Oral communications
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 - nicolas.epaillard@aphp.fr
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 - gpiton@chu-besancon.fr
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 - guerpillonbrice@gmail.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 - bmisset@wanadoo.fr
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 - olivier.pouly@hotmail.fr
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 - sara-benammi@hotmail.fr
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
Pottier Véronique1
1Hôpital de la Côte de Nacre, Caen, France
Correspondence: Pottier Véronique - veroniquepottier@icloud.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 - t.charuel@yahoo.fr
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 - sbailly@chu-grenoble.fr
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 - philippegoutorbe@me.com
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 - aude.gibelin@gmail.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 - laudangers@gmail.com
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 - augyjeanloup@hotmail.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 - lila.bouadma@bch.aphp.fr
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 - annefleur.haudebourg@gmail.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 - wulfran.bougouin@gmail.com
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 - leloup.mx@gmail.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 - romainronfle@hotmail.fr
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 - jeremie.joffre@aphp.fr
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 - alex.beurton@gmail.com
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 - al.nuzzo@gmail.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 - audreyjacquo@hotmail.com
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 - blevy@sfr.fr
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 - guillaume.geri@aphp.fr
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 - charles-edouard.luyt@aphp.fr
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 - drsellamiwalid@yahoo.fr
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 - nicolas.themelin@ulb.ac.be
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 - lionel.kerhuel@aphp.fr
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 - am.fourmont@gmail.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 - sebastien.besset@aphp.fr
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 - laurent.petit@chu-bordeaux.fr
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 - damien.droux@gmail.com
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 - cyriltouchard@hotmail.fr
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.
Reference
-
1.
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 - nicovgdb9@orange.fr
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 - matthieuschmidt@yahoo.fr
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 - ph.morimont@chu.ulg.ac.be
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 - romain.persichini@hotmail.fr
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 - claude.guerin@chu-lyon.fr
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 - sami.hraiech@ap-hm.fr
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 - jllitjos@gmail.com
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 -geoffroyhariri@hotmail.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 - christelle.maenhout@gmail.com
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 - ilaria.alice.crippa@gmail.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 - sivanthiny.sivanandamoorthy@aphp.fr
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 - thomas.daix@wanadoo.fr
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 - david_grimaldi2001@yahoo.fr
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 - c-milesi@chu-montpellier.fr
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 - blevy@sfr.fr
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-66 WITHDRAWN
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 - etienne.javouhey@chu-lyon.fr
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 - mortam@hotmail.fr
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 - bg.khalil@gmail.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 - nicolas.nardi@hotmail.fr
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 - anaischosidow@gmail.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 - naikebige@gmail.com
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 - aithamou-zakaria@hotmail.fr
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 - garnier.fanny26@gmail.com
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 - stanislas.faguer@gmail.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 - stephanegaudry@gmail.com
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 - benghanem.sarah89@gmail.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 - nicholas.heming@aphp.fr
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 - claire.roger@chu-nimes.fr
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 - dumas.guillaume1@hotmail.fr
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 - juliette.chommeloux@gmail.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-93 WITHDRAWN
CO-94 WITHDRAWN
CO-95 WITHDRAWN
CO-96 WITHDRAWN
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 - simon_bourcier@hotmail.com
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 - adrien.joseph@hotmail.fr
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 - adrien.benhamou@hotmail.fr
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 - amina.khaldi@erasme.ulb.ac.be
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 - simon_bourcier@hotmail.com
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 - pierrick_med@yahoo.fr
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 - alexandre.elabbadi@gmail.com
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 - ariane.roujansky@gmail.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 - flexmiailhe@hotmail.com
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 - pierre.jaquet@yahoo.fr
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.