EXCEL 2016 was used after exporting data from the Epi Info software, the variable of interest is mortality. p value and Chi2 are calculated, with a significance level of 5%.
Results: Over the study period (31 months), 135 patients were enrolled in our study > 16 years of age, with an age range between 16 and 89 years. The mean age of the patients was 34.07 ± 15.38 years. The average age of the survivors (30.83 ± 13.08 years) was lower than the mean age of the deceased (36.81 ± 16.68). RA was the cause of the trauma in 76% of the cases followed by the fall found cat 17% of the patients. Prehospital care only concerned 4% of patients. The univariate analysis showed that the main factors of occurrence of death were age (p = 0.02), glasgow score (p = 0.0001) anisocoria (p = 0.0009), shock (p = 0.002) 26% of deaths were due to intracranial hypertension, haemorrhagic shock in 15% of patients and ARDS in 7% of polytrauma patients.
Conclusion: The management of polytrauma can not be improvised. The medical teams must be coordinated by an emergency physician in prehospital, a doctor anesthesiologist-resuscitator at the reception. Some systematic gestures such as preparation of the reception allow to optimize the management of the time.
P-05 The prognostic factors of benign cranial trauma
Mayola Vanadiaku Ulrich1, Khaleq Khalid2
1Hôpital Beausejour, Casablanca, Morocco; 2University Hassan II, Casablanca, Morocco
Correspondence: Mayola Vanadiaku Ulrich - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-05
Introduction: Benign cranial trauma is a major public health problem due to both its frequency and the health costs it creates. The aim of this study was to identify relevant clinical factors that could predict the achievement of brain CT and situations at risk for neurosurgical care and for which CT was a necessity.
Patients and methods: This is a 24 month prospective study, including 404 patients with benign traumatic brain injury (Glasgow coma score GCS ≥ 13), patients under 16 years of age and patients with GCS < 13 were excluded. Epidemiological, clinical, paraclinical, therapeutic and evolutionary parameters were studied. A multivariate and univariate statistical study was carried out to reveal the predictive factors of a CT anomaly and the predictive factors for the neurosurgical care. Data were entered and analyzed using SPSS 16.0 and Excel 2007 software.
Results: The average age of patients was 34 years with a predominance of male, and sex ratio of 4.05. The cause of the BTB was mainly represented by the accidents of the public road in 73.27% of the cases. 28.22% of the patients were asymptomatic, the most common symptomatology was dominated by the initial loss of consciousness (52.72%), headache (35.64%). The Glasgow Coma Score was distributed as follows—GCS 15 (54.95%), GCS 14 (35.9%) and 13 (9.15%). 38.9% of patients had clinical signs of trauma to the skulland or face. Brain CT was performed in 88.4% of patients, and 25.5% had abnormal CT. The use of neurosurgical care was of the order of 3.22%. In univariate analysis—the predictive factors for a CT abnormality were the Intoxication during the brain trauma, the GCS < 15, Signs of trauma in the skull face, the vomiting, the Initial loss of consciousness, the Comitial crisis and the predictive factors of neurosurgical care were the GCS < 15, the anisocoria, Headache, the vomiting, the amnesia, the Initial loss of consciousness, the Comitial crisis, the anormal CT, the Extradural hematoma or the Subdural hematomat In multivariate analysis-the predictive factors for a CT abnormality were the GCS < 15, the Initial loss of consciousness and the predictive factors for the use of neurosurgical care were the GCS < 15, Signs of trauma in the skull face, the amnesia, the Comitial crisis, the HSD.
Conclusion: an algorithm must be applied in collaboration between resuscitators and neurosurgeons to improve the quality of benign cranial trauma management.
P-06 Prognostic value of hyperchloremia in patients with traumatic brain injury: a prospective observational study
Taghouti Sarah1, Jendoubi Ali2, Marzouk Mahmoud1, Charradi Nesrine1, Riahi Yosra1, Ghedira Salma1, Houissa Mohamed1
1University Tunis El Manar, Tunis, Tunisie; 2Hôpital Charles Nicolle, Tunis, Tunisie
Correspondence: Taghouti Sarah - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-06
Introduction: Background—Traumatic brain injuries (TBI) are a major public health problem. They are the leading cause of death among those aged less than 40 years. Hyperchloremia is a common electrolyte disturbance in patients with TBI. Hyperchloremia has been associated with increased morbidity and mortality in critically ill patients + however, its prognostic significance in TBI patients is poorly documented. The aim of this study is to describe the prevalence and outcomes of hyperchloremia in patients with TBI admitted to the intensive care unit.
Patients and methods: In a prospective design, we included 43 consecutive patients with TBI (37 males + median age—52 years) admitted to the ICU in Charles Nicolle Hospital of Tunis from Mars to September 2017. Adult patients (aged ≥ 18 years) with isolated TBI or associated with minor extra-cranial injuries (defined as all non-head Abbreviated Injury Scale < 3) were included. Hyperchloremia was defined as a chloride level > 110mEg/l. Clinical and laboratory variables were compared between survivors (n = 36) and non-survivors (n = 7). We assessed the association between hyperchloremia 24-h post-admission and 30-day mortality. p < 0.05 was taken to indicate statistical significance.
Results: The median SOFA score at T0 was 7 points and the median IGS 2 score was 32 points. The median ISS was 25 points. There were 11 cases of mild head injury, 12 moderate head injury and 20 severe head injury. The 30-day mortality was 16%. Hyperchloremia occurred in 15 patients (35%) and the incidence was significantly different between survivors and non-survivors (28 vs. 72%, respectively, p < 0.001). In addition to hyperchloremia (p = 0.018), other laboratory variables were associated with 30-day mortality—hypernatremia (p = 0.011) and hypoalbuminemia (p = 0.024).
Conclusion: Hyperchloremia 24-h post-admission was associated with 30-day mortality in patients with TBI. This index could be useful prognostic marker. Efforts should focus on the prevention of hypernatremia and hyperchloremia in this vulnerable group of critically ill patients.
P-07 Child traumatic brain injury
1Blida Rp, ALGÉRIE
Correspondence: Naili Amine - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-07
Introduction: Brain injury in children is common and mild in most cases, but it remains the leading cause of death and disability in children over 1 year of age worldwide. The peculiarity of the child is that he possesses not mature brain and that the consequences of injuries acquired by traumatic brain injury can lead to the loss of capacities, as well as the non-acquisition of function, but above all the risk impact on learning abilities. The objective of the study is to define the incidence rate of cranial trauma in children as well as the mortality and morbidity of this scourge which presents a major public health problem.
Patients and methods: It is a descriptive retrospective study of a series of 186 children hospitalized in neuro-resuscitation service during the period January 01 to December 31, 2016, including 22 children admitted for cranial trauma. Clinical, para-clinical, etiological and therapeutic data were collected from hospitalization records.
Results: In a series of 186 children hospitalized during the defined period, 22 children were admitted for cranial trauma, i.e. a frequency of 12%. The average age was 6 years [6 h of life-14 years], with a sex ration of 1 Among the 22 children, 12 had severe head trauma, a rate of 55% + whose causes are variable—6 road accidents, 3 domestic accidents, 2 traffic accidents, and 1 obstetric accident, admitted with a pediatric Glasgow score between 5 and 10, and all required mechanical ventilation of the 22 head trauma, 10 were operated for different lesions—3 extra-dural hematomas, 3 cranio-cerebral wounds, 2 sub-dural hematomas, 1 decompressive craniectomy, and 1 embarrure. 02 children had died following severe head trauma, i.e. a mortality rate of 9%, the morbidity rate of head trauma in the Tipaza wilaya was 1.1 100,000 children year, the average length of stay in intensive care units was 22 days, with several complications of decubitus, and functional due to the primary and secondary lesions of the cranial trauma.
Conclusion: The head trauma of the child is a public health problem, its functional prognosis can be dramatic when it is severe, its management must be early and multidisciplinary.
P-08 Factors associated with lung contusions in critically ill trauma children
Turki Olfa1, Chaari Anis1, Bahloul Mabrouk1, Ammar Rania1, Chelly Hedi1, Ben Hmida Chokri1, Bouaziz Mounir1
1CHU Habib Bourguiba, Sfax, Tunisia
Correspondence: Turki Olfa - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-08
Introduction: The aim of the study was to identify factors predicting lung contusion in trauma children.
Patients and methods: Retrospective study conducted for a period of 8 years (January 01, 2005–December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared—those with lung contusions (C + group) and those without lung contusions (C − group).
Results: We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2 + 95% confidence interval [CI], 1.2–8.6 + p = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1 + 95% CI 1.1–1.2 + p = 0.017), hepatic contusion (OR 4.8 + 95% CI 1.3–17.1 + p = 0.017), and pelvic ring fracture (OR, 3.5 + 95% CI 1.1–10.5 + p = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C + group (OR, 2.5 + 95% CI 1.2–5.4 + p = 0.021). However, mortality was not differentbetween the 2 groups after adjusting for PRISM score (OR, 1.2 + 95% CI 0.5–2.9 + p = 0.752) or after adjusting for Injury Severity Score (OR, 0.7 + 95% CI 0.3–2.1 + p = 0.565).
Conclusion: Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patientswith road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture.
P-09 Evaluation of bougie-assisted chest tube insertion technique for the drainage of post-traumatic pleural effusions
Ait Mamar Bouziane1, Bouchiha Nabil2, Lobo David2, Mounier Roman2, Martin Mathieu2, Attias Arié2, Cook Fabrice2, Dhonneur Gilles2
1CHU Henri Mondor - APHP, Créteil, France; 2Créteil, France
Correspondence: Ait Mamar Bouziane - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-09
Introduction: Chest trauma is often associated with pleural effusion (hemothorax and or pneumothorax). Drainage of the pleural space by a chest tube is a common intervention in such situations. Blunt dissection technique with a Kelly clamp is preferred to classical trocar techniques to prevent severe complications, like perforation of thoracic or abdominal organs. Despite these precautions, malposition remains the most common complication of tube thoracostomy. We investigated a new technique of bougie-assisted chest tube insertion to prevent chest tube malposition after chest drainage of post traumatic pleural effusion.
Patients and methods: We performed a controlled before-and-after study to assess the ability of a bougie-assisted chest tube insertion technique, compared to a standard blunt dissection technique, to prevent chest tube malposition. For the bougie-assisted group, we used a disposable Eschmann-style bougie, commonly used to guide the endotracheal tube during difficult intubations. Technique consisted in blunt dissection until the parietal pleura is opened. Thoracostomy tube was preloaded onto the bougie and bougie was advanced alongside the finger, with apical or caudal direction after entering the chest cavity, depending on the type of pleural effusion. Thoracostomy tube was then advanced forward utilizing a Seldinger technique. The primary end point was optimal position of the chest tube. The tube position was blindly assessed on standard chest X-ray. In pneumothorax, optimal position was apical (above the aortic arch), and in hemothorax or mixed-effusion it was basal (2 cm above the diaphragm or lower).
Results: A total of 58 patients were enrolled (bougie-assisted—n = 30 + conventional—n = 28). Chest tubes were optimally position in 29 (96%) in bougie-assisted group and 12 (43%) in conventional group, OR 38.5, IC 95% = [4.6–325.16], p < 0.0001. Efficacy of chest drainage (defined on chest X-ray as the absence of visible pleural line for pneumothorax and as a clear costophrenic angle for hemothorax) was assessed in 29 (96%) in bougie-assisted group and in 15 (53%) in conventional group, OR 25.13, IC 95% = [3.00–210.93], p < 0.001. Average procedure time was 281 s (95% CI 120–360 s) for bougie-assisted group and 558 s (95% CI 318–900 s) for conventional group, p < 0.0001. No severe complication was observed in both groups.
Conclusion: Bougie-assisted chest tube insertion technique prevents chest tube malposition, is safe, effective and shortens procedure time for the post traumatic pleural effusion drainage.
P-10 The Consommation of Antibiotics in plastic surgery
Khaleq Khalid1, Zaouit Maryam2, Derfoufi D1, Zerouali K1, Alharrar R1, Ezzoubi M1
1Centre Hospitaliser Universitaire Ibn Rochd, Casablanca, Morocco
Correspondence: Khaleq Khalid - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-10
Introduction: Infectious complications determine the prognosis of burned patients. However, the emergence of bacterial resistance to antibiotics threatens treatment efficacy, which is due to an inadequate antibiotic consumption inqualitative and quantitative terms. The objective of this study was to describe the profil of consumptionand susceptibility to antibiotics. And, to explore the predictive factors for theemergence of MRB in the service of burns and plastic surgery.
Patients and methods: It is a retrospective study including 122 severe burnedpatients hospitalized for 2 years in the plastic surgery department of theuniversity hospital Ibn Rochd from January 2015 to December 2016. Bacterialecology was described, and the distribution of the seeds by group, by species andby period of time was detailed. The DDD 1000JH (daily defined dosage reportedin 1000 days of hospitalization) was used to assess the consumption of antibiotics. P correlation coefficients were calculated to explore the association betweenconsumption of antibiotics and the emergence of the BMR (Multiresistantbacteria), and identified predictors of this emergence.
Results: On 512 samples taken, 539 bacterial and fungal strains were identified, with a predominance of P. aeruginosa (21.15%), A. baumani i (13%) and S. aureu s (13%), the number of strains increased with the duration of the stay reaching itsmaximum from 28 days in hospital. The ceftazidine (212.7 DDD 1000DH), imipenem (139.7 DDD 1000DH), and amikacin (122.4 DDD 1000DH) were themost used antibiotics during our study, also + the profile of consumption increasedbetween 2015 and 2016.362 BMR were isolated + the EBLSE were at the top (24.5%) follow up of theCRPA (21.8%), followed by the IRPA (20.7%) follow-up of the CRAB (17.1%) then the IRAB (13.5%) and finally the MRSA with a portion of 2.2%. The profile of bacterial resistance has varied significantly for severalantibiotics bacteria pairs.
Conclusion: It remains difficult to show correlations between antibioticconsumption and bacterial resistance. However, these data are particularly usefulin the epidemiological surveillance of bacteria to better guide probabilisticantibiotic therapy.
P-11 Obstetrical critical care in a subsaharan Intensive Care Unit (ICU)
Traoré Salah1, Bako Yves Paul1, Kabré Bamweleguedé Yvette1, Ki Kelan Bertille1, Bougouma Check Tidiane W. H.1, Simporé André1, Kaboré R Armel Flavien1, Sanou Joachim1, Ouédraogo Nazinigouba1
1CHU Yalgado Ouédraogo, Ouagadougou, BURKINA FASO
Correspondence: Traoré Salah - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-11
Introduction: Care delivery in severely ill obstetric patients remains problematic in developing countries, due to many factors such as poverty, sociocultural factors and paucity of research. The aim of this study is to describe the epidemiology, clinics and outcomes of the obstetric patients admitted in the ICU of a subsaharan country.
Patients and methods: It was a descriptive study including all obstetric patients admitted in the ICU during a 5 year period. We assessed their sociodemographic characteristics, clinical features and outcome.
Results: During the study period, among the 1686 patients admitted in the ICU, 174 were obstetric patients, representing 10.3% of the admissions. They were mainly young (mean age 27.7 ± 7.0 years), unschooled (53.3%) and unemployed (82.2%). Most of them were primiparous (29.3%) and had no clinical check during pregnancy (41.4%). A large number (89.8%) was admitted in ICU after delivery, 7% after abortion and 3.2% were still pregnant. Thirty-seven per cent (37%) of them had medical history of disease that can lead to obstetrical complication. The major causes of admission were severe sepsis (28.0%), eclampsia (21.0%) and hemorrhage (10.2%). Mortality was 39.5 and 67.7% of the deaths occurred within 72 h after admission. Infectious diseases were the major cause of mortality (56.5). Mortality rate of the neonates was 40.5%.
Conclusion: Mortality of critically ill obstetric patients admited in the ICU is high in our teaching hospital as in other developping countries and due to septic complications, éclampsia and hemorraege. Some initiatives most be taken to improve quality of obstetric critical care and identification of near miss cases in developping countries.
P-12 Eclampsia in a third level Tunisian hospital: from January 2004 to December 2016
Khedher Mouna1, Ferhi Fehmi1, Nasr Amal1, Nasr Amal1, Gardabou Omarkais1, Helel Najet1, Chaabani Marwa1, Nasr Amal1, Rahma Herch1, Khalil Tarmiz1, Khaled Benjazia1
1Farhat Hached University Teaching Hospital, Sousse, Tunisia
Correspondence: Khedher Mouna - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-12
Introduction: Eclampsia is a rare but serious threat to maternal and fetal well-being. The aim of this study was to assess the incidence of eclampsia and its morbidity and mortality.
Patients and methods: We conducted a retrospective survey in a third level Tunisian university teaching hospital from January 2004 to December 2016. We included all patients with the diagnosis of eclampsia.
Results: In study period 129847 deliveries were registered. 83 women with eclampsia were identified hence the incidence of eclampsia was 6.39 per 10000 deliveries. The median gestational age at the time of eclampsia was 36 weeks. No maternal deaths due to eclampsia were recorded. The delivery mode was caesarean section in 100% of eclamptic patients. The recurrence of eclampsia despite magnesium sulfate prevention was observed in 6% of patients. Severe complications of eclampsia were recorded in 10.8% of patients—4 posterior reversible encephalopathy syndrome, 2 acute pulmonary edema, and 3 HELLP syndrome. 10.8% of new born were preterm. There were 5 stillbirths and 2 neonatal deaths.
Conclusion: The incidence of eclampsia was very high probably due to center effect. It’s essential to raise awareness among mothers in the community regarding early signs and symptoms of preeclampsia eclampsia and to design a better tracking system for antenatal care program.
P-13 Study of maternal mortality in maternity level 3 from 1990 to 2015
Sellami Walid1, Rachdi Mohamed Amine1, Ben Mrad Ines1, Hajjej Zied1, Sammoud Walid1, Bousselmi Radhouene1, Yengui Olfa1, Gharssallah Hedi1, Labbene Iheb1, Ferjani Mustapha1
1Hôpital militaire de Tunis, Tunisia
Correspondence: Sellami Walid - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-13
Introduction: To monitor maternal mortality which is an indicator of the quality of obstetrical care and anesthesia resuscitation, Our country worked to set up several programs targeting maternal and child health. The aim of this work was—To evaluate the maternal mortality rate in our department and its evolution. To Identify the cause of death and classify it depending on whether it is preventable or not. To spot the deficiencies either in the care management or the organization of the care system. To propose ways to improve our care and to fill the failures.
Patients and methods: It was a retrospective study about maternal death, performed at the Department of Gynecology and Obstetrics, over a 25-year period (from 1990 to 2015), that have reported 14 cases of maternal death according to the World Health Organization definition.
Results: The Maternal Mortality Rate (MMR) was 22.43 for every 100,000 live births. The average age of our patients was 32.3 years. The main risk factors for maternal mortality are unfavorable socioeconomic conditions, high-risk pregnancies, multiparity, primiparity and a poor follow-up of the pregnancy. The main causes of maternal death are represented by direct obstetric causes (80%) allocated as follows—postpartum hemorrhage (45%), pregnancy toxemia (14%), acute fat hepatic steatosis (7%), infection (7%) and complications of anesthesia (7%). Indirect obstetric causes were found in 20% of deaths. Death was considered avoidable in 78.58% of cases.
Conclusion: At the end of this work, we were able to pull several recommendations in order to reduce M.M.R. Health education. Facilitate access to care for the parturient, improve care and conditions of childbirth. Continuous training of the medical and paramedical staff.
P-14 Impact of hyperoxemia on the prognosis of patients with septic shock subjected to pre-hospital invasive ventilation
Jouffroy Romain1, Saade Anastasia1, Castres Saint Martin Laure1, Philippe Pascal1, Idialisoa Rado1, Carli Pierre1, Vivien Benoit1
1Hôpital Necker Enfants Malades, Paris, France
Correspondence: Jouffroy Romain - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-14
Introduction: Mechanical ventilation can help improve the prognosis of sepsis. While adequate delivery of oxygen to tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at intensive care unit (ICU) admission affects mortality at day 28 (D28) in patients with septic shock subjected to mechanical out-of-hospital ventilation.
Patients and methods: We performed a monocentric retrospective observational study on 77 patients with septic shock admitted to the ICU. PaO2 was measured at ICU admission in patients subjected to invasive ventilation before any hospital admission. The primary outcome was mortality at day 28 (D28).
Results: Forty-nine (64%) patients with septic shock were mechanically ventilated before any hospital admission and transferred to the ICU. The mean PaO2 at ICU admission was 153 ± 77 and 202 ± 82 mmHg for alive and deceased patients at D28, respectively. PaO2 was significantly associated with mortality at D28 (p = 0.04). Using a ROC curve, the corresponding AUC was 0.70 [0.54–0.85]. For a PaO2 > 150 mmHg, the OR for mortality at D28 was 4.20 [1.25–15.95] (p = 0.02), whereas for a PaO2 < 150 mmHg, the OR was 0.24 [0.06–0.80] (p = 0.02).
Conclusion: In this study, we report a significant association between hyperoxemia at ICU admission and mortality at D28 in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The adjustment of the PaO2 is a crucial prognosis factor in patients with septic shock subjected to invasive out-of-hospital ventilation to avoid the toxic effects of hyperoxemia. However, blood gazometry is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of prehospital invasive ventilation.
P-15 Benefits of control CT-scan 24 h after thrombolysis in acute pulmonary embolism
Jamoussi Amira1, Jarraya Fatma1, Ayed Samia1, Merhebene Takoua1, Hantous Saoussen1, Ben Khelil Jalila1, Besbes Mohamed1
1Hôpital Abderrahmen Mami, Ariana, Tunisia
Correspondence: Jamoussi Amira - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-15
Introduction: Nowadays, benefit of enhanced CT-scan in positive diagnosis of acute pulmonary embolism (PE) is well established. It also allows evaluation of PE’s burden on the right heart and shows several signs of acute cor pulmonale (ACP). Objectives -We aimed to assess benefits of control CT-scan 24 h after thrombolysis in acute PE.
Patients and methods: We retrospectively enrolled patients with confirmed PE whom have been thrombolysed between January 2014 and August 2017 and controled with an enhanced CT-scan 24 h after thrombolysis. Assessement criteria were: Qanadli obstruction index; Signs of ACP—right ventricle diameter left ventricle diameter (RVD LVD) and paradoxical interventricular septum (IVS). Non inclusion criteria were: lack of initial or control CT-scan.
Results: During the study period (3 years and 8 months) we admitted 1790 patients from whom 98 patients had acute PE (5.5%). Very severe patients that were thrombolysed as rescue therapy without initial CT-scan and those who died before control CT-scan were not included. We enrolled 33 patients—high risk mortality PE (n = 10, 30.3%) and intermediate high risk PE (n = 23, 69.7%). Mean age was 60 years and sex-ratio was 1.06. At admission, mean severity scores were 22.1 ± 9.4 for SAPS II and 7.6 ± 4.2 for APACHE II. Evolution criteria are listed in Table 1.
Conclusion: Control CT-scan is highly useful 24 h after thrombolysis. It allows evaluation of response to pharmacological thrombolysis of acute PE and shows significative resolution of arterial obstruction degree and signs of ACP.
P-16 Thromboembolic disease in medical intensive care: evaluation of risk factors, WELLS and GENEVE scores in a Moroccan department
Ezzouine Hanane1, Soussane Mehdi1, Eljadid Siham1, Benslama Abdellatif1
1Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Morocco
Correspondence: Ezzouine Hanane - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-16
Introduction: Venous thromboembolic disease (VTE) is a major cause of morbidity and mortality for patients admitted to ICU. Recognition of risk factors is an essential element of management. the objective of our study is to evaluate the risk factors of MTEV in a Moroccan medical resuscitation department, the WELLS and GENEVE scores and the specificities of our patients.
Patients and methods: We carried out a retrospective study in the medical resuscitation department of the Ibn Rochd hospital in Casablanca, Morocco for 1 year (January to December 2015). All patients admitted to the department were included during the study period and the parameters evaluated and analyzed were the epidemiological, clinical, risk factors for VTE, the WELLS and GENEVE scores.
Results: 354 patients were included in the study. Their mean age was 42.9 years with a male predominance of 53.4%. 29.7% of patients were diabetic and 33.05% of admissions were for neurological disease. APACHE II average was 10.47 and SAPS II mean at 21.77. The average length of hospitalization was 7.64 days. 47.5% required mechanical ventilatory assistance and the duration of intubation was on average 3.71 days. 29.7% vascular prosthesis.81.4% received thromboembolic drug therapy. Low-molecular-weight heparin was used 70.9%. The thromboembolic risk assessment by the WELLS score noted that 70.3% had a low risk 28.5% had an average risk. For the GENEVE score, 1.4% were at high risk and 69.8% were at medium risk. Overall patient outcome was favorable in 62, 7%. 8 patients developed deep venous thrombosis and had an average risk factor of 23.8 l. 3 patients developed pulmonary embolism had an average risk factor of 23.6.
Conclusion: The risk of thromboembolism in a medical resuscitation environment requires an evaluation for each patient admitted. Thromboembolic prevention must be adapted to each level of risk. In our series, the low risk according to the Wells score is predominant as well as the intermediate risk according to the Geneva score. The choice of thrombophylaxis is a major determinant in the management in medical resuscitation.
P-17 Dare to decorate your Intensive Care Units during the Christmas holidays!
Beaudeau Lauren1, Lebut Jordane1, Henry Aline1, Jorge Sabrina1, Podeur Anaelle1, Dijoux Mathilde1, Roig Coralie1, Kaddour Jean Philippe1, Solbiac Sonia1, Partenet Frédérique1, Serrat Françoise1, Nicollet1, Martine, Joffredo Emilie1, Roucaud Nicolas1, Le Meur Matthieu1, Lau Nicolas1, Paulet Rémi1, Thyrault Martial1
1CH2 V - site Longjumeau, Longjumeau, France
Correspondence: Beaudeau Lauren - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-17
Introduction: In December 2016, after cancellation of the budget for a Christmas tree, the nurses and caregivers of the night team spontaneously made and hung Christmas decorations in our Intensive Care Unit to make patients and their families feel better. The context was difficult with controversies around secularity. The town of Paray Le Monial had been forced to remove a Nativity scene and the city of Melun had been criticized for setting one up. So we found it important to assess the perception of the approach by patients and relatives.
Patients and methods: Decorations -Hand-colored patterns about Christmas theme printed on A4 paper Decorations brought by the staff or already possessed by the unit—Christmas balls, garlands, silver starDecorations made with service equipment—Christmas tree consisting of inflated non-sterile gloves, cardboard, figurative Nativity scene without a recognizable figure in a cardboard box with cotton, bed sheet to simulate snow. Evaluation -All visitors and conscious patients received an anonymous single choice questionnaire with numerical scale and free fields from December 15th to December 31st, 2016.
Results: 59 answers were received, including-No negative opinion. 1 neutral answer by a person who had not noticed the decorations. 54 positive or extremely positive opinions. No answer without data. The comments pointed out the originality, the good idea, the warm comforting side. Some asked for more decorations. Others found them sober.
|Opinion||Shocked||Unpleasant||Inappropriate||No opinion||Why not||Good||Great|
|Answers (%)||0||0||0||1 (1.7)||4 (6.8)||25 (42.4)||29 (49.1)||59|
|With (%)||0||0||0||1 (1.9)||4 (7.9)||21 (41.2)||25 (49)||51|
|Without (%)||0||0||0||0||0||4 (50)||4 (50)||8|
Discussion: The results show the good perception of the spontaneous action by the patients and their relatives. There was no negative response, particularly offend persons. However, it is possible that relatives or patients with negative opinions did not dare to express themselves. The initiative demonstrated a good cohesion of the night paramedical team, encouraging the interns and the day teams to take part in the coloring of the decorations. The initiative was initially aimed at the wellbeing of the patients and their relatives. However it has enabled an activity similar to preventing psychosocial risks among the healthcare team, allowing them to adopt a positive attitude in their approach to care. In addition, no significant costs were incurred thanks to the use of cheap materials, mainly recycled cardboard and standard quality white paper.
Conclusion: The spontaneous decoration of our Intensive Care Unit by the night care team was very well received by the patients, their families and their relatives. The initiative also made possible to enhance team cohesion and to value it. The associated costs were negligible.
P-18 Arrhythmias and blood pressure variability during physicians’ night shifts in intensive care unit
Khedher Mouna1, Ferhi Fehmi1, Gardabou Omarkais1, Gharbi Anissa1, Chrigui Noura1, Assidi Bassem1, Bouslama Mohamed Amine1, Khalil Tarmiz1, Khaled Benjazia1
1Farhat Hached University Teaching Hospital, Sousse, Tunisia
Correspondence: Khedher Mouna - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-18
Introduction: Shift work is associated with an increased rate of cardiovascular diseases and accidents. The work organization in intensive care units with fixed daily working hours and additional schedules during the guard when residents is called upon to complete 24 h of continuous work, deserve special attention. The aims of this study is to evaluate the effects of a 24 h intensivist’s night shift on 24 h electrocardiogram (ECG), heart rate variability and blood pressure (BP).
Patients and methods: Forty-five healthy intensivists from 3 Tunisian University Teaching Hospitals were included. Risk factors for cardiovascular disease, lifestyle, incidents, conflicts, stressful situations, sleep deficit, and resynchronization of circadian rhythms during the 24 h of guard were evaluated. Twenty-four hours ECG and BP monitoring were performed after reference electrocardiogram. Participants were instructed to fill out an event diary.
Results: The median age was 29.8 years (range 28–31.0) + the sex ratio was 1.8 1. Twenty-four hours ECG showed a higher rate of ventricular premature beats (VPB) during early morning hours and increased low-frequency normalized units during night shift. The most observed abnormalities were—sinus tachycardia, sinus bradycardia, sinus pause, atrial premature beats, supraventricular tachycardia, and premature ventricular contractions. BP monitoring revealed a greater diastolic BP throughout 24 h as well as during night-time. Systolic BP higher than 125 mmHg during sleep time was observed in 55% of participants. The frequency of arrhythmias and blood pressure variability are correlated with the increase in work stress and conflicts.
Conclusion: Our results highlight the extent incidence of arrhythmia and blood pressure variability during intensive care unit night’s shift probably due to the increased neuroendocrine stress response.
P-19 Acute olanzapine poisoning in the intensive care unit: clinical features and pharmacokinetic data
Bérezel Ouissam1, Chevillard Lucie1, Gourlain Hervé1, Malissin Isabelle1, Deye Nicolas1, Voicu Sebastian1, Megarbane Bruno1
1Hôpital Lariboisière, Paris, France
Correspondence: Bérezel Ouissam - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-19
Introduction: Olanzapine, an atypical 2nd generation antipsychotic drug, is increasingly prescribed due to an improved efficiency to control chronic psychosis with reduced tolerance in comparison to the 1st generation antipsychotic drugs. Whereas side-effects are well-reported, acute poisonings remain less documented.
Patients and methods: We conducted a retrospective single-center descriptive study including all patients admitted in the intensive care unit (ICU) of a University Hospital between 01 2000 and 06 2017 in relation to olanzapine overdose, defined by the onset of compatible features and the increase in plasma olanzapine concentrations. The usual demographic, clinical, toxicological and outcome data were collected. When available, non-compartmental pharmacokinetics was modeled and the different parameters determined using WinNonlin v. 5.1 software.
Results: Seventy-one patients (38 females (54%) 33 males (46%) + age—36 years [27 + 44] (median [percentiles 25 + 75] + 55% with past suicide attempts + 18% of chronic alcoholics) were included. Multidrug ingestion (3 co-ingestants [2 + 4] with mainly psychotropic drugs including benzodiazepines in 69%) included olanzapine (ingested dose—200 mg [110 + 333] and plasma concentration on admission—0.310 mg L−1 [0.185 + 0.820]. Features consisted in consciousness impairment (Glasgow coma score—4 [3 + 8]), myorelaxation (68%), myosis (39%) or mydriasis (10%), abolished (31%) or increased tendon reflexes (28%), QT widening (23%) and QRS enlargement on the ECG (10%). No seizure was observed. Management included mechanical ventilation (91%), catecholamine infusion (18%), gastrointestinal decontamination (10%) and hemodialysis (4%). Three patients (4%) who presented pre-hospital cardiac arrest died in the ICU. Pharmacokinetic analysis suggested prolonged olanzapine elimination at elevated concentrations, attributed to the reduction in liver metabolism and renal clearance.
Conclusion: Olanzapine poisoning may result in ICU admission with life-threatening central nervous depression, cardiac toxicity and fatality risk. Co-ingestions including benzodiazepines may have masked the presence of olanzapine-induced anticholinergic manifestations. Olanzapine elimination in overdose is altered contributing to the clinical severity of poisoned patients.
P-20 Acute amitryptilin and clomipramine poisonings in the intensive care unit—clinical presnetation and pharmakinetic modelling
Meng Hélène1, Chevillard Lucie1, Mihoubi Mohamed El Amine1, Malissin Isabelle1, Nuzzo Alexandre1, Peron Nicolas1, Megarbane Bruno1
1Hôpital Lariboisière, Paris, France
Correspondence: Meng Hélène - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-20
Introduction: Amitriptylin (AMI) and clomipramine (CLO), two tricyclic antidepressants, are responsible for severe poisonings with anticholinergic encephalopathy, seizures and membrane stabilizing effects. Their prescriptions have decreased since 30 years following the marketing of the serotonin reuptake inhibitor (SRI) antidepressants. Our objective was to report a series of AMI and CLO poisonings in the era of SRI supremacy with the description of the clinical manifestations and pharmacokinetic data.
Patients and methods: We conducted a retrospective single-center descriptive study including all AMI- and CLO-poisoned patients admitted in a University Hospital ICU in 2000–2016, evidenced by plasma AMI and CLO concentrations in the toxic ranges. Non-compartmental analysis of AMI and CLO pharmacokinetics was performed using WinNonlin v.5.1 software. Comparisons were performed using Chi-2 and Mann–Whitney tests as required.
Results: Sixty patients (age—49 years [42 + 61] (median [percentiles 25 + 75]) + 68% females 32% males) + 75% with depression) were included. AMI (dose—1.5 g [1.0 + 2.6] + plasma concentration—0.7 mg L−1 [0.4 + 1.4]) was responsible for 3 times more intoxications than CLO (dose—3.0 g [1.6 + 5.6] + plasma concentration—0.7 mg L−1 [0.5 + 1.4] with 72 vs. 28%). The patients presented consciousness impairment (Glasgow coma score—3 [3 + 9]), tonic–clonic seizures (12%), mydriasis (23%), QT lengthening (55%) and QRS enlargement (50%). AMI was responsible for a significantly deeper coma (p < 0.0001) but fewer seizures than CLO (p = 0.02). Three patients (5%) died. Based on a univariate analysis, factors associated with death were cardiac arrest onset (p = 0.003), elevated plasma lactate concentration (p = 0.005), low arterial pH (p = 0.007), reduced PaO2 FiO2 ratio (p = 0.007) and prothrombine ratio (p = 0.008), increased aspartate aminotransferases (p = 0.009), alanine aminotransferases (p = 0.01) and serum creatinine concentration (p = 0.01) as well as marked catecholamine infusion rate (p = 0.02). The pharmacokinetic study showed significant increase in AMI (43 h vs. 24 h) and CLO (55 h vs. 21 h) elimination half-lives in overdose compared to pharmacological conditions, highlighting the contribution of organ failure to the delayed elimination of both toxicants.
Conclusion: AMI and CLO poisonings did not disappear and are still responsible for significant morbidities and mortality. AMI was responsible for deeper coma with fewer seizures in comparison to CLO. AMI and CLO elimination half-lives were significantly prolonged in overdose due to organ failure.
P-21 Investigation of the pharmacodynamic interaction involved in the respiratory depression attributed to diazepam buprenorphine combination
Vodovar Dominique1, Chevillard Lucie1, Pottier Géraldine2, Auvity Sylvain2, Caillé Fabien2, Risède Patricia1, Buvat Irène2, Tournier Nicolas2, Megarbane Bruno4
1HU Henri Mondor, Paris, France; 2Université Paris-Sud, Orsay, France; 4Hôpital Lariboisière, Paris, France
Correspondence: Vodovar Dominique - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-21
Introduction: Severe poisonings and fatalities have been attributed to buprenorphine (BUP) despite its ceiling respiratory effects, mainly if abused in co-ingestion with benzodiazepines. We previously showed that diazepam (DZP) BUP combination induces severe respiratory depression in the rat, while each drug by itself does not. The objective of this study was to investigate the mechanisms involved in this drug–drug interaction using 11C-BUP PET imaging and diaphragmatic electromyography in the Sprague–Dawley rat.
Patients and methods: 11C-BUP was administered intravenously, 30 mg kg unlabeled BUP intraperitoneally and 20 mg kg DZP subcutaneously. PET acquisition started with 11C-BUP PET injection, 15 min after DZP or its vehicle (VEH + N = 5 group) administration. SUV normalized time activity curves (TACs) were generated and 11C-BUP binding potential [BPND, i.e. the ratio of the total receptor density (Bmax) on the equilibrium dissociation constant (KD)] were modeled in different brain regions using a simplified reference tissue model with cerebellum as reference region. dEM, implanted under anesthesia 7 days before the experiment, was recorded during 240 min in rats receiving VEH VEH, DZP VEH, VEH BUP or DZP BUP (N = 6 group). After filtering and half-wave rectification, the first 60 min AUC of diaphragm contraction and workload were determined and compared between the groups.
Results: TACs and 11C-BUP BPND were not different between the DZP BUP and the VEH BUP groups in all studied brain regions. Diaphragm contraction was significantly increased in the VEH BUP group in comparison to the DZP BUP group (p < 0.05). Diaphragm workload was significantly increased in the VEH BUP group in comparison to the DZP VEH and the DZP BUP group (p < 0.05 and p < 0.01 respectively).
Discussion: DZP did not affect the 11C-BUP brain distribution and brain binding suggesting that DZP does not affect BUP transport across the blood brain barrier and BUP receptors density affinity. BUP administration induced an increase in diaphragm contraction and workload. This increase was inhibited in the presence of DZP suggesting that DZP BUP combination-induced respiratory depression is mostly related to DZP.
Conclusion: Respiratory depression related to DZP BUP combination results from a pharmacodynamic drug–drug interaction.
P-22 Is naloxone the best antidote to reverse tramadol-induced neuro-respiratory toxicity in overdose? An experimental investigation in the rat
Lagard Camille1, Malissin Isabelle1, Indja Wassila1, Risède Patricia1, Chevillard Lucie1, Megarbane Bruno1
1Hôpital Lariboisière, Paris, France
Correspondence: Lagard Camille - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-22
Introduction: Since the banning of dextropropoxyphene from the market, overdoses and fatalities attributed to tramadol, a WHO step-2 opioid analgesic, have increased markedly. Tramadol overdose results not only in central nervous system (CNS) depression attributed to its opioid properties but also in seizures, possibly related to non-opioidergic pathways, thus questioning the efficiency of naloxone to reverse tramadol-induced CNS toxicity. Our objective was to investigate the most efficient antidote to reverse tramadol-induced seizures and respiratory depression in overdose.
Patients and methods: Sprague–Dawley rats overdosed with 75 mg kg intraperitoneal (IP) tramadol were randomized into four groups to receive solvent (control group), diazepam (1.77 mg kg IP), naloxone (2 mg kg intravenous bolus followed by 4 mg kg h infusion) and diazepam naloxone combination. Sedation depth, temperature, number of seizures and intensity, whole-body plethysmography parameters and electroencephalography activity were measured. For each parameter, we compared the areas under the curves using Mann–Whitney tests for two-by-two comparisons between the four groups. Regarding the effects of treatments on seizures, comparisons were performed using two-way analysis of variance followed by multiple comparison tests using Bonferroni’s correction.
Results: Naloxone reversed tramadol-induced respiratory depression (p < 0.05) but significantly increased seizures (p < 0.01) and prolonged their occurrence time. Diazepam abolished seizures but significantly deepened rat sedation (p < 0.05) without improving ventilation. Diazepam naloxone combination completely abolished seizures, significantly improved rat ventilation by reducing inspiratory time (p < 0.05) but did not worsen sedation. Based on the EEG study, tramadol-treated rats experienced electro-clinical seizures as soon as 5 min after the injection, characterized by spike-waves and polyspikes with progressive decreased frequencies and inter-critical phases of slow delta waves until the next crisis. After diazepam naloxone injection, EEG waveforms consisted in 8 Hz-alpha rhythms and slow-down theta rhythms of drowsiness. None of these treatments significantly modified rat temperature.
Conclusion: Diazepam naloxone combination is the most efficient antidote to reverse tramadol-induced CNS toxicity. Our experimental data greatly encourage administering this combination rather than naloxone alone as first-line antidote in tramadol-poisoned patients as an alternative to tracheal intubation.
P-23 Acute Rubigine® poisoning in the French Overseas Departments of America: clinical characteristics and prognostic factors
Resiere Dabor1, Florentin Jonathan1, Valentino Ruddy1, Brouste Yanick1, Gueye Papa1, Mehdaoui Hossein1
1CHU de la Martinique, Fort-De-France, France
Correspondence: Resiere Dabor - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-23
Introduction: Rubigine® poisoning is a medical emergency that causes a major public health problem in underdeveloped countries, as it is frequently fatal. This poisoning is rare in France, but frequent in the French overseas departments (DOM). The Rubigine®, made of fluoride and used as a rust remover, is the main source of poisoning in the Caribbean. In Martinique, the exact incidence of this intoxication is unknown, as there is no national and regional register. It could represent up to 8–10% of severe acute poisoning. It was not until April 1994 that, following a prefectural order on the declaration, classification, packaging and labeling of substances, the composition of Rubigine® was modified to significantly reduce the mortality induced by its ingestion. The objective of our study was to describe the clinical features and complications that can occur after ingestion of Rubigine® as well as to determine the prognostic factors of death.
Patients and methods: We conducted a retrospective study over 16 years, from 2000 to 2016, including all patients admitted to emergency and intensive care units of the University Hospital Center (Martinique) for acute Rubigine® poisoning. The usual demographic and clinical data were collected and comparisons between surviving and deceased patients were performed using a univariate analysis.
Results: Fifty-five patients (mean age—43 years (15–82) + sex ratio male female—1,1) were hospitalized at the University Hospital of Martinique. One-quarter of patients had no significant history. The average length of stay was 3.3 days (1–37). Forty percent of patients experienced hypocalcaemia after initial intravenous calcium supplementation. Complications included acute respiratory failure requiring invasive mechanical ventilation (22% of patients, duration of ventilation—2.8 days, (1–16)), renal failure (20%, of which 50% required extra-renal treatment, hemodynamic failure (16%), hepatic failure (15%), coagulation failure (15%), neurological failure (12%) and multi-visceral failure (10.9%). Three patients presented cardiogenic refractory shock requiring VA ECMO (5.5%) and another patient with digestive perforation (1.8%). The mortality was 10.9%, allowing the identification of prognostic factors of death.
Conclusion: Rubigine® poisoning is responsible for significant morbidity and mortality, despite optimal management. However, its incidence seems to have decreased sharply in recent years thanks to the strong mobilization and awareness of the population following the implementation of an information system by the University Hospital ‘s clinical toxicology and toxico-vigilance unit, and different preventive measures introduced by the health authorities.
P-24 Acute insulin overdose with suicidal attempt: management and complications
Khzouri Takoua1, M’Rad Aymen1, Foudhaili Nasreddine1, Mahdhaoui Soumaya1, Bachrouch Maissa1, Fatnassi Meriem1, Barghouth Manel1, Brahmi Nozha1
1Centre Mahmou Yaacoub d’assistance médicale urgente, Tunis, Tunisia
Correspondence: Khzouri Takoua - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-24
Introduction: Acute insulin overdose with suicidal attempt (AIOSA) is rare and understudied. The aim of this work was to provide epidemiolgical, cilnical, biological, therapeutic and pronostic features of this condition.
Patients and methods: We conducted a retrospective study of patients admitted for AIOSA with hypoglycemia in our intensive care unit during the period between January 2012 and December 2016.
Results: Sixty-two patients were included, they were 24 males and 38 females aged of 32 ± 13 years. Fifty percent of patients were diabetics, 30% were long term treated by insulin and 19% had a history of AIOSI. Intermediate-acting insulin (IAI) was found in 54% (n = 33), rapid-acting insulin (RAI) in 28% (n = 17), insulin glargine in 10% and mixed intoxications in 8%. Route of administration was subcutaneous in all cases. Median capillary glycaemia on the first medical contact was 44 mg dl [36 + 71]. The most common signs and symptoms were sweats (33%), dizziness (19%), palpitations (16%), coma (21%), paresthesia (12%) and nausea (12%). The most common electrolyte abnormality was hypokalemia (29%). The amount of insulin was similar in the group IAI (500 UI) and RAI (555 UI). However, there were a difference in term of delay of symptom onset which was of was of 198 ± 98 min in the IAI group versus 80 ± 40 min in the RAI group (p < 0.001), hypoglycemia duration—24 ± 11 h in the IAI group versus 20 ± h in the RAI group (p = 0.447) and finally the mean required dose of carbohydrates—254 ± 140 g in IAI group versus 250 ± 95 g in RAI group (p = 0.908). Outcome was favorable in 95% of cases (n = 49) who discharged hospital in 47 ± 13 h. Two patients kept neurological sequelae because of late management and one patient died.
Conclusion: Insulin intoxication is rare with some unusual presentations. Basis of treatment are carbohydrates administration and blood glucose monitoring. It is a potentially serious condition with low mortality and a risk of electrolyte disorders and severe neurological sequelae. Early care is the main prognosis factor.
P-25 Delayed neuropsychiatric sequelae observed in outpatients victims of carbon monoxide poisoning
Khzouri Takoua1, Foudhaili Nasreddine1, Mahdhaoui Soumaya1, Bachrouch Maissa1, Ben Hamida Samia1, Fatnassi Meriem1, M’Rad Aymen1, Brahmi Nozha1, Essafi Fatma1, Chatbri Bassem1, Mhamdi Ammar1, BahriaWided1, Thabet Hafedh1
1Centre Mahmou Yaacoub d’assistance médicale urgente, Tunis, Tunisie
Correspondence: Khzouri Takoua - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-25
Introduction: Carbon monoxide (CO) poisoning can lead to late neurological sequelae. The prevalence of these sequelae is rarely reported. The present study aims to determine the prevalence of neuropsychiatric sequelae after CO poisoning in outpatients, to analyse their characteristics and to identify the main associated risk factors.
Patients and methods: Carbon monoxide (CO) poisoning can lead to late neurological sequelae. The prevalence of these sequelae is rarely reported. The present study aims to determine the prevalence of neuropsychiatric sequelae after CO poisoning in outpatients, to analyse their characteristics and to identify the main associated risk factors.
Results: Eighty-three patients were included. They were 17 males and 66 females aged of 33 ± 12 years [6–69]. They were healthy in 80% of cases. The mean serum HbCO level on admission was 15 ± 8% (5–40%). Hyperbaric oxygen therapy was required in 12.5% of patients (n = 10). The mean telephone contact delay was 16 ± 9 months (4–36). The prevalence of affected patient was of 26%. The mean onset time of symptoms was 5 ± 3 months (1–10). The main identified disorders were persistent headaches (39%), anxiety-depressive disorders (39%), irritability (22%) and cognitive disorders (22%). No identified risk factors for developing delayed neuropsychiatric sequelae following CO poisoning were found in this study.
Conclusion: Despite the high prevalence of neurological sequelae after CO poisoning, no identified risk factors has been found, particularly hyperbaric oxygen therapy. It is very important to inform patients about the risk of late sequelae and to prompt them to consult as soon as the first signs appear.
P-26 Mechanisms of tramadol-induced seizures in overdose in the rat
Vodovar Dominique1, Lagard Camille1, Chevillard Lucie1, Jacques Callebert1, Liang Hao1, Risède Patricia1, Tournier Nicolas1, Megarbane Bruno1
1Université Paris-Diderot, Paris, France
Correspondence: Vodovar Dominique - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-26
Introduction: Since dextropropoxyphene withdrawal from the market, overdoses and fatalities attributed to tramadol, a WHO step-2 opioid analgesic drug, have increased markedly. Besides central nervous system depression, tramadol overdose may result in seizures, usually included in the related serotonin syndrome. However, the serotoninergic mechanism of tramadol-induced seizures has been recently questioned. We investigated the effects of various specific pretreatments on tramadol-induced seizure onset and alterations in brain monoamines in the rat.
Patients and methods: Sprague–Dawley rats were randomized into five groups (N = 6 group) to be pretreated with various agonists antagonists before receiving 75 mg kg tramadol intraperitoneally—1.77 mg kg IP diazepam + 2 mg kg IV bolus followed by 4 mg kg h infusion naloxone + 10 mg kg IP cyproheptadine, and 15 mg kg IP fexofenadine. Seizure severity was graded according to the modified Racine Score (1). We measured neurotransmitter concentrations in the frontal cortex using high performance liquid chromatography coupled to flurorimetry or radioenzymatic assay, as required. We used positron emission tomography-computed tomography to investigate Interactions of tramadol with GABA-A receptors. The effects of treatments on seizures were compared using two-way analysis of variance followed by multiple comparison tests with Bonferroni’s correction. The Areas under the curves of the effects on monoamine concentrations and the binding potentials in the PET-imaging study were compared two-by-two using Mann–Whitney U tests.
Results: Diazepam abolished tramadol-induced seizures, by contrast to naloxone, cyproheptadine and fexofenadine pretreatments. Interestingly, despite seizure abolishment, diazepam significantly enhanced tramadol-induced increase in the brain serotonin (p < 0.01), histamine (p < 0.01), dopamine (p < 0.05) and norepinephrine (p < 0.05) while no significant modifications were observed with the other tested pretreatments. Based on Positron emission tomography imaging using 11C-flumazenil fixation in the rat brain, we demonstrated molecular interaction between tramadol and γ-aminobutyric acid (GABA)-A receptors not related to a competitive mechanism between tramadol and flumazenil on the benzodiazepine binding site. Our findings clearly ruled out the involvement of serotoninergic, opioidergic, histaminergic, dopaminergic and norepinephrinergic pathways in tramadol-induced seizures while strongly suggested tramadol-induced specific allosteric change in GABAA receptors that could contribute to seizures onset in overdose.
Racine RJ. Modification of seizure activity by electrical stimulation. Electroencephalogr Clin Neurophysiol 1972 + 32–269–299.
Conclusion: Tramadol-induced seizures in overdose are mainly related to the GABAergic pathway.
P-27 Clinical and biological aspects of Heparin-induced thrombocytopenia in intensive care unit
Sellami Walid1, Dhaouadi Imen2, Hajjej Zied2, Ben Mrad Ines2, Yengui Olfa2, Sammoud Walid2, Bousselmi Radhouene2, Gharssallah Hedi2, Labbene Iheb2, Ferjani Mustapha2
1Montefleury, Tunis, Tunisia; 2Hôpital Militaire, Tunis, Tunisia
Correspondence: Sellami Walid - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-27
Introduction: Heparin-Induced Thrombocytopenia (HIT) is a serious iatrogenic complication of heparinic treatments. The diagnosis of HIT is difficult in the resuscitation environment because thrombocytopenia is a frequent and multifactorial phenomenon. The aim of this work was to study the clinical and biological presentation of patients with HIT and the consequences attributable to HIT on the evolution of patients in terms of morbidity and mortality and to develop a diagnostic strategy for HIT for resuscitation patients.
Patients and methods: This was a retrospective, monocentric, descriptive and evaluative study conducted in our intensive care unit (ICU) over a period of 4 years 6 months. An anti-PF4 antibody test was performed in patients who developed thrombocytopenia or a 30% drop in their initial platelet kinetics and the clinical picture.
Results: The incidence of HIT was 1.71% in patients hospitalized in ICU. The clinicobiological severity scores, the reasons for admission to resuscitation were similar in both groups (HIT+ and HIT−) as well as the characteristics of the heparins used. The time of occurrence of thrombocytopenia was similar in the two groups. The diagnosis of HIT was more often the only plausible diagnosis in the HIT+ group. The 4T’s score was significantly higher in the HIT+ group. The evolution of the platelet count was similar in the two groups, in the decay phases as well as in the recuperation phase. HIT+ patients showed significantly more thrombosis than HIT− patients. There was no significant difference between the transfusion needs of HIT+ and HIT− patients. Mortality was identical in both groups, as was the length of stay in ICU.
Conclusion: HIT is a rare disease. There was no evidence of a predisposing factor for the occurrence of the disease in a uniform resuscitation population. The diagnosis of HIT is based on a cluster of arguments and not on an isolated event. Biological tools are indispensable, in a complementary way to the clinical picture.
P-28 Pulmonary embolism in patients with sickle cell disease in intensive care unit: a challenging diagnosis
Jamoussi Amira1, Zayet Souheil1, Merhebene Takoua1, Ayed Samia1, Ben Khelil Jalila1, Besbes Mohamed1
1Hôpital Abderrahmen Mami, Ariana, Tunisia
Correspondence: Jamoussi Amira - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-28
Introduction: Pulmonary embolism (PE)’s occurence within sickle cell disease (SCD) is already reported and may be due to intrinsic hypercoagulability. However, PE’s diagnosis can be difficult because of clinical similarities with acute chest syndrome. In addition, SCD is a systemic disease that could be associated to chronic or acute pulmonary hypertension with unknown pathophysiology. Aim—To describe the clinical manifestations, diagnosis, ultrasound parameters, and management of PE in patients with SCD in intensive care unit.
Patients and methods: We conducted a retrospective and descriptive study, including SCD patients hospitalized in medical ICU of Abderrahmen Mami Hospital, diagnosed with PE during 11 years and 3 months period from January 2006 to March 2017.
Results: During the study period, a total of 26 patients with SCD were admitted. Among them, 20 presented with respiratory distress and chest pain and then benefited first of trans-thoracic echocardiography that often showed right ventricle dilation and systolic PAP > 30 mmHg (n = 11). All the 20 patients underwent enhanced CT-scan and the diagnosis of PE was finally retained in 6 cases (18.8%) and hence colliged.
The average age was 32.5 years ± 9.4 [20–42 years] with a sex-ratio = 1. The mean of APACH II score was 7. SCD were diagnosed at the age of 8.2 years ± 6.2 [3–15 years] with a regular follow up in 83%. The reason for admission was acute respiratory failure in all cases. Patients had clinical symptoms of pneumonia: pleuritic chest pain (n = 6), dyspnea (n = 5) and fever (n = 2). All patients had a chest X-ray showing an alveolo-interstitial syndrome in 4 cases (66.6%) and an associated pneumonia in 2 cases (3.33%). At enhanced CT-scan, PE was unilateral in all cases with an average Kanadly obstruction index of 27.9% [12.5–42%]. Echocardiographic findings are illustrated in Table 1. PE’s mortality risk was low or intermediate low so there was no need for thrombolysis in all cases. Heparin at curative dose was prescribed in all cases with a relay by oral anticoagulant. Mean ICU stay was 6 days [3–11 days]. A favorable outcome was achieved in all cases.
Conclusion: PE occurrence is considerable within SCD. PE’s diagnosis is challenging in ICU among SCD patients presenting clinical and echocardiographic signs that could mimic acute chest syndrome. Enhanced CT-scan is often necessary to confirm or to exclude PE.
P-29 Acute pulmonary hypertension during acute chest syndrome in adult patients with sickle cell disease: Is there a hypercoagulability state?
Voiriot Guillaume1, Jutant Etienne-Marie1, Gerotziafas Grigorios1, Labbe Vincent1, Mokrani Hayat1, Fartoukh Muriel1
1Hôpital Tenon, Paris, France
Correspondence: Voiriot Guillaume - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-29
Introduction: Acute chest syndrome (ACS) is the most severe complication of sickle cell disease and its evolution is unpredictable. Acute pulmonary hypertension (PH) in ACS is associated with an increased mortality, but its mechanism remains poorly known. Our hypothesis is that acute PH is associated with a biological state of hypercoagulability in ACS.
Patients and methods: In a prospective single center study, all consecutive SCD patients with ACS admitted to the intensive care unit (ICU) of Tenon hospital were included. Specialized haemostasis dosages were performed on ICU admission. A trans-thoracic echocardiogram was also performed on admission, and was repeated at steady state.
Results: Among 29 patients with ACS, 22 had a trans-thoracic echocardiogram and 6 had a high echocardiographic probability of acute PH, including 1 patient with bilateral pulmonary embolism and 1 patient who developed multiple organ failure and died. There were no significant clinical, biological or radiological differences between patients with a low-intermediate probability of acute PH and those with a high probability of acute PH+ their evolution was similar. The exploration of haemostasis did not show between-group differences, regarding each parameter of haemostasis. However, when using a hierarchical cluster analysis, distinct profiles of coagulation were evidenced, defining 3 biological classes. The subset of patients with a high echocardiographic probability of acute PH was more frequent in biological classes 2 and 3 which corresponded to hypercoagulability states. Acute PH was transient in patients (n = 17) with a repeated echocardiography at steady state.
Conclusion: Acute PH may likely occur in patients with ACS and a biological condition of hypercoagulability. Further studies are needed to confirm these findings.
P-30 Prognostic role of modified Glasgow prognostic score in lung cancer patients admitted in intensive care
Gorham Julie1, Ameye Lieveke1, Paesmans Marianne1, Berghmans Thierry1, Sculier Jean-Paul1, Meert Anne-Pascale1
Institut Jules Bordet, Bruxelles, Belgium
Correspondence: Gorham Julie - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-30
Introduction: The prognostic and predictive roles of the modified Glasgow Prognostic Score (mGPS), based on serum C-reactive protein and albumin levels, have been shown in patients with operable and inoperable cancers. Its value for hospitalization and death during hospitalization in a population of patients with lung cancer (LC) consulting at the emergency department has also been demonstrated previously. The aim of our retrospective study was to evaluate the prognostic role of mGPS in LC patients admitted to intensive care unit (ICU).
Patients and methods: We performed a retrospective study in a cancer hospital between September 1st 2008 and December 31st 2013. We included all patients with LC admitted into the ICU for a medical or surgical complication and for whom the data (CRP and albumin levels) used to calculate the mGPS were available.
Results: CRP and albumin values were available to calculate the mGPS in 148 patients with LC admitted in the ICU. The majority of patients were younger than 70 years (72.3%), were male (63.5%) and had non-small cell lung cancer (NSCLC) (79.1%). Cardiovascular (33.1%), respiratory (26.4%) and neurological complications (17.6%) were the three main causes of admissions. Hospital mortality was 26.4%. SAPS 2 score (OR 1.07 + 95% CI 1.03–1.11 + p < 0.001) and respiratory distress (OR 3.46 + 95% CI 1.41–8.51 + p 0.007) were the 2 independent predictors of hospital mortality. Presence of metastases (HR 2.25 + 95% CI 1.37–3.69 + p = 0.001) and mGPS (HR 1.30 + 95% CI 1.01–1.68 + p = 0.04) were the two independent predictors of survival after hospital discharge.
Conclusion: In lung cancer patients admitted into the ICU, the mGPS is an independent predictor of survival after hospital discharge but not for mortality during ICU stay. This inflammatory score could therefore be used as a long-term prognostic marker in this population of patients and would be more reflective of cancer, than reflecting the acute complication leading to ICU admission. Prospective and multicentric studies must be carried out to validate these results.
P-31 Interest of FVIIa factor in postpartum haemorrhage: about 14 cases
Ferjani Wassim1, Ben Jdidia Bilel1, Saoudi Fedi2, Haddad Hayfa2, Azri Ines2, Romdhane Hayfa2, Zaidi Bacem2, Barhoumi Mohamed Hafed3
1CHU Habib Bourhuiba sfax, Sfax, Tunisie; 2Monastir, Tunisie; 3Kairouan, Tunisie
Correspondence: Ferjani Wassim - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-31
Introduction: Recombinant active factor VII is a pro-hemostatic treatment used in obstetric haemorrhage, but no study has made it possible to specify its exact place in the decision algorithm. The objective of our work is to evaluate the efficacy and the benefit risk ratio of recombinant factor VIIa in the treatment of severe postpartum hemorrhage.
Patients and methods: We conducted a prospective study at the IBN JAZZAR University Hospital in Kairouan during the period from January 1, 2015to December 31, 2016. In total, we collected 15 cases of recombinant factor VIIa in one postpartum haemorrhage.
Results: The mean age of our patients was 31 + 5.96 years. The rate of childbirth was 33.33%. The caesarean was the mode of delivery chosen for 10 patients. The causes of postpartum haemorrhage in our series were—uterine atony in 5 cases, uterine rupture and cervico-uterine tear 3 cases each, retroplacental hematoma and placenta accreta 1 cases for each two and placenta prævia in 2 cases. Our patients were treated in an intensive care unit and the average hospital stay was 4.1 days. Sulprostone was reported in 7 cases (46.6%), and all patients received a massive transfusion. The average time to administer rFVIIa was 6 h 40 min. The mean dose of factor VIla recombinant was 78.8 ± 9.24 μg kg. Five patients received a single dose, 8 patients received a second injection and 2 patients received 3 doses. Clinical efficacy—After a single injection, clinical efficacy with reduction in bleeding was observed in 8 patients, i.e. 60%. The most frequent complication was insufficiencyrenal in 7 cases including 2 requiring hemodialysis, CIVD in 4 cases, OAP in 2 cases, a multivisceral failure in 2 cases, a septic shock in 1 case and a mesenteric infarction in 1 case. The progression was favorable in 12 patients, while 3 patients died (21.9%).
|Before||After||% of reduction|
Conclusion: It is important that new studies be carried out and shared experiences around the world on this drug appear to be effective and prevent invasive actions in the therapeutic arsenal of postpartum heamorrhage.
P-32 Early administration of tranexamic acid and fibrinogen concentrate reduces mortality in postpartum hemorrhage
Khedher Mouna1, Ferhi Fehmi1, Gardabou Omar Kais1, Nasr Amal1, Chrigui Noura1, Bouslema Med Amine1, Tarmiz Khalil1, Ben Jazia Khaled1
1Research unit on maternal morbidity and mortality UR17SP08, Sousse, Tunisia
Correspondence: Khedher Mouna - firstname.lastname@example.org
Annals of Intensive Care 2018, 8(Suppl 1):P-32
Introduction: Post-partum haemorrhage (PPH) is a life-threatening complication and remains a leading cause of maternal morbidity worldwide. The WOMAN trial* estabished that early administration of Tranexamic Acid (TA) reduces mortality due to the bleeding in women with PPH. Our study purpose was to determine the effects of early administration of TA and fibrinogen concentrate on death, hysterectomy and transfusion in women with severe PPH.
Patients and methods: This retrospective, monocentric study was performed in a third level Tunisian hospital providing healthcare for more than 10000 pregnant women per year. Were included in this study women with diagnosis of severe post partum haemorrhage after a vaginal or caesarean delivery from 2014 to 2016. Patients who received TA and fibrinogen concentrate were assessed in group 1(G1) and who not in group 2(G2).
Results: The incidence of severe PPH was 35/10000 deliveries. 166 women were retained for data analysis G1 (n = 109), G2 (n = 57). Anthropomorphic and obstetrics characteristics were not significantly different between the two groups. There was a significant difference between the two groups regarding to transfused units of red blood cells however, no difference in term of the use of frozen plasma and platelets concentrates was observed. Perioperative hemoglobin nadir was significantly higher in G 1. The frequency of hysterectomy and pelvic packing were higher in G2 (Table 1). No thromboembolic events and no haemorrhage related mortality were observed in the two groups.
Conclusion: In this retrospective study, early administration of tranexamic acid and fibrinogen reduces risk of hysterectomy transfusion. These encouraging results strongly support the need for a large, international, double-blind study to investigate the potential of the association “TA—Fibrinogen concentrate” to reduce maternal haemorrhage related morbidity and mortality.
P-33 Outcome of hematologic patients with respiratory failure in a pediatric intensive care unit
Vanel Noemie1, Ughetto Fabrice1, Michel Fabrice1, Barlogis Vincent1, Picon Julie1
1Hôpital de La Timone Marseille, Marseille, France
Correspondence: Vanel Noemie - Noemie.VANEL@ap-hm.fr
Annals of Intensive Care 2018, 8(Suppl 1):P-33
Introduction: Immunodeficiency, acquired or congenital, is the first comorbidity associated with poor outcome in pediatric patients with acute respiratory distress syndrome 1(ARDS). The aim of this study was to describe outcome of pediatric patient with hematologic disease hospitalized in our intensive care unit for respiratory failure and to investigate the clinical variables associated with mortality.
Patients and methods: It was a retrospective monocentric descriptive study including all immunodeficient pediatric patient (malignant hemopathy, congenital immunodeficiency, bone marrow transplantation…) from hematology hospitalized in our 14 beds pediatric intensive care unit with the diagnosis of respiratory failure between January 2003 and February 2017.
Results: Fifty one patients were included corresponding to 53 admissions. Nighty percent of the patients met criteria for pediatric ARDS—67% were severe, 15% moderate and 2% mild. Extracorporeal circulation (ECC) was needed for 7 patients. Global mortality rate at PICU discharge was 47%. Twenty four patients (45%) received noninvasive ventilation (NIV). Height of them (33%) did not need invasive mechanical ventilation (IMV). In patients who received IMV, mortality rate was significantly higher if patients received before NIV (81 vs. 41%) p = 0.001. All patients who needed IMV after more than 24 h of NIV died (n = 3). Mortality was higher in children with griffon versus host disease (80 vs. 40% p = 0.04). Mortality of patients receiving ECC and renal replacement therapy (RTT) was respectively 71 and 80%.
Conclusion: In our study, most of the patients hospitalized for respiratory failure met criteria for pediatric ARDS. If NIV decrease IMV requirement, it could be associated with higher mortality rate in case of failure. This result support recent recommendation2 that immunodeficiency is not a sufficient criteria to delayed IMV.
P-34 Influence of different non-invasive respiratory support devices on tidal volume (Vt): a bench study
Maraffi Tommaso1, Haudebourg Anne-Fleur1, Razazi Keyvan1, De Prost Nicolas1, Mekontso Dessap Armand1, Carteaux Guillaume1
1Hôpital Henri Mondor, Créteil, France
Correspondence: Maraffi Tommaso - email@example.com
Annals of Intensive Care 2018, 8(Suppl 1):P-34
Introduction: Multiple devices are available for non-invasive respiratory support—mask noninvasive ventilation (M-NIV), helmet NIV (H-NIV), high flow nasal cannula (HFNC) and continuous positive airway pressure (CPAP). There are conflicting data about their respective effects during acute respiratory failure. Vt is a key determinant of both efficacy and safety during ventilatory support. We assess whether Vt is influenced by noninvasive ventilatory device.
Patients and methods: Six setups were tested using the RespiSim® Manikin connected to an ASL 5000® breathing simulator—no device + oxygen mask at 15 L min flow + HFNC at 60 L min + CPAP at 10 cm H2O+ M-NIV and H-NIV both with a PEEP of 5 cm H2O and a pressure support of 10 cm H2O. Three different respiratory mechanics were simulated—normal (compliance—60 ml cm H2O, resistance—5 cm H2O L sec), obstructive (compliance—60 ml cm H2O, resistance—20 cm H2O L sec) and restrictive (compliance—30 ml cm H2O and resistance—5 cm H2O L sec) + each mechanics was tested at three simulated efforts—low (inspiratory muscle pressure (Pmus)—5 cm H2O), moderate (inspiratory Pmus—10 cm H2O), and respiratory distress (inspiratory Pmus—20 cm H2O, expiratory Pmus—10 cm H2O). Flow and airway pressure were recorded at the ASL inlet and mouth pressure into the manikin mouth. We defined “device driving pressure” as the peak mouth pressure minus the tele-expiratory mouth pressure. Continuous data are reported as mean ± SD.
Results: As compared to the oxygen mask, Vt increased significantly with M-NIV and H-NIV whatever the simulated respiratory effort (599 ± 201 and 537 ± 217 vs. 307 ± 121 ml respectively with the moderate simulated effort, p &l