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Proceedings of Reanimation 2022, the French Intensive Care Society International Congress

Acknowledgements

This abstract report was edited and corrected by the members of the Congress Committee of the French Intensive Care Society

Laetitia BODET-CONTENTIN1, Emmanuel CANET2, Guillaume CARTEAUX3, Jean-Pierre FRAT4, Guillaume GERI5, Olfa HAMZAOUI6, Julie HELMS7, Mathieu JOZWIAK8, Saad NSEIR9, Mehdi OUALHA10, Frédéric PÈNE11, Nicolas WEISS12

1CHU de Tours, Tours, France; 2CHU de Nantes, Nantes, France; 3Hôpital Henri Mondor, Assistance-Publique des Hôpitaux de Paris (AP-HP), Créteil, France; 4CHU de Poitiers, Poitiers, France; 5Clinique Ambroise Paré, Neuilly s/Seine, France; 6Hôpital Antoine Béclère, AP-HP Université Paris-Saclay, Clamart, France; 7CHU de Strasbourg, Strasbourg,France; 8CHU de Nice, Nice, France; 9CHU de Lille, Lille, France; 10Hôpital Necker-Enfants Malades, AP-HP, Paris, France; 11Hôpital Cochin, AP-HP. Centre, Université Paris Cité, Paris, France; 12Sorbonne Université, Groupe Hospitalier AP-HP.Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France

Oral communications

CO-01 Platelet transfusion efficacy in intensive care unit: a prospective multicenter observational

REIZINE Florian1, LE MAREC Sarah2, LE MEUR Anthony3, CONSIGNY Maëlys2, BERTEAU Florian1, GESLAIN Marie2, LE NIGER Catherine2, HUNTZINGER Julien5, SEGUIN Philippe1, THIBERT Jean-Baptiste6, REIGNIER Jean3, EGRETEAU Pierre-Yves4, TADIÉ Jean-Marc1, HUET Olivier1, ASFAR Pierre7, EHRMANN Stephan8, AUBRON Cécile2

1CHU de Rennes, Rennes, France; 2CHU de Brest, Brest, France; 3CHU de Nantes, Nantes, France; 4CH de Morlaix, Morlaix, France; 5CH de Vannes, Vannes, France; 6Etablissement français du sang Bretagne, Rennes, France; 7CHU d’Angers, Angers, France; 8CHU de Tours, Tours, France
Correspondence: Florian REIZINE (florian.reizine@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-01

Rationale: Up to 15% of critically ill patients receive platelets in intensive care units (ICU) (1). Both preventive and therapeutic platelet transfusions (PT) are not fully supported by high levels of evidence and the benefits of platelet transfusion remain subject to debates in some settings. This study aims to describe the efficacy of PT in ICU, and its impact on patients’ outcomes.

Patients and methods/Materials and methods: From June 2018 to November 2019, we conducted a prospective multicenter observational study recruiting patients that received at least one PT in one of the 9 participating ICUs. Inefficacy of preventive PT was defined as a Corrected Count Increment (CCI, that adjusts for the transfused platelet dose and the body weight) < 7 at 18 to 24 h after PT. Factors associated with transfusion inefficacy were assessed by performing an univariate analysis and in a mixed effect model.

Results: Of the 310 included patients, 119 patients (38.4%) received curative PT while 191 patients (61.6%) were treated preventively. Of the 975 transfusion episodes, 765 were given in prevention of bleeding because of low platelet count and 210 in treatment of active bleeding. PT efficacy according to the CCI was assessed in 679 preventive transfusion. Inefficacy criteria were met in 297 episodes (43.7%). Demographic and baseline characteristics associated with preventive PT inefficacy in the univariate analysis were younger age (57.7 years [Interquartile range (IQR) 44.5–66.6] versus 62.5 [53.1–69.5]; p = 0.01); immunosuppression (69.9% versus 51.8%; p = 0.025) and lower haemoglobin (8.5 g/dL [7.4–10] versus 9.7 g/dL [7.8–11.5]; p = 0.0028). Among clinical features, PT inefficacy was associated with higher heart pulse (106 [92–120] versus 99 [86–114]; p < 0.0001) and higher temperature prior to PT (37.2 [36.5–37.9] versus 37 [36.4–37.6]; p = 0.016), both possible surrogate of sepsis. Interestingly, ABO compatibility did not affect PT efficacy. The mixed effect model identified haemoglobin (Estimate (E): 1.83 [Confidence Interval 95% (CI) 0.56–3.11]; p = 0.0051), heart pulse before transfusion (Estimate: − 0.17 [− 0.3 to − 0.03]; p = 0.016), curative anticoagulation (E: 14.1 [4.36; 23.77]; p = 0.008), chronic kidney injury (E: 20.12 [0.86; 39.37]; p = 0.008) and mean age of platelet transfused (E: − 3.21 [− 5.61; − 0.81]; p = 0.009) being independently associated with the CCI.

Conclusion: Almost half of preventive PT in ICU do not meet efficacy criteria based on the CCI. Further research is warranted to investigate whether changes in the identified independent risk factors for PT inefficacy improve patients’ outcomes.

Reference 1: Arnold DM, Crowther MA, Cook RJ, et al. (2006) Utilization of platelet transfusions in the intensive care unit: indications, transfusion triggers, and platelet count responses. Transfusion 46:1286–1291. https://doi.org/10.1111/j.1537-2995.2006.00892.x

Compliance with ethics regulations: Yes in clinical research.

CO-02 Platelet transfusion in ICU: are we applying guidelines?

LE MAREC Sarah1, REIZINE Florian2, LE MEUR Anthony3, CONSIGNY Maëlys1, BODENES Laetitia1, BERTEAU Florian4, GESLAIN Marie1, LE NIGER Catherine1, HUNTZINGER Julien5, SEGUIN Philippe2, THIBERT Jean-Baptiste6, REIGNIER Jean3, EGRETEAU Pierre-Yves4, TADIÉ Jean-Marc2, HUET Olivier1, ASFAR Pierre7, EHRMANN Stephan8, AUBRON Cécile1

1CHU de Brest, Brest, France; 2CHU de Rennes, Rennes, France; 3CHU de Nantes, Nantes, France; 4CH de Morlaix, Morlaix, France; 5CH de Vannes, Vannes, France; 6Etablissement français du sang Bretagne, Rennes, France; 7CHU d’Angers, Angers, France; 8CHU de Tours, Tours, France
Correspondence: Florian REIZINE (florian.reizine@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-02

Rationale: National and international guidelines for platelet transfusion in ICU are mostly based on studies conducted in non-critically ill patients or on low level of evidence leading to the potential risk of non-conformity to those recommendations. We study the conformity to both, French guidelines performed by High Health Authority (HHA) and American guidelines by the American Association of Blood Banks (AABB).

Patients and methods/Materials and methods: This is a prospective multicenter observational study conducted in 9 French ICU over a 18-month period. Indications and conformity of platelet transfusion (PT) to national and international guidelines were analyzed by two independent investigators and by a third one in case of disagreement between those 2 investigators. Parameters associated with PT conformity and the impact of non-conformity to 28-day mortality were identified.

Results: Of the 975 platelet transfusion episodes given to 310 patients, 210 (21.5%) were transfused to treat major bleeding, 407 (41.7%) to prevent bleeding because of low platelet count, 192 (19.8%) before an invasive procedure or surgery and 166 (17%) in treatments for minor bleeding. Among them, 80% (IC 95% 77–82) were conform to the French HHA guidelines, and 62% (IC 95% 59–65) to the AABB. The factors independently associated with non-conformity to the French guidelines were preventive PT in patients with low platelet count (OR 5.28; IC 95% 3.66–7.63, p < 0.0001), and ongoing curative anticoagulation (OR 2.21; IC 95% 1.30–3.77, p = 0.0034). There was no difference in mortality between patients receiving conform and non-conform PT.

Conclusion: Around 20% and 40% of PT were non-conform to the national and the international guidelines, respectively. Independent risk factors for non-conformity were preventive PT for low platelet count, and ongoing curative anticoagulation. Our results highlight the need for further research to better define PT indications in ICU.

Compliance with ethics regulations: Yes in clinical research.

CO-03 Prognostic factors of renal function in critically ill patients with hemolytic and uremic syndrome: a 6-year retrospective multicenter study

QUELVEN Quentin1, COIRIER Valentin1, DELAMAIRE Flora1, MARIOTTE Eric2, FILLATRE Pierre4, DELBOVE Agathe3, GUILLOT Pauline1, GACOUIN Arnaud1, TADIÉ Jean-Marc1, CAMUS Christophe1, MAAMAR Adel1

1CHU Rennes, Pontchaillou, Rennes, France; 2Hopital Saint Louis, Paris, France; 3CH Bretagne Atlantique, Vannes, France; 4CH Yves Le Foll, Saint Brieuc, France
Correspondence: Quentin QUELVEN (quentinquelven@hotmail.fr)

Annals of Intensive Care 2022, 12(1):CO-03

Rationale: Hemolytic and uremic syndrome (HUS) is a field of heterogeneous pathologies whose diagnostic and therapeutic management remain difficult. We aimed to describe clinical and biological features of critically ill patients admitted to intensive care unit (ICU) for HUS and assess the impact of common therapeutics on renal function.

Patients and methods/Materials and methods: We performed a 6-year retrospective multicenter study from 2014 to 2019 of patients admitted for a proven HUS in four French ICU. HUS was defined by the presence of anemia with arguments in favor of a hemolytic origin and non-autoimmune origin, associated with thrombocytopenia, or with histologic evidence of thrombotic microangiopathy. Clinical features, biological features and therapeutics initiated during the ICU stay were retrospectively collected. Glomerular filtration rate (GFR) was assessed by the Chronic Kidney Disease Epidemiology Collaboration at day-30, 90 and 180. We also assessed 30-day mortality. A repeated-measures analysis of variance was employed to assess the changes in GFR with the use of plasma exchange, Eculizumab and extra renal replacement therapy (RRT) during the ICU stay.

Results: We included 103 patients (median age 54 [32–65], males 48 (47%)). Twenty-seven (26%) had STEC-HUS, 13 (13%) aHUS and 59 (57%) secondary HUS. Among these patients, 71 (69%) received plasma exchange, 18 (18%) received eculizumab and 46 (45%) received renal replacement therapy (RRT) during their ICU stay. Ninety-two (89%) survived in ICU and 78 (86%) were alive at day 30. At day-180, 13 (12.6%) still required RRT. Renal function at six months was not significantly different between the patients who received plasma exchange (69 [41–91] versus 43 [23–50] mL/mn/1.73 m2, p = 0.17), Eculizumab (55 [50–73] versus 69 [31–91] mL/min/1.73 m2, p = 0.57) or RRT (49 [31–69] versus 69 [36–91] mL/mn/1.73 m2, p = 0.40). Moreover, ICU and hospital lengths of stay were significantly longer for patients who received plasma exchange and they had a longer duration of RRT. Finally, multivariate analysis shows that RRT in ICU is a prognosis factor independently associated with RRT at day-180.

Conclusion: Plasma exchange, eculizumab and RRT were not associated with an improvement of day-180 renal function in our multicenter study. Further studies are still needed to define the best therapeutic management of these patients.

Reference 1: Pène F, Vigneau C, Auburtin M, Moreau D, Zahar J-R, Coste J, et al. Outcome of severe adult thrombotic microangiopathies in the intensive care unit. Intensive Care Med. janv 2005;31(1):71-8

Compliance with ethics regulations: Yes in clinical research.

figure a

CO-04 Epidemiology, clinical presentation, evolution and prognostic factors for survival of patients with eosinophilia in intensive care: retrospective national multicenter cohort study "REO"

GAILLET Antoine7, BAY Pierre2, PÉJU Edwige8, FAGUER Steven4, ASMA Mabrouki10, AZOULAY Elie10, PÈNE Frédéric8, TANDJAOUI-LAMBIOTTE Yacine11, COHEN Yves11, GERI Guillaume12, VIEILLARD-BARON Antoine12, PINETON DE CHAMBRUN Marc2, BENCHABANE Nacim5, LARCHER Romaric5, GRANGE Steven9, QUENOT Jean-Pierre14, AIT OUFELLA Hafid13, TIMSIT Jean-Francois3, MEKONTSO DESSAP Armand7, KAHN Jean-Emmanuel12, DARGENT Auguste6, HERAULT Antoine9, GROH Matthieu1

1Foch, Suresnes, France; 2Pitié Salpêtrière, Paris, France; 3Bichat, Paris, France; 4Rangueil, Toulouse, France; 5Lapeyronie, Montpellier, France; 6Edouard Herriot, Lyon, France; 7Henri Mondor, Créteil, France; 8Cochin, Paris, France; 9CHU Rouen, Rouen, France; 10Saint Louis, Paris, France; 11Avicenne, Bobigny, France; 12Ambroise Paré, Boulogne-Billancourt, France; 13Saint Antoine, Paris, France; 14François Mitterrand, Dijon, France
Correspondence: Antoine GAILLET (gaillet.antoine75@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-04

Rationale: The objectives of the “REO” study are to describe the epidemiological characteristics of situations associated with eosinophilia in intensive care units (ICU) and to identify predictors of mortality in this situation.

Patients and methods/Materials and methods: Retrospective, national, multicenter cohort (14 centers), including adult patients (≥ 18 years old) who presented, from 01/01/2013 to 12/31/2018, eosinophilia ≥ 1000/mm3 on two samples (not necessarily consecutive) performed from the day before admission to the end of the stay in ICU.

Results: 620 patients were included (i.e. approximately 1.2% of all stays over the period and participating centers): 248 (40%) with early eosinophilia (occurring within the first 24 h of admission, ICU-Eo1 group) and 348 (56%) with delayed eosinophilia (> 24 h after admission, ICU-Eo2 group), 24 patients with no reported time to onset of eosinophilia. In the ICU-Eo1 group, eosinophilia was mostly non-idiopathic (with a high incidence of onco-haematological pathologies: 26% vs. 4% in the ICU-Eo2 group, p < 0.001), most often symptomatic (59% vs 25% for ICU-Eo2, p < 0.001), especially with respiratory involvement. Eosinophilia in patients in the ICU-Eo2 group was most often idiopathic or related to drug hypersensitivity (85% vs. 47% in patients in the ICU-Eo1 group, p < 0.001), and visceral skin involvement was at first plan (72% of visceral damage in ICU-Eo2 vs. 32% in the ICU-Eo1 group). Nevertheless, in 14% of ICU-Eo2 patients, an “unexpected” etiology (particularly parasitic, onco-haematological) was identified, especially when the patient had a prior history of eosinophilic disease, was admitted for acute respiratory distress or had an eosinophilia peak > 5000/mm3 during ICU stay. The risk factors for mortality at day 60 highlighted in multivariate analysis for the ICU-Eo1 group were age > 65 years (HR 1.78 95% CI [1.02; 3.13] p = 0.044), current immunosuppressant therapy at ICU admission (HR 2.32 95% CI [1.18; 4.54] p = 0.014), SOFA score > 8 (HR 2.26 95% CI [1.17; 4.39] p = 0.015), admission for acute respiratory distress (HR 2.43 IC95% [1.06; 5.60] p = 0.037) or for shock (HR 3.08 95% CI [1.15; 8.29] p = 0.026) and finally that the current eosinophilia is of onco-haematological origin (HR 4.41 [2.47; 7.90] p < 0.001). About the ICU-Eo2 group, only the use of invasive ventilation during the stay was associated with poor prognosis (HR 5.54 [1.32; 23.35] p = 0.019).

Conclusion: In ICU, two distinct populations of eosinophilia seem to be defined according to the time of onset of this one. When eosinophilia is present on admission, the onco-haematological origin particularly affects the prognosis.

Compliance with ethics regulations: Yes in clinical research.

CO-05 Etoposide-containing regimens for the treatment of critically ill patients with hematological malignancy-related hemophagocytic lymphohistiocytosis

LE STANG Valentine1, VIGNERON Clara2, DECROOCQ Justine2, PÉJU Edwige2, BURRONI Barbara2, CHAPUIS Nicolas2, CHARPENTIER Julien2, PÈNE Frédéric2

1La Pitié Salpétrière, Paris, France; 2Hôpital Cochin, Paris, France
Correspondence: Valentine LE STANG (vavaw_100@hotmail.fr)

Annals of Intensive Care 2022, 12(1):CO-05

Rationale: Hemophagocytic lymphohistiocytosis (HLH) related to hematological malignancies is a rare condition likely responsible for life-threatening multiple organ failure. Etoposide is often used as a first-line treatment in this setting but its impact on the course of HLH-defining criteria and organ failures has not been investigated.

Patients and methods/Materials and methods: We conducted an 8-year (2013–2020) single-center retrospective study in a medical ICU of a tertiary-care center, including adult patients with severe hematological malignancy-related HLH treated with etoposide.

Results: Twenty-four patients were analyzed, including 17 with lymphoma. Median H-score was 253.0 [226.3–287.0] and 16 patients fulfilled at least five HLH-2004 diagnostic criteria. All patients received first-line etoposide treatment, combined with corticosteroids in 21 patients, followed by combination chemotherapy in 16 patients after a median of 4 days [1.5–7.0]. Following etoposide initiation, body temperature decreased from 38.9 °C [38.0–39.5] to 37.6 °C [36.8–39.0] within 24 h (p = 0.01) (Fig. 1) and ferritin levels decreased by 59.8 ± 28.9% within 7 days. Lactate level decreased from 3.0 mmol/L [1.5–4.3] to 2.1 mmol/L [1.6–3.0] (p = 0.02) within 24 h from etoposide (Fig. 1). Patients exhibited early and transient deterioration in non-platelet SOFA score (npSOFA) that significantly increased from 5 [1.3–10] at etoposide initiation to 9.5 [2–15] at day 1, and thereafter improved to npSOFA value of 7 [1–11] at day 2 (Fig. 1). In-ICU, in-hospital and 1-year mortality were 45.8%, 54.2% and 66.7%, respectively.

Conclusion: Etoposide as single treatment or as part of sequential combination regimen was able to rapidly dampen some dynamic HLH-defining variables and to eventually improve organ failures.

Compliance with ethics regulations: Yes in clinical research.

CO-06 Clinical significance of thrombocytopenia in patients with septic shock

PÉJU Edwige1, FOUQUÉ Gaëlle1, CHARPENTIER Julien1, VIGNERON Clara1, JOZWIAK Mathieu2, MIRA Jean-Paul 1, CARIOU Alain1, JAMME Matthieu3, PÈNE Frédéric1

1APHP/Hôpital Cochin, Paris, France; 2CHU de Nice/Hôpital l'Archet, Nice, France; 3Hôpital CHI Poissy/Saint-Germain-en-Laye, Paris, France
Correspondence: Edwige PÉJU (edwigepeju@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-06

Rationale: Thrombocytopenia is a common disorder in critically ill patients and is known to be associated with poor prognosis. Whether thrombocytopenia accounts for a bystander of severity or may drive specific complications is unclear. With respect to the various immune and procoagulant functions of platelets, the aim of this study is to address the impact of thrombocytopenia on the development of ICU-acquired infections, bleeding and ischemic events in high-risk patients with septic shock.

Patients and methods/Materials and methods: This was a single-center retrospective study conducted in a medical ICU over a 12-year period (2008–2019). Patients admitted for septic shock (Sepsis-2 definition) were included if still alive in the ICU after 48 h, to retain patients at risk of further ICU-acquired complications. Morning platelet counts were collected daily. Groups of patients were defined according to 7-day platelet count trajectories estimated using latent class mixed model. Outcomes were ICU mortality and ICU-acquired complications including infections, severe bleeding events (WHO grade 3–4) and thrombotic events.

Results: The cohort comprised 1024 48-h survivors. Among them, 39% were immunocompromised, including one third with hematological malignancies. Upon admission, 153 patients (15%) had profound thrombocytopenia with platelet count below 50 G/L. The in-ICU mortality rate was 27% (n = 281). ICU-acquired infections, severe bleeding events and thrombotic events occurred in 28%, 13% and 12% of patients, respectively. The latent class model identified five subgroups with consistent 7-day platelet count trajectories. The subgroup of patients with initial low and sustained thrombocytopenia (n = 224) was associated with high prevalence (39%) of hematologic malignancies and displayed increased mortality when compared to patients with alternative platelet trajectories (49% vs. 13%, 21%, 30%, 24%, p < 0.001). In multivariate analysis, initial low and sustained thrombocytopenia (cause-specific hazard (CSH) = 2.96 [95% CI 2.16–4.06], p < 0.001) and initial normal with fast decrease in platelet count (CSH = 2.21 [1.19–4.12], p = 0.01) were independently associated with mortality. Sustained profound thrombocytopenia was independently associated with increased risk of bleeding (CSH = 1.57 [1.02–2.65], p = 0.004). Platelet count trajectories were not significantly associated with the development of ICU-acquired infections and thrombotic events.

Conclusion: Patterns of thrombocytopenia are associated with outcomes in septic shock. Sustained profound thrombocytopenia and fast relative thrombocytopenia were both independent determinants of ICU mortality. Sustained profound thrombocytopenia was associated with an increased risk of severe bleeding. Platelet count trajectories did not impact on the risk of ICU-acquired infections or thrombotic events.

Compliance with ethics regulations: Yes in clinical research.

CO-07 Reliability of peak inspiratory pressure to estimate plateau pressure in infants with severe virus airway infection

ROTAVA BURATTI Cecília1,2,3, JOUVET Philippe3, ANDREOLIO Cinara1,2, BRUNO Francisco1,2, ANDRADE Lívia2, MARCON Mônica1, NAVARRO Nádia1,2, PIVA Jefferson1,2

1Hospital de Clínicas de Porto Alegre, Porto Alegre, Bresil; 2Postgraduate program in child and adolescent health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; 3Sainte Justine Research Center, Montreal, Canada
Correspondence: Rotava Buratti CECÍLIA (ceciliaburatti@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-07

Rationale: Peak inspiratory pressure (PIP) measured in decelerating-flow mode (PIPdc), i.e. pressure modes, is close to plateau pressure (Pplat) in children with pediatric acute respiratory distress syndrome1. Since one third of children admitted to the PICU are less than 1 year old and that bronchiolitis is the leading cause of hospitalization in this age group2, our aim was to evaluate the reliability of PIPdc to estimate Pplat in volume control (VC) in infants with severe respiratory virus infection (SRVI), which is characterized by increased airway resistance.

Patients and methods/Materials and methods: A retrospective observational study was developed including infants diagnosed as SRVI, mechanically ventilated, and with respiratory mechanics measurements taken between 2017 and 2021. Measurements were taken during inspiratory and expiratory pauses after switching ventilatory mode from pressure control to volume control in patients without respiratory effort. Statistical analysis included paired t-test, Pearson correlation (r) and coefficient of determination (R2).

Results: Thirty-seven patients were included with a median age of 3 months (2–5), a Pediatric Index of Mortality-2 of 0.2% (0.2–0.6) and a mean oxygen saturation index of 4.3 ± 1. Inspiratory (RIaw) and expiratory airway resistance (REaw) were 136 ± 43 and 168 ± 66 cmH2O/L/s, respectively, and static compliance: 0.75 ± 0.30 ml/kg/cmH2O. PIPdc was lower than PIP in VC, but still higher than measured Pplat (33 ± 3, 36 ± 5 and 26 ± 5 cmH2O respectively, p = 0.01 between PIP and Pplat). PIPdc overestimates Pplat with a moderate correlation (r = 0.57, p < 0.001 and R2 = 0.33, p < 0.001) and a mean difference of 7.3 ± 4 cmH2O (Figure).

Conclusion: A large difference between PIP and Pplat can be observed in infants with a significant increase in airway resistance. In the absence of Pplat measurement in a static condition, any estimation of Pplat from PIP needs to consider the resistive component of respiratory system.

Reference 1: Patel B et al.: Agreement Between Peak Inspiratory Pressure in Decelerating-Flow Ventilation and Plateau Pressure in Square-Flow Ventilation in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2022.

Reference 2: Fujiogi M et al.: Trends in bronchiolitis hospitalizations in the United States: 2000–2016. Pediatrics 2019.

Compliance with ethics regulations: Yes in clinical research.

figure b

Difference between positive inspiratory pressure in decelerating-flow modes (PIPdc) and plateau pressure (Pplat) in volume control according to time constant, in mechanically ventilated children.

Figure Legend: Difference between positive inspiratory pressure in decelerating-flow modes (PIPdc) and plateau pressure (Pplat) in volume control according to time constant, in mechanically ventilated children. Panel A: cohort of Patel et al.1, patients with pediatric acute respiratory distress syndrome n = 52, median age 8.6 yo. And from our sample it has been shown Panel B, C and D. Panel B: patients with severe respiratory virus infection (SRVI) n = 9, median age 4 mo, RIaw 50–100 cmH2O/L/s; Panel C: patients with SRVI n = 13, median age 3 mo, RIaw 100–150 cmH2O/L/s; Panel D: patients with SRVI n = 15, median age 3 mo, RIaw 150–200 cmH2O/L/s. RIaw: inspiratory airway resistance; REaw: expiratory airway resistance.

CO-08 Predictive factors of high flow nasal canula (HFNC) short term failure in severe acute bronchiolitis

ZINI Justine1, VAUGIER Isabelle1, BERGOUNIOUX Jean1

1CHU Raymond Poincaré, Garches, France
Correspondence: Justine ZINI (justine.zini@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-08

Rationale: High flow oxygen nasal cannula therapy (HFNC) is a non-invasive respiratory support increasingly used to treat bronchiolitis induced respiratory failure. HFNC utilisation spread in pediatric emergencies department because of its affordable material and ease of use. However, regular monitoring and clinical assessment of the HFNC treated child by emergency physicians and nurses is needed. Its use has been shown to avoid transfers to intensive care that is a limited resource in epidemic period. However, at the early time of its implementation, it is difficult and yet critical for the security of the patient to predict its efficiency in treating the bronchiolitis induced respiratory failure.

Objective: The aim of this study was to identify factors predicting early failure of HFNC once it has been implemented in a pediatric emergency department to treat bronchiolitis induced respiratory failure.

Patients and methods/Materials and methods: This is a retrospective multicenter study in 4 Ile-de-France region hospitals (France), comparing biometric, anamnestic, clinical, biological and radiological patient date before and until 12 h HFNC treatment. Patients included were aged 0 to 12 months, admitted to the pediatric emergency department and diagnosed with acute bronchiolitis with initiation of high-flow oxygen therapy within 12 h of arrival in the pediatric emergency department.

Results: 160 patients were included with 52 HFNC failures. Abnormal consciousness and apneas during the use of high-flow oxygen therapy were a predictor of early high-flow oxygen therapy failure (p = 0.0001). We showed a correlation of lower the pH, higher PCO2 and bicarbonate levels with early HFNC failure (p < 0.001). Similarly, lack of improvement in pH (p = 0.03), PCO2 (p = 0.017), and bicarbonate levels (p = 0.0005) shortly HFNC implementation are predictors of high-flow oxygen therapy failure. Chest X-ray atelectasis was a predictive factor for failure of OHD (p = 0.003). Wheezing heard before and during HFNC was associated with success (p = 0.01).

Conclusion: Our results showed that blood gases before and after HFNC implementation were a major predictive element for success or failure in the very first hours of HFNC treatment but that blood gases bicarbonate blood levels were also strongly correlated to HFNC success. Several clinical criteria were also associated with success such as the presence of wheezing sound, atelectasia, hypoxemia before HFNC. We believe that those results may help pediatric emergency physicians to anticipate HFNC success or failure in infant with acute bronchiolitis presenting to the pediatric emergency department.

Reference 1: The New England Journal of Medicine 2018 “A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.” Donna Franklin.

Reference 2: Eur Respir J 2020 “A randomised trial of high-flow nasal cannula in infants with moderate bronchiolitis” Philippe Durand.

Compliance with ethics regulations: Yes in clinical research.

figure c

Table 1. Analyze data before introduction of HFNC treatment, by collecting anamnestic, clinical and blood gas characteristics (pH, pCO 2 , bicarbonates), between two groups (HFNC therapy success vs HFNC therapy failure). HFNC: High flow nasal cannula. n and (%)

CO-09 Mechanical ventilator settings during extracorporeal membrane oxygenation for pediatric acute respiratory distress syndrome: An European observational study

RAMBAUD Jerome1, BROMAN Lars2, VISCONTI Federico6, LEGER Pierre Louis1, BUTRAGUEÑO LAISECA Laura 5, PILOQUER Jean Eudes4, DINARDO Matteo3

1Armand-Trousseau, Paris, France; 2Karolinska Institute, Stockholm, Suede; 3Ospedale Pediatrico Bambino Gesù, Rome, Italie; 4Nantes universitary hospital, Nantes, France; 5Hospital General Universitario Gregorio Marañón, Madrid, Espagne; 6University Hospital of Padova, Padoue, Italie
Correspondence: Jerome RAMBAUD (jerome.rambaud@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-09

Rationale: The main objective of the study was to first describe which settings are used for mechanical ventilation during ECMO for pediatric acute respiratory distress syndrome. The secondary objective of this study is to identify risk factors associated with poor prognosis or uncomplete recovery.

Patients and methods/Materials and methods: A retrospective observational study in five European centers. All children aged 1 month—18 years supported by ECMO for refractory P-ARDS from January 2009 to December 2019 were included. Collected data were pre-ECMO clinical score invasive ventilation parameters before ECMO and at day 1, 3, 7 and 14 of assistance (positive end-expiratory pressure, mean pressure, plateau pressure, driving pressure), adjunctive therapies during ECMO (prone positioning, steroids, tracheostomy, bronchoscopy and cross-sectional imaging). Finally, we gathered outcomes parameters (survival rate, length of ECMO and invasive ventilation).

Results: We included 256 patients. Median oxygenation index and oxygenation saturation index were 37 and 24.7, respectively. Half of the P-ARDS cases were viral pneumonia. Before ECMO implantation, prone positioning and neuromuscular blockers were used in 39% and 61% of the patients. Veno-venous ECMO was offered in 62%, and dual-lumen cannula was used in one quarter of VV ECMO cases. Preferential ventilator mode during ECMO was barometric setting during the whole study period. Positive end-expiratory pressure (PEEP) and mean airway pressure were significantly different between centers. Prone positioning (16%), recruitment maneuvers (2%), cross sectional imaging (8%), and tracheostomy (3%) during ECMO remained limited. Higher PEEP and higher mean airway pressure during the whole study period were associated with higher mortality.

Conclusion: Ventilatory setting during ECMO for acute respiratory distress syndrome are highly dependent on center. Associations between high PEEP and mean airway pressure with lower survival rate raise the question to define the best way to manage patients under ECMO for ARDS.

Compliance with ethics regulations: Yes in clinical research.

CO-10 Pediatric microcirculation monitoring during ECMO weaning

SUC Violette1, RAMBAUD Jerome1, STARCK Julie1, LEGER Pierre-Louis1

1Hôpital Armand Trousseau, Paris, France
Correspondence: Violette SUC (violette.suc@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-10

Rationale: ECMO is an extracorporeal respiratory and circulatory support used in children for severe respiratory failure or refractory shock states. The usual monitoring of patient under ECMO makes it possible to understand the macrocirculatory system. Perfusion and tissue oxygenation are represented by microcirculation. It has been shown to be a powerful prognostic factor for survival in children in septic shock (reference 1). The duration of ECMO depends on the remission of the organs. Early and successful weaning from ECMO reduces morbidity and mortality of the technique. The aim of the study was to determine the relevance of the sublingual microcirculation to predict the risk of “difficult weaning” of ECMO in children, expressed by the occurrence of severe hemodynamic failure during the clamping of ECMO.

Patients and methods/Materials and methods: A single-center prospective study on patients hospitalized in pediatric intensive care at Trousseau Hospital between March 2017 and December 2020. A video analysis in sidestream dark field was performed for all patients at the weaning time as well as an echocardiography and a blood gas. Patients were classified into two groups: “easy weaning” or “difficult weaning” depending on the outcome after ECMO clamping. Difficult weaning group was defined as patients with hemodynamic failure and need of restart ECMO within 24 h of the weaning, or patients who presented one of the following criteria: hemodynamic failure requiring introduction or increase of vasopressorss, cardiac dysfunction requiring introduction or increase of inotropic drugs, pulmonary arterial hypertension requiring vasodilator treatment, ventilation increase (Pmax > 28–30 cmH20), refractory hypoxemia (SpO2 < 94% with FiO2 > 75%) or hypercapnic acidosis (pH < 7.30).

Results: 30 patients were included in the study (13 newborns, median age at admission 29 days [1–770]) including 18 (60%) in veino-arterial ECMO. 19 patients were classified in the “easy weaning” group and 11 in the “difficult weaning” group. The small vessel Microvascular Flow Index at weaning was high in both groups (median 2.3 [1.8-2.4] vs 2.3 [2.3-2.6], p = 0.24) without a significant difference (Table 1). There were no differences in macro-circulatory indices, nor by ECMO type or age. The microcirculation parameters were not a predictive factor of mortality.

Conclusion: Our study is the first pediatric study to present microcirculation data at the ECMO weaning time. The microcirculation parameters at the weaning time in ECMO don’t seem to be predictive of success or failure of weaning. Post-clamping analysis may be relevant.

Reference 1: Top APC, Ince C, de Meij N, van Dijk M, Tibboel D. Persistent low microcirculatory vessel density in nonsurvivors of sepsis in pediatric intensive care. Crit Care Med. 2011.

Compliance with ethics regulations: Yes in clinical research

figure d

Microcirculatory parameters after one hour of weaning test

CO-11 Beta-lactam exposure of children on ECMO: are conventional dosing appropriate?

MARSAUX Alice1, LÉGER Pierre-Louis2, BILLE Emmanuelle3, RENOLLEAU Sylvain3, TRELUYER Jean-Marc4, LORROT Mathie2, GRIMAUD Marion3, TOUBIANA Julie3, BERANGER Agathe3, OUALHA Mehdi3

1APHP, Paris, France; 2Hopital Trousseau, APHP, Paris, France; 3Hopital Necker, APHP, Paris, France; 4Hopital Cochin, APHP, Paris, France
Correspondence: Alice MARSAUX (alice.marsaux@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-11

Rationale: Children under Extracorporeal Membrane Oxygenation (ECMO) are at high risk of complications, particularly infectious ones, which may worsen their prognosis. However, recommendations for the use of antibiotics, particularly beta-lactams dosing which are frequently administered, are extrapolated from adult data and are not adapted to the pharmacokinetic and pharmacodynamic (PK/PD) changes observed in children on ECMO. Therefore, there is a risk of inadequate exposure using the standard dosing. The objective of this study is to describe, for children undergoing ECMO, the exposure to beta-lactams at currently used dosing; and to identify factors associated with inadequate exposure.

Patients and methods/Materials and methods: This was an observational, retrospective, bicentric study conducted in 2 pediatric intensive care units, on 57 children undergoing veno-arterial or veno-venous ECMO. Plasma concentrations of beta-lactams used were measured and interpreted according to EUCAST, then to the minimum inhibitory concentration (MIC) found and according to the following PK/PD targets: serum concentration 4 times above the MIC throughout the dosing interval (100% fT > 4 × MIC).

Results: We included 57 patients (21 (36.8%) died during our study), who received 11 types of beta-lactams (including 30 patients receiving piperacillin/ tazobactam) resulting in 226 concentrations analyzed. A total of 32 infections were documented. Based on the PK/PD target of 100% fT > 4 × MIC, for the highest MICs, 58.8% of concentrations were insufficient, mainly in young children (p = 0.035) with a low bodyweight (p = 0.013), or in case of hypoalbuminemia (p = 0.011), reflecting the increase in volume of distribution, and also in case of increased renal clearance (p 0.032). The risk of supra-therapeutic concentrations was 10.5% and was mainly associated with poor elimination (presence of renal impairment (p < 0.01)).

Conclusion: There is a non-negligible risk of under-exposure in children receiving conventional dosing of beta-lactam and ECMO support (mainly related to renal function and volume of distribution variations). Therapeutic drug monitoring combined with the application of specific PK/PD models would reduce this risk and ultimately improve the prognosis of these patients.

Compliance with ethics regulations: Yes in clinical research

figure e

Association between clinical variables and the result of concentrations for all dosages and Piperacillin/Tazobactam (for an exposure assumption of serum concentration 4 times above the MIC throughout the dosing interval (100% fT > 4 × MIC)

CO-12 Anti-infective prescription practices in children undergoing renal replacement therapy: a multicenter survey

THY Michael1,3, NAUDIN Jérôme4, GENUINI Mathieu4, LETEURTRE Stéphane5, OUALHA Mehdi2,3

1Assistance Publique-Hôpitaux de Paris, Infectious and tropical diseases department, Bichat University Hospital, Université de Paris, Paris, France; 2Assistance Publique-Hôpitaux de Paris, Paediatric Intensive Care Unit, Necker-Enfants Malades University Hospital, Université de Paris, Paris, France; 3EA 7323 - Pharmacology and Therapeutic Evaluation in Children and Pregnant Women, Université de Paris, France; 4Assistance Publique-Hôpitaux de Paris, Paediatric Intensive Care Unit, Robert-Debré University Hospital, Université de Paris, Paris, France; 5Pediatric Intensive Care Unit, CHU Lille, Lille, France
Correspondence: Michael THY (michael245thy@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-12

Rationale: The need of renal replacement therapy (RRT) in septic children may occur and add variability leading to unpredictable anti-infective concentrations with risks of treatment failure, toxicity and emergence of multidrug resistant bacteria. We aim to better understand anti-infective prescription practices in children undergoing RRT.

Patients and methods/Materials and methods: An online survey was sent via email to physicians working in pediatric intensive care units (PICU) from the Groupe Francophone de Réanimation et d’Urgences Pédiatiques (GFRUP). The survey form assessed the characteristics of the PICU, practices of RRT, anti-infective prescription and therapeutic drug monitoring. We excluded plasma exchanges and adsorption techniques from the survey. When several respondents from the same center answered, we selected the most complete form.

Results: From 10/04/2021 to 10/05/2021, 47 physicians answered the survey corresponding to 26 different centers including 21 French centers, corresponding to 88% of response rate for French PICU > 4 beds. The median [IQR] number of ICU beds was 12 [8-16] and intermediate care beds was 5 [2-8]. Every PICU used continuous RRT with mainly Prismaflex® machine. Adaptation of anti-infective prescriptions to the presence of RRT were declared in 23 (89%) PICU according to the molecular weight in 6 (26%), to the molecule protein binding in 6 (26%), to the lipo/hydrophilic nature of the molecule in 4 (17%), to the elimination routes in 15 (65%). The anti-infective were adapted to the residual diuresis in 9 (41%) PICU, to the RRT flow in 6 (26%) and to the type of RRT used in 15 (65%). Most of the PICU declared no available guidelines (n = 20, 80%) but used VIDAL® in 12 (46%) or GPR© in 4 (15%). We noticed great variability even between the physicians from the same department. Adaptation of the anti-infective doses from the respondents are displayed on Fig. 1. Most of the centers (n = 20, 77%) used therapeutic drug monitoring under RRT and was systematically done for betalactams in 18 (69%) PICU, for aminoglycosides in 22 (92%), for glycopeptides in 21 (84%), for linezolid in 13 (54%), for antivirals in 16 (64%), for azoles 15 (60%), for candins in 12 (48%). Obstacles for monitoring were mainly (n = 11, 42%) the delay for the results and the absence of on-site laboratory (n = 8, 31%). Anti-infective stewardship was available with a specialist (pharmacologist or infectiologist) in 11 (42%) PICU.

Conclusion: Our survey reported great variability of anti-infective prescription practices in children undergoing RRT pointing out the need for specific guidelines.

Compliance with ethics regulations: Yes in clinical research.

figure f

Figure 1: Adaptation of anti-infective doses in children under RRT

CO-13 High-flow nasal oxygen alone or alternating with noninvasive ventilation in critically ill immunocompromised patients with acute respiratory failure. A randomised controlled trial

COUDROY Rémi1, FRAT Jean-Pierre1, EHRMANN Stephan2, PÈNE Frédéric3, DECAVÈLE Maxens4, TERZI Nicolas5, PRAT Gwenael6, GARRET Charlotte7, CONTOU Damien8, GACOUIN Arnaud9, BOURENNE Jérémy10, GIRAULT Christophe11, VINSONNEAU Christophe12, DELLAMONICA Jean13, LABRO Guylaine14, JOCHMANS Sébastien15, HERBLAND Alexandre16, QUENOT Jean-Pierre17, DEVAQUET Jérôme18, BENZEKRI Dalila28, VIVIER Emmanuel19, NSEIR Saad20, COLIN Gwenahel21, THEVENIN Didier22, GRASSELLI Giacomo23, BOUGON David24, ASSEFI Mona4, GUÉRIN Claude25, LHERM Thierry26, KOUATCHET Achille27, RAGOT Stéphanie1, THILLE Arnaud W.1

1CHU de Poitiers, Poitiers, France; 2CHU de Tours, Tours, France; 3Hôpital Cochin, Paris, France; 4Pitié-Salpêtrière, Paris, France; 5CHU Grenoble Alpes, Grenoble, France; 6CHU de Brest, Brest, France; 7CHU de Nantes, Nantes, France; 8Centre Hospitalier Victor Dupouy, Argenteuil, France; 9CHU de Rennes, Rennes, France; 10CHU La Timone 2, Marseille, France; 11CHU de Rouen, Rouen, France; 12Centre hospitalier de Béthune, Beuvry, France; 13CHU de Nice, Nice, France; 14CHU de Besançon, Besançon, France; 15Centre hospitalier Sud-Ile-de France, Melun, France; 16Centre hospitalier Saint Louis, La Rochelle, France; 17CHU Dijon-Bourgogne, Dijon, France; 18Hôpital Foch, Suresnes, France; 19Hôpital Saint Joseph Saint Luc, Lyon, France; 20CHU de Lille, Lille, France; 21Centre Hospitalier Départemental de Vendée, La Roche Sur Yon, France; 22CH de Lens, Lens, France; 23Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italie; 24Centre Hospitalier Annecy Genevois, Annecy, France; 25Hôpital de La Croix-Rousse, Lyon, France; 26Hôpital de Chartres, Chartres, France; 27CHU d'Angers, Angers, France; 28CHR d'Orléans, Orléans, France
Correspondence: Rémi COUDROY (remi.coudroy@chu-poitiers.fr)

Annals of Intensive Care 2022, 12(1):CO-13

Rationale: Whereas noninvasive ventilation is recommended for immunocompromised patients with acute respiratory failure in the intensive care unit (ICU), it may have deleterious effects in most severe patients. High-flow nasal oxygen alone may be an alternative to reduce mortality. We aimed to determine whether high-flow nasal oxygen alone could reduce the rate of mortality at day 28 compared to its alternation with noninvasive ventilation in this setting.

Patients and methods/Materials and methods: The FLORALI-IM is a multicenter, open-label randomised clinical trial was conducted in 30 ICUs (29 in France and one in Italy). Adult immunocompromised patients with acute respiratory failure defined as respiratory rate ≥ 25/min and a partial pressure of oxygen to inspired fraction of oxygen ≤ 300 mmHg were randomly assigned to high-flow nasal oxygen alone (n = 154) or noninvasive ventilation alternating with high-flow nasal oxygen (n = 145). The primary outcome was mortality at day 28. The trial is registered with ClinicalTrials.gov, number NCT02978300.

Results: Between January 2017 to March 2019, 299 patients were included in the intention-to-treat analysis. Mortality rate at day 28 was 36% (56/154) with high-flow nasal oxygen alone and 35% (51/145) with noninvasive ventilation alternating with high-flow nasal oxygen (absolute difference, 1·2% [95% CI, − 9·6 to 11·9%], p = 0·83). Intubation rate at day 28 was 51% (78/154) with high-flow nasal oxygen alone and 46% (67/145) with noninvasive ventilation alternating with high-flow nasal oxygen (difference, 4·4% [95% CI, − 6·8 to 15·5%], p = 0·44). None of the other prespecified secondary outcomes were different between groups except for greater decreased discomfort after initiation of high-flow nasal oxygen than with noninvasive ventilation (− 4 mm on visual analogic scale [95 %CI, − 18 to 4] vs. 0 mm [95% CI, − 16 to 17], p = 0·04).

Conclusion: In critically ill immunocompromised patients with acute respiratory failure, the mortality rate did not differ between high-flow nasal oxygen alone and noninvasive ventilation alternating with high-flow nasal oxygen.

Compliance with ethics regulations: Yes in clinical research.

CO-14 Lung histopathology of Covid-19 patients with acute respiratory distress syndrome: a French multicenter study

MORIN Jean1, SAGAN Christine1, PLANTEFEVRE Gaetan2, CHELHA Riad3, ASFAR Pierre4, SIRODOT Michel5, SIMON Georges6, FERRE Alexis7, KAMEL Toufik8, PENE Frédéric9, DECAVELE Maxens10, BADIE Julio11, BOYER Alexandre12, SOUWEINE Bertrand13, HRAIECH Sami14, DELBOVE Agathe15, FOUCAULT Camille16, AUCHABIE Johann17, CHANAREILLE Paul-Marie18, ARGAUD Laurent19, RICHARD Jean-Christophe20, BEURET Pascal21, GARÇON Pierre22, HAYON Jan23, BONNY Vincent24, LEGAY François25, GERI Guillaume26, REIGNIER Jean1, CANET Emmanuel1

1CHU de Nantes, Nantes, France; 2Centre Hospitalier Victor Dupouy, Argenteuil, France; 3Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France; 4CHU Angers, Angers, France; 5Centre Hospitalier Annecy Genevois, Annecy, France; 6Centre Hospitalier de Troyes, Troyes, France; 7Hôpital de Versailles, Le Chesnay, France; 8CHR Orléans, Orléans, France; 9CHU Cochin, Paris, France; 10CHU Pitié Salpêtrière, Paris, France; 11Hôpital Nord Franche-Comté, Belfort, France; 12CHU de Bordeaux, Bordeaux, France; 13CHU Clermont-Ferrand, Clermont-Ferrand, France; 14APHM CHU Nord, Marseille, France; 15CHBA Vannes-Auray, Vannes, France; 16CH Cahors - Hôpital Jean Rougier, Cahors, France; 17CH Cholet, Cholet, France; 18GHPP Montélimar, Montélimar, France; 19CHU Edouard Herriot, Lyon, France; 20CHU Hôpital Lyon Sud, Lyon, France; 21CH de Roanne, Roanne, France; 22GHEF site de Marne-La-Vallée, Jossigny, France; 23CHI Poissy-Saint-Germain-en-Laye, Poissy, France; 24CHU Saint-Antoine, Paris, France; 25CH de Saint-Brieuc, Saint-Brieuc, France; 26CHU Ambroise Paré, Boulogne, France
Correspondence: Emmanuel CANET (emmanuel.canet@chu-nantes.fr)

Annals of Intensive Care 2022, 12(1):CO-14

Rationale: COVID-19 is a viral pneumonia which may deteriorate into acute respiratory distress syndrome (ARDS). Analysis of the pathological features in the lung tissues of patients who have died from COVID-19-ARDS might help to understand the disease pathogenesis.

Patients and methods/Materials and methods: We conducted a multicenter study which involved 26 French ICUs. All Covid-19 patients who died from COVID-19-ARDS between February 1st 2020 and April 30th 2021 were eligible. The lung biopsies were performed by the intensivists immediately after the death following anatomical landmarks.

Results: Overall, 171 patients were included in the study. We report the results of the first 90 patients analyzed. Age was 70 [65–76] years-old, 62 (69%) patients were men, and 18 (20%) patients had a pre-existing pulmonary disease. Time from the onset of mechanical ventilation (MV) to death was 18 [10–31] days. The durations of moderate and severe ARDS were 6 [2–12] and 8 [3–15] days, respectively. The main causes of death were refractory shock and hypoxemia (42.2%), refractory hypoxemia (31.1%), and refractory shock (8.9%). Of the 90 biopsies performed, 85 (94%) had lung tissue available for pathological analysis. The most common primary lesions of the alveoli were: type-2 pneumocyte hyperplasia (84.7%), fibrin deposition (62.3%), plugs of fibroblastic tissue (36.4%), hyaline membranes (29.4%), fibrin balls (15.3%). The primary lesions identified in the septa were: proliferation of fibroblastic tissue (82.4%), lymphocytic infiltrate (20%), oedema (15.3%), and collagen deposition (8.2%). Microthrombi were identified in 7% of biopsies. Final pathological diagnosei were: late phase of proliferative diffuse alveolar damage (DAD) (38.8%), early phase of proliferative DAD (34.1%), unclassified interstitial pneumonia (29.4%), acute fibrinous and organizing pneumonia (AFOP) (12.9%), acute exsudative DAD (11.8%), and organizing pneumonia (OP) (7.1%). Early deaths (before day-10 of MV) were characterized by a high rate of acute exsudative DAD and early phase of proliferative DAD and the absence of collagen deposition. In contrast, late phase of proliferative DAD was the most common lesion encountered in late deaths (after day-30 of MV) with extensive proliferation of fibroblastic tissue. AFOP and OP were diagnosed in patients who died before day-30 of MV.

Conclusion: The predominant pattern of lung lesions in patients who died from Covid-19-ARDS is DAD. Fibroblastic tissue proliferation, AFOP, and OP were commonly reported while collagen fibrosis was rare. Our results support further evaluation of steroids in non-resolving ARDS Covid-19 given the significant proportion of potential steroid-sensitive patterns.

Compliance with ethics regulations: Yes in clinical research.

CO-15 Management and outcomes of pregnant woman with severe pneumonia related to SARS-CoV-2 infection admitted in intensive care unit

PÉJU Edwige1, BELICARD Félicie1, STEIN Silva30, HRAIECH Sami24, TADIÉ Jean-Marc7, MULLER Grégoire13, THILLE Arnaud11, GOURY Antoine18, GRIMALDI David26, JUNG Boris23, PITON Gael17, PIAGNERELLI Michael27, GIBOT Sébastien14, THIERY Guillaume20, LASCARROU Jean-Baptiste8, BOUHEMAD Belaid16, ARGAUD Laurent22, TERZI Nicolas31, TAMION Fabienne5, EHRMANN Stephan10, VIGNON Philippe19, BELONCLE François9, PUGIN Jérrôme25, AUBRON Cécile6, BERTRAND Pierre-Marie28, GUITTON Christophe12, KAIDOMAR Michel29, MAIZEL Julien3, MEZIANI Ferhat15, SOUWEINE Bertrand21, JOURDAIN Merce4, JOZWIAK Mathieu2

1Hôpital Cochin - APHP, Paris, France; 2CHU de Nice, Nice, France; 3CHU de Amiens, Amiens, France; 4CHU de Lille, Lille, France; 5CHU de Rouen, Rouen, France; 6CHU de Brest, Brest, France; 7CHU de Rennes, Rennes, France; 8CHU de Nantes, Nantes, France; 9CHU de Angers, Angers, France; 10CHU de Tours, Tours, France; 11CHU de Poitiers, Poitiers, France; 12Hôpital du Mans, Le Mans, France; 13CHR d'Orléans, Orléans, France; 14CHRU de Nancy, Nancy, France; 15CHRU de Strasbourg, Strasbourg, France; 16CHU de Dijon, Dijon, France; 17CHU de Besançon, Besançon, France; 18CHU de Reims, Reims, France; 19CHU de Limoges, Limoges, France; 20CHU de Saint Etienne, Saint Etienne, France; 21CHU de Clermond-Ferrand, Clermond-Ferrand, France; 22CHU de Lyon, Lyon, France; 23CHU de Montpellier, Montpellier, France; 24CHU de Marseille, Marseille, France; 25CHU de Genève, Genève, Suisse; 26Hôpital Erasme, Bruxelles, Belgique; 27CHU de Charleroi, Charleroi, Belgique; 28Hôpital de Cannes, Cannes, France; 29CHI de Fréjus, Fréjus, France; 30CHU de Toulouse, Toulouse, France; 31CHU de Grenoble, Grenoble, France
Correspondence: Edwige PÉJU (edwigepeju@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-15

Rationale: Pregnancy is a risk factor of developing a severe form of SARS-CoV-2 infection. So far, the management and outcomes of pregnant women with severe SARS-CoV-2 infection requiring intensive care unit (ICU) admission remain to be investigated.

Patients and methods/Materials and methods: This multicentric, retrospective and observational study was conducted in 31 ICUs in France, Belgium and Switzerland between March 2020 and December 2021. All patients admitted in ICU for severe pneumonia related to SARS-CoV-2 infection during pregnancy or just after fetal extraction were included. Maternal ventilatory and obstetrical management in ICU as well as maternal and fetal outcomes were collected and analyzed. Risk factors of intubation were also assessed.

Results: Overall, 165 patients were included with a median age of 34 [30–37] years old and a median gestation length of 29 [26–33] amenorrhea weeks. Among them, 61 (37%) had obesity, 10 (6%) had diabetes mellitus and 53 (32%) had pregnancy-related complications. The median time between the onset of symptoms and ICU admission was 8 [6–10] days. Corticosteroids and Tocilizumab were administered in 141 (85%) and 23 (14%) patients respectively, CT-Scan was performed in 120 (73%) patients and pulmonary embolism was found in 8 (5%) patients. Regarding ventilatory management, 107 (65%) patients were treated with high-flow nasal cannula oxygenation therapy, 40 (20%) with non-invasive ventilation, 74 (45%) required to be intubated, 20% of them prior to ICU admission, and 12 (7%) required veno-venous extracorporeal membrane oxygenation. Awake prone positioning was performed in 7 (4%) patients prior to any fetal extraction and in 2 (1%) after fetal extraction. In multivariate analysis, obesity (OR = 3.22 [1.11–9.88], p = 0.03), term (OR = 1.14 [1.05–1.27], p = 0.005), extent of CT-Scan abnormalities > 50% (OR = 3.37 [1.17–10.13], p = 0.03) and non-invasive ventilation use (OR = 3.70 [1.20–12.24], p = 0.03) were associated with intubation. Fetal extraction was performed prior to ICU admission in 19 (12%) patients and was required during ICU stay in 58 (35%) patients, always by cesarean section: 45 (78%) for maternal respiratory worsening and 7 (12%) for fetal suffering. The maternal ICU mortality rate was 1%. Main maternal complications were infection, thrombosis and hemorrhage (18%, 7%, 7%, respectively). The fetal mortality rate was 5% with 7 (4%) stillborns, 69 (40%) prematures including 55 (32%) requiring ICU admission and 103 (60%) born at term.

Conclusion: Despite low maternal and fetal mortality rates, half of pregnant women admitted in ICU for severe pneumonia related to SARS-CoV-2 infection required to be intubated and required fetal extraction. Risk factors of intubation were obesity, term, extent of CT-Scan abnormalities > 50% and non-invasive ventilation use. Inclusions are still in progress.

Compliance with ethics regulations: Yes in clinical research.

CO-16 Impact of obesity on survival in COVID-19 ARDS patients receiving ECMO: results from an ambispective observational cohort

DAVIET Florence1,3, GUILLOUX Philippe2, HRAIECH Sami1,3, TONON David2, VELLY Lionel2, BOURENNE Jeremy4, PORTO Alizee5, GRAGUEB CHATTI Ines1, BOBOT Mickaël1, BAUMSTARCK Karine6, PAPAZIAN Laurent1,3, COLLART Frederic5, FOREL Jean-Marie1,3, GUERVILLY Christophe1,3

1Assistance Publique Hôpitaux de Marseille - Hôpital Nord- Medecine Intensive reanimation, Marseille, France; 2Assistance Publique Hôpitaux de Marseille- Hôpital de la Timone -Département d’Anesthésie-réanimation, Marseille, France; 3Aix-Marseille Université, Faculté de Médecine Centre d’Études et de Recherches sur les Services de Santé et qualité de vie EA 3279, Marseille, France; 4Assistance Publique Hôpitaux de Marseille- Hôpital de la Timone -Réanimation des Urgences, Marseille, France; 5Assistance Publique Hôpitaux de Marseille- Hôpital de la Timone -Département de chirurgie cardiaque, Marseille, France; 6Faculté de Médecine, Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Marseille, France
Correspondence: Florence DAVIET (florence.daviet@ap-hm.fr)

Annals of Intensive Care 2022, 12(1):CO-16

Rationale: Since March 2020, healthcare systems were importantly affected by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) outbreak, with some patients presenting severe Acute Respiratory Distress Syndrome (ARDS), requiring extracorporeal membrane oxygenation (ECMO).

Patients and methods/Materials and methods: We designed an ambispective observational cohort study including all consecutive adult patients admitted to 5 different ICUs from a university hospital. The main objective was to identify the risk factors of severe COVID-19 ARDS patients supported by ECMO associated with 90-day survival.

Results: Between March 1st and November 30th 2020, 76 patients with severe COVID-19 ARDS were supported by ECMO. Median (interquartile range IQR) duration of mechanical ventilation (MV) prior to ECMO was of 6 (3–10) days. At ECMO initiation, patients had a median PaO2/FiO2 ratio of 71 mmHg (IQR 62–81), median PaCO2 of 58 mmHg (IQR 51–66) and a median arterial pH of 7.33 (IQR 7.25–7.38). Forty-five patients (59%) were weaned from ECMO. Twenty-eight day, 60-day and 90-day survival rates were respectively 92, 62 and 51%. Factors associated with 90-day survival in univariate analysis were younger age, higher BMI and lower Charlson score. Of note, time from ICU admission to intubation (2 days (0–5) in survivors versus 4 days (1–7) in non survivors, p = 0.02) and time to ECMO cannulation (9 days (4–11) in survivors versus 11 (8–14) in non survivors, p = 0.02) were shorter in 90-day survivors. In multivariate logistic regression analysis, with 2 models, one with the RESP score and one with the PRESERVE score, we found that higher BMI was associated with higher 90-day survival (Odds ratio (OR): 0.669 (0.506–0.886), p = 0.005) and 0.757 (0.632–0.907) respectively). Younger age was also associated with 90-day survival in one model (OR: 1.14 (1.007–1.292), p = 0.039). Kaplan–Meier cumulated survival curves according to the presence of obesity were significantly different (Fig. 1, p = 0.006), the survival was also different when comparing the different obesity grades (p = 0.003). Obese patients were ventilated with higher PEEP than non-obese patients (14 (10–15) vs. 10 (8–12) cm H2O; p < 0.001) with comparable Pplat, (29 (25–31) vs. 28 (25–30) cm H2O, respectively (p = 0.923)). There was a trend to higher compliance of respiratory system in obese patients as compared with non-obese patients, respectively 26.2 (21–39.1) and 23 (15.5–27.3) mL/cm H2O (p = 0.07).

Conclusion: In this ambispective observational cohort of COVID-19 severe ARDS supported by ECMO, obesity was an independent factor associated with improved survival at 90-day.

Compliance with ethics regulations: Yes in clinical research.

figure g

Kaplan–Meier cumulated survival curves at day 90 since ICU admission in obese (red curve) and non-obese patients (blue curve). Obesity was defined as a BMI > 30 kg/m 2 .

CO-17 Management of acute exacerbations of chronic obstructive pulmonary disease in the intensive care unit: the Outcomerea database, 1997–2018

GALERNEAU Louis-Marie1,2, BAILLY Sébastien1,2, TERZI Nicolas1,2, RUCKLY Stéphane3, GARROUSTE-ORGEAS Maité4, COHEN Yves5, HONG TUAN HA Vivien6, GAINNIER Marc7, SIAMI Shidasp8, DUPUIS Claire9, DARMON Michael10, AZOULAY Elie10, FOREL Jean-Marie11, RIGAULT Guillaume1, ADRIE Christophe12, GOLDGRAN-TOLEDANO Dany13, BRUNEEL Fabrice14, DE MONTMOLLIN Etienne15, ARGAUD Laurent16, REIGNIER Jean17, PEPIN Jean-Louis1,2, TIMSIT Jean-François15

1CHU Grenoble Alpes, La Tronche, France; 2Université Grenoble Alpes, INSERM U1300 HP2, La Tronche, France; 3Département de biostatistiques, Outcomerea, Paris, France; 4Hopital Franco-Britanique, Levallois-Perret, France; 5AP-HP, Hôpital Avicenne, Paris, France; 6Grand Hôpital de l'Est Francilien, Meaux, France; 7Hôpital de ta Timone, Marseille, France; 8Centre Hospitalier Sud Essonne, Etampes, France; 9CHU Gabriel-Montpied, Clermont-Ferrand, France; 10AP-HP, Hôpital Saint-Louis, Paris, France; 11Hôpital Universitaire Marseille Nord, Marseille, France; 12Hôpital Delafontaine Hôpital, Saint-Denis, France; 13Groupe Hospitalier Intercommunal Le Raincy Montfermeil, Montfermeil, France; 14Centre Hospitalier de Versailles, Le Chesnay, France; 15AP-HP, Hôpital Bichat, Paris, France; 16Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France; 17CHU de Nantes, Nantes, France
Correspondence: Louis-Marie GALERNEAU (lmgalerneau@chu-grenoble.fr)

Annals of Intensive Care 2022, 12(1):CO-17

Rationale: The natural history of COPD is punctuated of acute exacerbations of COPD (AECOPDs) leading to hospitalization in intensive care units (ICU) for the most severe cases. The daily practice of corticosteroids/antibiotics prescriptions and the respective proportions of invasive and non-invasive ventilation (NIV) have evolved over time in the ICU. These contextual changes might have implications regarding AECOPDs management and ICU outcomes such as length of stay, intubation rates and mortality. The aim of the current study was to assess over 22 years the evolution of AECOPDs changes in the management practices and the impact on main outcomes including length of stay and mortality in ICU and in post-ICU stay.

Patients and methods/Materials and methods: 1,816 patients admitted for AECOPDs were included prospectively between 1997 and 2018 in the Outcomerea French database from 32 ICUs. Evaluation of time trends were performed with analysis of the evolution of these variables over time out using a mixed model. Time series analyses were performed to assess the relationship between mortality in ICU and use of corticosteroids, antibiotics and invasive mechanical ventilation, using a dynamic regression model.

Results: We observed limited changes in anthropometrics of AECOPD patients admitted to ICUs except a slight increase in body mass index (+ 0.32%/year, p = .01) and severity was greater at ICU admission (+ 0.6% of SAPS II score/year, p < .01). There was overtime a significant reduction in the prescription of corticosteroids (− 4.7%/year, p < .01) and antibiotics (− 5.8%/year, p < .01), without these changes being correlated with the evolution of mortality in ICU in a time series analysis. The proportion of patients treated with invasive mechanical ventilation (IMV) also gradually declined (− 3.7%/year, p = .01) with this time a significant correlation between variations of use of IMV and variations of deaths in ICU in the time series analysis (p < .01). Rate of NIV failures decreased over time (− 6.2%/year, p < .01) with a diffusion of NIV for facilitating IMV weaning (+ 8.1%/year, p < .01). There was a significant shortening of length of stay in ICU (− 3.2%/year, p < .01) and total duration of hospital stays (− 2.6%/year, p < .01). We observed an improvement of the prognosis (− 4.1%/year of deaths in ICU, p = 0.03; − 4.2%/year of deaths in hospital post-ICU stay, p = 0.02 and − 4.98%/year of 90-day mortality, p = 0.02).

Conclusion: Lengths of stay decreased with a better prognosis of AECOPD in ICU. The management of ventilatory support has improved. And if prescriptions for corticosteroids and antibiotics have been reduced, prescription strategies for these therapeutics in ICU have to be precised.

Compliance with ethics regulations: Yes in clinical research.

CO-18 WeanIng according to new definition: burden and long-term outcomes of WIND 2 and 3 survivors (WIND BLOWS) study

BEDUNEAU Gaëtan1, GILLIBERT André1, DEMOULE Alexandre4, RICHARD Jean Christophe2, MERCAT Alain2, BROCHARD Laurent5, PHAM Tài3

1CHU Rouen, Rouen, France; 2CHU Angers, Angers, France; 3CHU Tenon, Paris, France; 4CHU La Pitié, Paris, France; 5Hôp Universitaire Montréal, Montréal, Canada
Correspondence: Gaëtan BEDUNEAU (gaetan.beduneau@chu-rouen.fr)

Annals of Intensive Care 2022, 12(1):CO-18

Rationale: In order to analyze hospital burden and long-term outcomes of prolonged and difficult to wean patients we performed a follow-up of patients included in the WIND study.

Patients and methods/Materials and methods: Among the 2709 patients included in the WIND study (ref 1), 508 were classified either in group 2 (difficult weaning, n = 273) or 3 (prolonged weaning, n = 235), of whom 459 were included in France. The 339 patients of French centers alive at the end of the princeps study constituted the eligible population of our study. Each center investigator collected vital status, intercurrent hospitalization, life at home, need for oxygen therapy or home ventilation up to 8 years after the study participation.

Results: Data were obtained for 284 patients: 94 (33%) females, mean (standard deviation) age of 64 (14). The mean (SD) SAPS-II score at ICU admission was 50 (17) and 164 (58%) belonged to WIND group 2. We observed mortality rates of 27% at one year, 50% at 5 years and 60% at 8 years. Between 1 and 8 years, the standardized mortality ratio (SMR) compared to the general French population of the same age, sex and period distribution was estimated at 3.20 (95% CI 2.69 to 3.65). Overall mortality was higher for group 3 patients than group 2 patients (66% vs 55%, p = 0.06, Fig. 1). At 1, 5 and 8 years, respectively 88%, 89% and 90% of alive patients had no oxygen or ventilation support and 89%, 93% and 92% lived at home. The estimated cumulative risks of having at least one rehospitalization among survivors at 1, 5 and 8 years were respectively 51%, 71% and 76%.

Conclusion: Although the risk of death and readmission is high, especially in the first year following discharge, survivors at 8 years mostly live at home without oxygen or home ventilation.

Reference 1: AJRCCM Vol195, 772–783.

Compliance with ethics regulations: Yes in clinical research.

figure h

Probability of survival

CO-19 HIV-infected patients hospitalized in intensive care from 1997 to 2020: analysis of the OUTCOMEREA multicenter cohort

GAILLET Antoine1, ELIE Azoulay2, ETIENNE Demontmollin3, GARROUSTE Maite4, COHEN Yves5, DUPUIS Claire6, SCHWEBEL Carole7, REIGNIER Jean8, SHIDASP Siami9, ARGAUD Laurent10, ADRIE Christophe14, MOURVILLIER Bruno12, RUCKLY Stephane7, FOREL Jean-Marie13, TIMSIT Jean-Francois3

1Henri Mondor, Créteil, France; 2Saint Louis, Paris, France; 3Bichat, Paris, France; 4Saint Joseph, Paris, France; 5Avicenne, Bobigny, France; 6Gabriel Montpied, Clermont Ferrand, France; 7Grenoble Alpes, Grenoble, France; 8CHU Nantes, Nantes, France; 9Sud Essone, Etampes, France; 10Edouard Herriot, Lyon, France; 11Delafontaine, Saint Denis, France; 12CHU Reims, Reims, France; 13Hopital Nord, Marseille, France; 14Cochin, Paris, France
Correspondence: Antoine GAILLET (gaillet.antoine75@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-19

Rationale: Despite antiviral therapy (ARV), HIV infection is still responsible for 800,000 deaths per year. In parallel with the good virological control and the aging of this population, multiple comorbidities (HIV associated non-AIDS (HANA) conditions) have developed in this population. The objectives of the “VIHREA” study were to describe the phenotypic evolution of HIV patients admitted to intensive care unit (ICU) from 1997 to 2020 and then to identify risk factors for day-60 (D60) death.

Patients and methods/Materials and methods: Prospective, multicenter cohort (23 centers, OutcomeRea™), including HIV adult patients (≥ 18 years old) hospitalized in ICU from 01/01/1997 to 12/31/2020, with trend analysis through 3 periods dichotomized according to the integrase inhibitors appearance (2007) and WHO recommendation for systematic treatment of all HIV patients (2016). A survival model was used to study prognostic factors at D60.

Results: Of the 24,298 stays registered, 630 (2.6%) concerned first stays for a HIV patient. Throughout the 3 periods, the mean age increased (51.6 years in period 3 versus 44.2 years in period 1, p < 0.001), as did the level of comorbidity of the patients (diabetes, renal and respiratory history, solid neoplasia). The proportion of HIV discovered on ICU admission decreased significantly (9.8% versus 28.4%, p < 0.001) while the median duration of HIV disease (18 years versus 5 years, p < 0.001) as well as the percentage of patients admitted on ARV (72% versus 47.6%, p < 0.001) increased. The main reasons for admission distribution remained stable over time (acute respiratory distress > shock > coma). Moreover, while we observed a significant drop in the rate of active opportunistic infections on admission (24% versus 36.2%, p = 0.007), pneumocystosis (9.2%) and tuberculosis (6.9%) being the most frequent, the rate of active hemopathy classifying AIDS increased non-significantly (p = 0.154) but was associated with a significant increase in the administration of chemotherapy in ICU (12.7% versus 1.4%, p < 0.001), non-Hodgkin’s lymphoma being the majority (14.3%). Admissions for HANA (11.2%) or non-HIV (50.4%) reasons were stable over time, as were SOFA score on admission (p = 0.668), and the proportions of mechanically ventilated (49.4% versus 48.4%, p = 0.707) and dialysed patients (20.2% versus 14.9%, p = 0.128). In multivariate analysis, predictors of D60 mortality were advanced age, chronic liver disease, prior chemotherapy, SOFA score > 4 at admission, hospitalization time before admission to intensive care > 24 h, AIDS status, but not the period of admission.

Conclusion: The phenotype of HIV patients admitted to intensive care has evolved over time (HIV better controlled but more comorbidity associated). Mortality risk factors remain stable over time, including AIDS status.

Compliance with ethics regulations: Yes in clinical research.

figure i

Predictors of death at D60 after ICU admission in the VIHREA cohort (Cox regression)

CO-20 Necrotizing soft tissue infections in neutropenic patients requiring ICU admission: a French multicenter retrospective cohort study

ARRESTIER Romain1,2,3, CHABA Anis4, MABROUKI Asma5, SACCHERI Clément6, CANET Emmanuel7, PINETON DE CHAMBRUN Marc8, STOCLIN Anabelle9, PICARD Muriel10, WALLET Florent11, PERIER François12, TURPIN Matthieu13, ARGAUD Laurent14, DECAVELE Maxens15, ISSA Nahema16, CADOZ Cyril17, KLOUCHE Kada18, COHEN Johana19, MOKART Djamel20, URBINA Tomas21, HUA Camille22, CHOSIDOW Olivier22, MEKONTSO-DESSAP Armand1,2,3, AZOULAY Elie5, DE PROST Nicolas1,2,3

1Service de Médecine Intensive et Réanimation, APHP Hôpital Henri Mondor, Créteil, France; 2Groupe de Recherche Clinique CARMAS, faculté de Santé de Créteil, UPEC, Créteil, France; 3INSERM, IMRB, Université Paris Est Créteil, Créteil, France; 4Service de médecine intensive et réanimation, APHP Hôpital Cochin, Paris, France; 5Service de médecine intensive et réanimation, APHP Hôpital Saint-Louis, Paris, France; 6Service de médecine intensive et réanimation, Hôpital Archet 1, Nice, France; 7Service de médecine intensive et réanimation, Centre Hospitalier de Nantes, Nantes, France; 8Service de médecine intensive et réanimation, APHP Hôpital La Pitié Salpétrière, Paris, France; 9Service de médecine intensive et réanimation, Institut Gustave Roussy, Villejuif, France; 10Service de Réanmation Polyvalente, Centre Hospitalier Universitaire de Toulouse, Oncopôle, Toulous, France; 11Service d'anesthésie, médecine intensive, réanimation, Hospices Civils de Lyon, Lyon, France; 12Réanimation Médico-Chirurgicale, Hôpital André Mignot, Versailles, France; 13Service de médecine intensive et réanimation, APHP, Hôpital Tenon, Paris, France; 14Service de médecine intensive et réanimation, Hôpital Edouard Herriot, Lyon, France; 15Service de Pneumologie, Médecine Intensive et Réanimation, APHP Hôpital La Pitié Salpétrière, Paris, France; 16Service de médecine intensive et réanimation, Hôpital Saint-André, CHU Bordeaux, Bordeaux, France; 17Réanimation Polyvalente, CHR Metz-Thionville, Metz, France; 18Service de médecine intensive et réanimation, CHU Montpellier, Montpellier, France; 19Service de médecine intensive et réanimation, Groupe Hospitalier Intercommunal Le Raincy Montfermeil, Montfermeil, France; 20Unité Traitement Soins Intensifs, Institut Paoli .Calmettes, Marseille, France; 21Service de médecine intensive et réanimation, APHP Hôpital Saint-Antoine, Paris, France; 22Service de Dermatologie, APHP Hôpital Henri Mondor, Créteil, France
Correspondence: Romain ARRESTIER (romain.arrestier@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-20

Rationale: Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Immunocompromised patients have an increased risk of dying. Among them, neutropenic patients could have a particularly high risk of poor outcome but data are scarce. Our objectives are to describe the characteristics and the mortality of neutropenic patients with NSTI requiring intensive care unit (ICU) admission.

Patients and methods/Materials and methods: We conducted a retrospective multicenter cohort study in 18 French ICUs. Patients admitted in participating ICUs between 2011 and 2021 with either surgically confirmed NSTI or clinically suspected diagnosis of NSTI and neutropenia < 1.5 G/L at diagnosis were included. Characteristics and hospital mortality of patients with neutropenic NSTI were compared to a historical cohort of ICU patients with non-neutropenic NSTI. The factors associated with hospital mortality were identified using Cox regression.

Results: 83 neutropenic patients were included and compared to 129 historical non-neutropenic patients. Neutropenia was related to haematological malignancy in 64 (77.1%) patients and to solid cancer in 10 (12%) patients. Median time from neutropenia onset to NSTI was 4 [1-14] days. Other patients’ characteristics are described in Table 1. As compared to non-neutropenic patients, neutropenic patients were younger (65 [56–75] vs 58 [46.5–64] years, p < 0.001), had less frequent lower limb (70.3% vs 42.2%, p < 0.01) and more abdomino-perineal NSTIs (25% vs 42.2%, p = 0.014). Neutropenic patients presented more frequent bacteraemia (58.5% vs 26.4%, p < 0.001). The most frequent bacteria isolated in neutropenic patients were Enterobacteriaceae (42.2%) and Pseudomonas aeruginosa (30.1%). In contrast, non-neutropenic patients were more frequently infected by Streptococcus species than neutropenic patients (68.2% (n = 88) vs 2.4% (n = 2), p < 0.001). Time from NSTI diagnosis to first surgery was shorter in non-neutropenic patients than in others (0 [0–0] days vs 1 [1–2] days, p < 0.001). 28-day and in-hospital mortality rates were significantly higher in neutropenic than in non-neutropenic patients (48.2% vs 25.6%, p = 0.001, and 54.2% vs 35.7%, p = 0.012). In multivariate analysis, factors associated with hospital mortality for neutropenic patients were age (adjusted Hazard Ratio (aHR) = 1.04 (1.02–1.06), p = 0.001) and SOFA score (aHR = 1.16 (1.08–1.25, p < 0.001), while treatment with G-CSF (aHR = 0.34 (0.17–0.66), p = 0.002) was protective.

Conclusion: NSTI in neutropenic patients presented different characteristics and higher mortality than in non-neutropenic patients requiring ICU. Treatment with G-CSF could be associated with better outcomes, although this finding should be interpreted with caution due to the presence of potential unadjusted confounding factors.

Reference 1: Urbina, T. et al. Early identification of patients at high risk of group A streptococcus-associated necrotizing skin and soft tissue infections: a retrospective cohort study. Crit Care 23, 417 (2019).

Compliance with ethics regulations: Yes in clinical research

figure j

Characteristics and ICU outcomes of neutropenic and non-neutropenic patients

CO-21 Critically ill patients with infective endocarditis, neurological failure and indication for cardiac surgery: a multicenter propensity-adjusted study

GROS Alexandre1, GUETTARD Yves Olivier1, SEGUY Benjamin1, PILLOIS Xavier1, PREVEL Renaud1, ORIEUX Arthur1, PREAU Sebastien2, LAVIE-BADIE Yoan3, COUPEZ Elisabeth7, COUDROY Remi4, MAREST Delphine5, MARTINS Raphael6, HIKARU Fukutomi1, GRUSON Didier1, TOURDIAS Thomas1, BOYER Alexandre1

1CHU Bordeaux, Bordeaux, France; 2CHU Lille, Lille, France; 3CHU Toulouse, Toulouse, France; 4CHU Poitiers, Poitiers, France; 5CHU Nantes, Nantes, France; 6CHU Rennes, Rennes, France; 7CHU Clermont-Ferrand, Clermont-Ferrand, France
Correspondence: Alexandre BOYER (alexandre.boyer@chu-bordeaux.fr)

Annals of Intensive Care 2022, 12(1):CO-21

Rationale: The benefit-risk balance and/or optimal timing of surgery for infective endocarditis (IE) with neurological events (ischemic or haemorrhagic stroke) remain debated, especially in critically ill patients. Our hypothesis is that these patients should still benefit from surgery. The main objective of this study was to compare their neurological functional outcome whether they received surgery or not.

Patients and methods/Materials and methods: We conducted a retrospective (2010–2017), French multi-center study of critically ill patients with acute IE. They were included if they met the following criteria: (i) left-sided IE according to the modified Duke criteria, (ii) with cerebral complications documented by cerebral imaging before cardiac surgery and (iii) with Sequential Organ Failure Assessment score (SOFA) ≥ 3; one of these justifying admission to ICU. Exclusion criteria were isolated right endocarditis, in-hospital acquired endocarditis and patients who developed cerebral complications only after cardiac surgery. All patients were explored with brain imaging before surgery. The primary analysis consisted in a propensity score adjusted logistic regression of surgery as an independent variable of the primary outcome, i.e. modified Rankin score (mRS) at 6 months. The 1-year mortality rate was the main secondary outcome.

Results: 192 patients were included whom 67 patients had medical treatment (35%) and 125 underwent cardiac surgery (65%). Delayed surgery according to theoretical recommended timing was decided in 62/125 (50%). Ischemic stroke was the most prevalent neurological complications (74.5%) followed by hemorrhagic lesion (15.6%). In the propensity score-adjusted logistic regression, the odds ratio (OR) for favorable 6-month functional outcome was 0.08 (95% CI 0.03–0.13) in favor of surgery. One-year mortality was strongly reduced with surgery in the fixed-effect propensity adjusted cox model (Hazard Ratio 0.23; 95% CI 0.14–0.36; p < 0.001). These effects remained whether the patients received delayed surgery or not and whether they were deeply comatose or not (Glasgow score > 10).

Conclusion: In this study of critically ill patients with simultaneous infectious endocarditis, indication for surgery and cerebral events, a better propensity-adjusted functional outcome was associated with surgery compared with medical treatment, whatever the deepness of coma. A delayed surgery should be considered in severe acute regurgitations. In the absence of randomized study precluded for ethical concerns, an individualized strategy remains highly suggested.

Compliance with ethics regulations: Yes in clinical research.

CO-22 Predicting central venous catheter-tip colonization in the ICU: development and validation of a score in several randomized trials

IACHKINE Jeanne1, BUETTI Niccolò2, BRIANT Anaïs1, MIMOZ Olivier3, MÉGARBANE Bruno5, MIRA Jean-Paul6, RUCKLY Stéphane8, SOUWEINE Bertrand4, DU CHEYRON Damien1, TIMSIT Jean-François7, PARIENTI Jean-Jacques1

1CHU Caen, Caen, France; 2Hôpitaux universitaires de Genève, Genève, Suisse; 3CHU de Poitiers, Poitiers, France; 4CHU de Clermont-Ferrand, Clermont-Ferrand, France; 5Hôpital Lariboisière AP-HP, Paris, France; 6Hôpital Cochin AP-HP, Paris, France; 7Hôpital Bichat AP-HP, Paris, France; 8Université de Paris, Paris, France
Correspondence: Jeanne IACHKINE (jeanne.iachkine@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-22

Rationale: Catheter-related bloodstream infection (CRBSI) requires urgent removal of the central venous catheter (CVC). However, the majority of CVCs removed because of a suspicion of CRBSI proves sterile. We aimed to develop and validate a score predictive of catheter-tip colonization with pathogens other than Coagulase-negative Staphylococcus (CoNS).

Patients and methods/Materials and methods: We conducted a retrospective study based on databases from two multicenter randomized controlled trials investigating the effect of the catheter insertion site on intravascular complications (training cohort). Catheter colonization was defined as growth of > = 103 colony-forming units per milliliter from the catheter tip culture yielding to pathogens other than skin contaminants according to Brun-Buisson quantitative technique. Potential factors associated with catheter colonization were identified using a generalized linear model with binomial distribution to account for several CVCs per patients, in univariate and multivariate analyses. Internal validation of these risk factors was performed using bootstrap with 500 replications. Then, a score was computed from the adjusted Odds Ratio coefficients. Finally, external validation was performed in three other independent RCTs investigating the effect of different prevention strategies on the incidence of catheter-related infections (validation cohort). Discrimination was assessed by the Area Under the Curve (c-index).

Results: Among 3,681 CVCs and dialysis catheters included in the training cohort, 357 (9.7%) were colonized with microorganisms other than CoNS. Age, obesity, diabetes, site of insertion (jugular and femoral versus sub-clavian), type of catheter (dialysis versus CVC), catheterization duration, fever and local inflammation at removal were independently associated with colonization in multivariate analysis. Diabetes, site of insertion, type of catheter, catheterization duration, fever and local inflammation at removal were robust after internal validation and were computed in the score. Area under the ROC curve for the score was 0.70, 95% CI [0.68–0.73] in the training cohort (Hosmer and Lemeshow goodness of fit test: p = 0.94). The validating cohort included 6,299 dialysis catheters and CVCs, of which 262 (4.2%) were colonized. AUC for the score was 0.65, 95% CI [0.62-0.69] in the validation cohort (Hosmer and Lemeshow goodness of fit test: p = 0.18) (see Fig. 1). Among 1340 catheters removed for suspicion of CRBSI infection in the training and validating cohorts, 1168 (87.2%) were sterile.

Conclusion: This score had a moderate ability to discriminate central venous catheter colonization. Further research is needed to assess the clinical utility of this score for managing CVCs in the ICU, in particular to help clinicians’ decision facing a catheter-related infection suspicion.

Compliance with ethics regulations: Yes in clinical research.

figure k

Roc curves for the scores in (a) training (b) cohorts. AUC, area under the curve.

CO-23 Efficacy of carbapenem vs carbapenem-sparing therapy as empiric antimicrobial therapy in patients with extended-spectrum Beta-lactamase-producing Enterobacteriales urinary septic shock: a propensity-weighted multicenter cohort study (SCRUTIN study)

CARIOU Erwann1, PREVEL Renaud1, SILVA Stein2, FAGUER Stanislas2, SEGUIN Thierry2, NSEIR Saadalla3, CANET Emmanuel4, DESCLAUX Arnaud1, SOUWEINE Bertrand6, KLOUCHE Kada5, GUISSET Olivier1, PILLOT Jerome7, PICARD Walter8, SAGHI Tahar9, DELOBEL Pierre2, GRUSON Didier1, BOYER Alexandre1

1CHU de Bordeaux, Bordeaux, France; 2CHU de Toulouse, Toulouse, France; 3CHU de Lille, Lille, France; 4CHU de Nantes, Nantes, France; 5CHU de Montpellier, Montpellier, France; 6CHU de Clermont Ferrand, Clermont Ferrand, France; 7Ch de Bayonne, Bayonne, France; 8CH de Pau, Pau, France; 9Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
Correspondence: Erwann CARIOU (erwann.ca@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-23

Rationale: Extended-spectrum beta-lactamase-producing Enterobacteriales (ESBL-E) is a serious health threat with $1.2 billion estimated attributable US healthcare costs in 2017. Their dissemination has led to a major increase in the use of carbapenems, last-resort antibiotics. The objective of this study was to assess the efficacy of carbapenem-sparing regimen as empiric therapy in extended-spectrum β-lactamase-producing Enterobacteriales (ESBL-E) urinary septic shock.

Patients and methods/Materials and methods: This retrospective propensity-weighted multicenter observational study conducted in 11 ICUs compared the outcomes of ESBL-E urinary septic shock patients treated with carbapenem or carbapenem-sparing regimen as empiric treatment (piperacillin–tazobactam (PTZ) + aminoglycosides or 3rd generation cephalosporin (3GC) + aminoglycosides). The primary outcome was Day-30 mortality. Secondary outcomes included in-ICU and Day-90 mortality rates, severity of illness, septic shock resolution, ICU and in-hospital length of stay and Clostridium difficile infection.

Results: Among 156 patients included in the study, 69 received a carbapenem and 87 received non-carbapenem antibiotics as empiric treatment. Baseline clinical characteristics were similar between the 2 groups. Patients who received an empiric carbapenem-sparing therapy had similar Day-30 mortality (OR = 0.462 [0.173; 1.775] p = 0,143), illness severity, resolution of septic shock and ESBL-E infection recurrence rates than patients who received carbapenem. The rate of secondary infection with C. difficile was comparable.

Conclusion: In ESBL-E urinary septic shock, empiric treatment with carbapenem-sparing regimen was not associated with higher mortality, compared to a carbapenem regimen.

Reference 1: Harris PNA, Tambyah PA, Lye DC, et al. Effect of piperacillin-tazobactam vs meropenem on 30-day mortality for patients with E coli or Klebsiella pneumoniae bloodstream infection and ceftriaxone resistance: a randomized clinical trial. JAMA 2018; 320:984–9.

Reference 2: Karaiskos I, Giamarellou H. Carbapenem-sparing strategies for ESBL producers: when and how. Antibiot Basel Switz 2020; 9:E61.

Compliance with ethics regulations: Yes in clinical research

figure l

Outcomes.

CO-24 Intravenous Interleukin-7 to restore absolute lymphocyte counts in patients with sepsis

DAIX Thomas1, JEANNET Robin1, MATHONNET Armelle2, MIRA Jean-Paul3, DEQUIN Pierre-François4, MORRE Michel5, WALTON Andrew6, HOTCHKISS Richard6, FRANÇOIS Bruno1

1CHU Dupuytren, Limoges, France; 2CHR Orléans, Orléans, France; 3Hôpital Cochin, AP-HP, Paris, France; 4CHRU de Tours, Tours, France; 5Revimmune, Inc., Bethesda, Md, Etats-Unis; 6Washington University School of Medicine, St Louis, Mo, Etats-Unis
Correspondence: Thomas DAIX (thomas.daix@chu-limoges.fr)

Annals of Intensive Care 2022, 12(1):CO-24

Rationale: Sepsis leads to deep apoptosis-induced depletion of T-cells resulting in increased rate of secondary infection and late morbidity (1). Interleukin-7 (IL-7) is a pluripotent cytokine essential for lymphocyte proliferation and survival. By intra-muscular (IM) or subcutaneous route, IL-7 improved immunity by increasing T-cell count and reversed the marked loss of immune effector cells in lymphopenic patients with septic shock (2). Because IL-7 by IM route led to injection site reactions due to local lymphocytic infiltration, we designed a phase II study evaluating efficacy and safety of a potentially better tolerated route (intravenous).

Patients and methods/Materials and methods: Phase II prospective, randomized, double blind, placebo-controlled trial in 8 ICUs in France and 2 in the United States. Immunocompetent patients with vasopressor-dependent sepsis, two successive absolute lymphocyte counts (ALC) < 900 cells/mm3 and acute respiratory failure and/or acute kidney injury at 48 h after ICU admission were eligible. Forty patients were planned to be randomized 3:1 to receive IV administration of recombinant IL-7 (CYT107) at 10 µg/kg or placebo twice a week for 3 weeks. Primary objective was to determine if IV IL-7 induces an increased ALC at day 29 or hospital discharge. Secondary objective was to assess the safety and tolerability of CYT107.

Results: Between June 2019 and March 2020 21 patients (63.8 ± 15.8 y.o.; SOFA score = 8.8 ± 4.4, APACHE II = 17.5 ± 5.6) received CYT107 (n = 15) or placebo (n = 6). ALC was similar in both group at baseline (0.73 ± 0.38 G/L vs 0.70 ± 0.57 G/L). CYT107 tended to increase the ALC at day 29 or hospital discharge (1.71 ± 1.2 G/L in treatment groups vs 1.18 ± 0.79 G/L in control group; p = 0.17) (Figure). Patients in the treatment group had more organ support-free days (22.13 vs 7.7 days; p = 0.01) and slightly less secondary infections (26.7% vs 33%). Three patients developed fever, tachypnea and evidence of hypercytokinemia associated with IL-7 administration, which necessitated discontinuing therapy. Following the review of these events by the Data Safety Monitoring Board, a pharmacokinetic control was carried out and evidenced a higher concentration of CYT107 than expected (Cmax at 41,423 ± 8,548 ng/ml and an AUC at 273,772 ± 107,786 pg/mlh) at time of adverse event.

Conclusion: While IV injection of IL-7 showed ability to reverse sepsis-related lymphopenia, safety issues related to this route led to favor IM or subcutaneous route for the next phase III trial.

Reference 1: Drewry AM, Samra N, Skrupky LP, Fuller BM, Compton SM, Hotchkiss RS. Persistent lymphopenia after diagnosis of sepsis predicts mortality. Shock. 2014;42(5):383–391.

Reference 2: Francois B, Jeannet R, Daix T, et al. Interleukin-7 restores lymphocytes in septic shock: the IRIS-7 randomized clinical trial. JCI Insight. 2018;3(5):e98960.

Compliance with ethics regulations: Yes in clinical research.

figure m

Absolute Lymphocyte Count (ALC) at day 0 and day 29 (or hospital discharge). Blue dots represent placebo-treated patients and red squares CYT107-treated patients.

CO-25 Intravenous immunoglobulins in patients with COVID-19-associated moderate-to-severe acute respiratory distress syndrome (ICAR): multicentre, double-blind, placebo-controlled, phase 3 trial

MAZERAUD Aurélien1, JAMME Matthieu2, LUCAS Bruno3, SYLLA Khaoussou1, SHARSHAR Tarek1

1GHU Paris Psychiatrie et Neurosciences, Paris, France; 2CH Poissy Saint Germain en Laye, Poissy, France; 3Institut Cochin, INSERM, Paris, France
Correspondence: Aurélien MAZERAUD (aurelien.mazeraud@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-25

Rationale: Acute respiratory distress syndrome (ARDS) is a major complication of COVID-19 and is associated with high mortality and morbidity. We aimed to assess whether intravenous immunoglobulins (IVIG) could improve outcomes by reducing inflammation-mediated lung injury.

Patients and methods/Materials and methods: In this multicentre, double-blind, placebo-controlled trial, done at 43 centers in France, we randomly assigned patients (1:1) receiving invasive mechanical ventilation for up to 72 h with PCR confirmed COVID-19 and associated moderate-to-severe ARDS to receive either IVIG (2 g/kg over 4 days) or placebo. Random assignment was done with a web-based system and was stratified according to the participating center and the duration of invasive mechanical ventilation before inclusion in the trial (< 12 h, 12–24 h, and > 24–72 h), and treatment was administered within the first 96 h of invasive mechanical ventilation. To minimize the risk of adverse events, the IVIG administration was divided into four perfusions of 0·5 g/kg each administered over at least 8 h. Patients in the placebo group received an equivalent volume of sodium chloride 0·9% (10 mL/kg) over the same period. The primary outcome was the number of ventilation-free days by day 28, assessed according to the intention-to-treat principle. This trial was registered on ClinicalTrials.gov, NCT04350580.

Results: Between April 3, and October 20, 2020, 146 patients (43 [29%] women) were eligible for inclusion and randomly assigned: 69 (47%) patients to the IVIG group and 77 (53%) to the placebo group. The intention-to-treat analysis showed no statistical difference in the median number of ventilation-free days at day 28 between the IVIG group (0·0 [IQR 0·0–8·0]) and the placebo group (0·0 [0·0–6·0]; difference estimate 0·0 [0·0–0·0]; p = 0·21). Serious adverse events were more frequent in the IVIG group (78 events in 22 [32%] patients) than in the placebo group (47 events in 15 [20%] patients; p = 0·089).

Conclusion: In patients with COVID-19 who received invasive mechanical ventilation for moderate-to-severe ARDS, IVIG did not improve clinical outcomes at day 28 and tended to be associated with an increased frequency of serious adverse events, although not significant. The effect of IVIGs on earlier disease stages of COVID-19 should be assessed in future trials.

Compliance with ethics regulations: Yes in clinical research.

CO-26 Unsupervised clustering in critically ill COVID-19 patients: corticosteroid therapy may not fit for all

ZERBIB Yoann1, CARPENTIER Mathieu1, RICHECOEUR Jack2, TAMION Fabienne3, CUGNART Cécile3, BONEF Olivier4, VANDERBECKEN Carla1, MICHAUD Audrey1, KONTAR Loay1, SLAMA Michel1, BRAULT Clément1, MAIZEL Julien1

1CHU Amiens PICARDIE, Amiens, France; 2CH Simone Veil, Beauvais, France; 3CHU Rouen, Rouen, France; 4CH Saint Quentin, Saint Quentin, France
Correspondence: Yoann ZERBIB (zerbib.yoann@chu-amiens.fr)

Annals of Intensive Care 2022, 12(1):CO-26

Rationale: Since the beginning of the COVID-19 pandemic, corticosteroid therapy has become a standard treatment for critically ill patients. The aim of this study was to identity COVID-19 clusters and investigate therapeutic response among clusters.

Patients and methods/Materials and methods: We performed a multicenter observational retrospective study between March 2020 and December 2021. A hierarchical clustering on principal components (HCPC) was used to establish COVID-19 profiles based on standard laboratory tests. Demographic data, ICU management, mortality and therapeutic response were compared between clusters.

Results: During the period, 329 patients were included in the analysis. HCPC could identified 2 clusters. Patients of Cluster 2 were older (69 [61, 74] vs 64 [55, 71], p = 0.001) and had more comorbidities (3.50 [2, 5] vs 2 [1, 4], p = < 0.001). These patients had a more severe organ failure. Requirement of invasive mechanical ventilation (69.9% (n = 58) vs 56.5% (n = 139); p = 0.033) and renal replacement therapy (39.8% (n = 33) vs 14,2% (n = 31), p < 0.001) were more frequent. In line with this, in-ICU mortality rate was 44.6% (n = 37) while patients of Cluster 1 died in 27,2% of cases (n = 67) (p = 0,004). Corticosteroid therapy was associated with better outcome among patients of Cluster 1 (Relative Risk = 0.66, 95% CI [0,45–1,001], p = 0.06 and Log Rank test = 0,035) while it was not associated with better survival among patients of Cluster 2 (Relative Risk = 1.51, 95% CI [0,94–2,2], p = 0.12 and Log Rank test = 0,12)

Conclusion: Based on HCPC, we could identify 2 distinct profiles with different severity and different outcome. More importantly, corticosteroid therapy was associated with a better outcome only in the less severe patients. This approach might help clinician to undertake personalized ICU management.

Compliance with ethics regulations: Yes in clinical research.

CO-27 Relationship between corticosteroid adjuvant therapy and incidence of ventilator-associated lower respiratory tract infections: a planned ancillary analysis of the coVAPid cohort

SAURA Ouriel1, ROUZÉ Anahita1, POVOA Pedro3, MARTIN-LOECHES Ignacio2, MAKRIS Demosthenes4, ARTIGAS Antonio5, LABREUCHE Julien1, NSEIR Saad1

1CHU Lille, Lille, France; 2St James Hospital, Dublin, Irlande; 3Hospital de Sao Francisco Xavier, Lisbone, Portugal; 4University Hospital of Larissa, Larissa, Grece; 5Corporacion Sanitaria Universitaria Parc Tauli, CIBER Enferme dades Respiratorias, Sabadell, Espagne
Correspondence: Ouriel SAURA (ouriel.saura@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-27

Rationale: Ventilator-associated lower respiratory tract infection (VA-LRTI) is a common and severe complication in patients admitted to the intensive care unit (ICU) for SARS-CoV-2 pneumonia. Corticosteroids are widely used to treat these patients although the impact of this adjuvant therapy on the incidence of VA-LRTI in this population is still unclear. We sought to determine the relationship between corticosteroid adjuvant therapy and the incidence of VA-LRTI in a large cohort of COVID-19 critically ill patients.

Patients and methods/Materials and methods: This is a planned ancillary analysis of the retrospective multicenter coVAPid study. Adult patients invasively ventilated for more than 48 h for a SARS-CoV-2 pneumonia during the first epidemic surge were consecutively included. VA-LRTI diagnosis required strict definition with clinical, radiological and microbiological documentation. We assessed the association between VA-LRTI and corticosteroid adjuvant therapy using univariate and multivariate cause-specific Cox’s proportional hazard models with adjustment on prespecified confounders and with time stratification.

Results: 545 patients were included, 191 (35%) received corticosteroids. The incidence of VA-LRTI was not significantly different in the corticosteroid-treated versus non-treated patients (p = 0.068 for the likelihood ratio in adjusted model). We found a significant time varying effect of corticosteroid on the incidence of VA-LRTI (p = 0.018), with a non-significant increased risk of developing VA-LRTI after the 14th day following intubation (adjusted cHR 1.38 (95% CI 0.99 to 1.92)).

Conclusion: We found no significant association between corticosteroid adjuvant therapy and the incidence of VA-LRTI in a cohort of COVID-19 critically ill patients. We demonstrated a significant time-varying effect of corticosteroids on the risk of developing VA-LRTI all along the 28-day follow-up.

Compliance with ethics regulations: Yes in clinical research.

CO-28 Impact of corticosteroid therapy on the incidence of ventilator-associated pneumonia in patients with COVID-19: retrospective multicenter observational study

FORT Romain1, VACHERON Charles Herve1, BOHE Julien1, RICHARD Jean Christophe2, RIMMELE Thomas2, LUKASZEWICZ Anne Claire2, ARGAUD Laurent2, DAILLER Frederic2, AUBRUN Frederic2, FELLAHI Jean Luc 2, ALLAOUCHICHE Bernard1, BESTION Audrey2, HODILLE Elisabeth2, LEVRARD Melanie1, GERBAUD COULAS Chloe1, JOFFREDO Emilie1, THIOLLIERE Fabrice1, VASSAL Olivia1, DE SEISSAN DE MARIGNAN Donatien1, JAY Lucille1, PIRIOU Vincent1, FRIGGERI Arnaud1, WALLET Florent1

1CHLS - HCL, Pierre-Bénite, France; 2HCL, Lyon, Gambie
Correspondence: Romain FORT (romain.fort@chu-lyon.fr)

Annals of Intensive Care 2022, 12(1):CO-28

Rationale: Several epidemic reports indicated a high incidence of ventilator-associated pneumonia (VAP) in patients with severe SARS-CoV2 pneumonia (1). Considering the common use of dexamethasone (DXM) since the 2nd wave, we conducted a large retrospective multicenter study to evaluate the influence of DXM exposure on the incidence of VAP.

Patients and methods/Materials and methods: 2088 patients with a diagnosis of COVID-19 admitted to the intensive care unit (ICU) between 27/02/20 and 30/05/21 were included. Among them 1080 (42.2%) had mechanical ventilation (MV) > 48 h, and thus separated into 2 groups according to exposure or not to DXM (protocol defined in the RECOVERY trial): DXM+ (n = 751) and DXM− (n = 329). The diagnosis of VAP was based on clinical and microbiological arguments.

Results: The 2 groups were similar. Majority of patients were on MV within the first 24 h after admission; however, with a longer median time from admission to intubation in the DXM+ group (1 [0–3] vs 0 [0–1]; p < 0.001). Patients exposed to DXM had also a longer duration of intubation: 15 days [8–28] vs 13 days [4–25], p = 0.003. The univariate analysis found a higher proportion of VAP in the DXM+ group (58.7%) compared with the DXM− group (51%) (p = 0.023). The overall incidence rate of VAP episodes was essentially the same in the 2 groups: 50.4‰ ventilator days [46.9–54.2] in the DXM+ group vs 49‰ [43.4–55.1] in the other group. Considering competing factors such as extubation and death, the cumulative incidence of the first episode of VAP was higher in the DXM+ group (p = 0.006) with respectively at 7 days: 37.1% [33.7–40.6] vs. 26.4% [21.7–31.2]; at 14 days: 52.7% [49.2–56.2] vs. 43.5% [38.2–48.7]; and at 28 days: 57.8% [54.3–61.2] vs. 49.9% [44.6–55.1] (Figure). But in multivariate analysis, DXM was not identified as an independent risk factor for VAP: HR = 1.08 [0.89–1.30]; p = 0.444. The microbiological distribution was approximately the same in both groups, most often with polymicrobial documentation represented essentially by gram-negative bacteria (GNB) with an overrepresentation of enterobacteria (45%) and non-fermenting GNB (20%). There was also no difference in terms of mortality.

Discussion: The incidence of VAP in our series is close to that found in Rouzé et al. study (2) of 1576 patients with the same diagnostic criteria for VAP.

Conclusion: In this large multicenter cohort of patients treated for severe SARS-CoV2 infection, there is no association between the incidence of VAP and the use of DXM.

Reference 1: Yang X, Yu Y, Xu J, et al.: Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine 2020; 8:475–481.

Reference 2: Rouzé A, Martin-Loeches I, et al.: Relationship between SARS-CoV-2 infection and the incidence of ventilator-associated lower respiratory tract infections: a European multicenter cohort study. Intensive Care Medicine 2021; 47:188–198.

Compliance with ethics regulations: Yes in clinical research.

figure n

Cumulative incidence curve of the first episode of VAP in patients exposed and not exposed to DXM

CO-29 Citrulline administration in COVID-19 associated ARDS patients: a randomized controlled trial

REIZINE Florian1, LESOUHAITIER Mathieu1, GREGOIRE Murielle1, DULONG Joelle1, LAUNEY Yoann1, LEBOUBIER Thomas1, BENDAVID Claude1, HAMON Catherine1, LE PABIC Estelle1, GACOUIN Arnaud1, MAAMAR Adel1, PAINVIN Benoit1, ROUSSEL Mikael1, PRONIER Charlotte1, LE TULZO Yves1, LAVIOLLE Bruno1, COGNE Michel1, TARTE Karin1, TADIÉ Jean-Marc1

1CHU de Rennes, Rennes, France
Correspondence: Florian REIZINE (florian.reizine@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-29

Rationale: COVID-19 induces a sustained immunosuppression responsible for secondary infections acquisition and late mortality. We recently demonstrated that COVID-19 was responsible for T-cells dysfunction through arginine depletion. Several studies have found that supplementation with citrulline, which is converted in arginine through the activity of argininosuccinate synthetase and argininosuccinate lyase, was more efficient than arginine to increase plasma level of arginine. In the present study, we aimed to assess the effect of citrulline supplementation in COVID-19-associated Acute Respiratory Distress Syndrome (ARDS) patients as an adjuvant therapy with the goal to relieve immunosuppression and help virus clearance.

Patients and methods/Materials and methods: We performed a prospective randomized controlled trial. Patients with RT-PCR confirmed COVID-19 associated ARDS were randomized to receive enteral citrulline supplementation 7 g/day for 7 days or placebo. The primary endpoint was SOFA score on day 7. Secondary outcomes included SOFA score on day 14, Intensive Care Unit (ICU) length of stay (LOS), Day-28 mortality and SARS-CoV2 PCR positivity in tracheal aspirates at day 14 and plasma arginine concentration at day 7.

Results: A total of 32 patients were included (10 women, median age 66 years). SOFA score at day 7 were not statistically different between the two groups (4 (IQR: 3–6) versus 3.5 (3–4); p = 0.8) nor was the SOFA score at day 14 despite a trend towards a diminished SOFA score in the citrulline group (3(2.5–6.5) versus 2 (1–5); p = 0.068). Interestingly, a lower proportion of SARS-COV2 PCR positive respiratory samples was observed at day 14 in citrulline patients (30.8% versus 75%; p = 0.027). ICU LOS did not differ between the two groups (18.5 (13–28) versus 15.5 (10.5–25.5); p = 0.32. Arginine concentrations in patients treated by citrulline were higher at day 7 (51.9 (44.5–70.4) versus 77.7 (56.1–102.6), p = 0.026). Finally, Day-28, mortality was 0/16 in the citrulline group and 2/16 in the placebo group, log-rank test p = 0.2.

Conclusion: In this proof-of-concept study, citrulline supplementation among COVID-19 ARDS patients did not improve day-7 SOFA score. The higher viral clearance promoted by such treatment deserves further investigations.

Compliance with ethics regulations: Yes in clinical research.

CO-30 Decontamination regimen in COVID-19 ICU patients

MASSART Nicolas1, REIZINE Florian2, FILLATRE Pierre1, SEGUIN Philippe2, LACOMBE Béatrice4, FREROU Aurélien5, EGRETEAU Pierre-Yves6, HOURMANT Baptiste7, KERGOAT Pierre8, LORBER Julien9, SOUCHARD Jerome2, CANET Emmanuel10, RIEUL Guillaume3, FEDUN Yannick3, DELBOVE Agathe3, CAMUS Christophe2

1CH Saint-Brieuc, Saint-Brieuc, France; 2CHU de Rennes, Rennes, France; 3CH de Vannes, Vannes, France; 4CH Bretagne SUD, Lorient, France; 5Centre Hospitalier de Saint-Malo, Saint-Malo, France; 6Centre Hospitalier de Morlaix, Morlaix, France; 7CHU de Brest, Brest, France; 8CH de QUIMPER, Quimper, France; 9CH de Saint-Nazaire, Saint-Nazaire, France; 10CHU de Nantes, Nantes, France
Correspondence: Nicola MASSART (nicolasmassart@hotmail.fr)

Annals of Intensive Care 2022, 12(1):CO-30

Rationale: Critically ill patients admitted with SARS-COV 2 infectious disease (COVID-19) are at high risk of ventilator-associated infection (VAP) and ICU acquired bloodstream infection (BSI) with implications for outcomes. Among strategies that aimed to prevent both such acquired infections (AI), selective decontamination regimen has been poorly studied in COVID-19 setting.

Patients and methods/Materials and methods: We performed an ancillary analysis of the COCOREVAP study which is a multicenter retrospective observational study in 15 ICUs in western France. All adults admitted with COVID-19 from February 1st, 2020 until December 31th 2021 who required mechanical ventilation were eligible. In addition to standard care, 3 ICUs used a multiple-site decontamination regimen (MSD), a variant of selective digestive decontamination, which consists of the administration of topical antibiotics including an aminoglycoside (tobramycin or gentamicin), polymyxin and amphotericin B, four times daily in the oropharynx and the gastric tube, chlorhexidine body washing and a 5-day nasal mupirocin course in patients who had an expected intubation duration of 24 h or more. AI and death risk factors were estimated using logistic regression.

Results: During study period, 614 of 1158 COVID-19 patients admitted in our ICUs were intubated for at least 48 h. Due to missing data regarding AIs in 153 patients, 461 patients were finally included. Baseline characteristics in both groups were similar at the exception of a lower age (62 years [55–71] vs 68 [61–73] p = 0.002), a lower body mass index (27.46 [24.39–31.40] vs 28.76 [25.38–32.16] p = 0.026) and a lower proportion of patients admitted during fall 2020 (31.5% vs 48.1% p < 0.001) in the MSD group. Compared with the standard-care group, AI were less frequent in the MSD group with incidence rates of 30.6 per 1000 patients-days and 16.1 per 1000 patients-days (Incidence Rate Ratio = 0.53 95% CI [0.37–0.75] p < 0.001) respectively. In multivariate analysis, MSD administration was associated with a lower risk of AI (OR = 0.36, 95% CI [0.21–0.63]; p < 0.001). Regarding AI site, MSD remained independently associated with a significant lower risk of VAP (OR = 0.35, 95% CI [0.20–0.60]; p < 0.001) but not of BSI (OR = 0.54, 95% CI [0.57–1.31], p = 0.17). Hospital mortality was lower among patients receiving MSD (30.1% vs 16.9% p = 0.017) (Figure), with an independent protective effect (OR = 0.49, 95% CI [0.24–0.99]; p = 0.049).

Conclusion: MSD was associated with a lower incidence of AI among ventilated COVID-19 patients. These promising results deserve confirmation by randomized controlled trials.

Compliance with ethics regulations: Yes in clinical research.

figure o

Figure. Survival curves

CO-31 The association of induced hypothermia at 33 °C and controlled normothermia at 37 °C with outcome in patients with shock on ICU admission after cardiac arrest in non-shockable rhythm: a post-hoc analysis of the HYPERION trial

ZIRIAT Ines1, LE THUAUT Aurélie1, LASCARROU Jean-Baptiste1

1CHU de Nantes, Nantes, France

Correspondence: Ines ZIRIAT (ziriat.inesnaila@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-31

Rationale: Last consensus of ERC-ESICM on temperature management indicates there was insufficient evidence to recommend for or against temperature control at 32–36 °C or early cooling after cardiac arrest. Post-resuscitation shock defined as need for vasopressors after return of spontaneous circulation is associated with high mortality and brain damage. A post-hoc analysis of TTM2 trial indicated a safety signal about higher mortality when 33 °C was chosen as target during TTM. We perform a post-hoc analysis of HYPERION trial to explore interaction between post-resuscitation shock status and temperature targeted after cardiac arrest.

Patients and methods/Materials and methods: Post-analysis of HYPERION trial which include patients with ROSC after cardiac arrest in non-shockable rhythm. Patients were divided according to presence or absence of post-resuscitation shock after cardiac arrest. Impact of induced hypothermia (33 °C) or controlled normothermia (37 °C) on favorable functional outcome (defined as Cerebral Performance Category (CPC) 1 or 2 at day 90) was evaluated.

Results: We included, 581 patients: 339 with post-resuscitation shock and 242 without. Of patient with post-resuscitation shock, 159 received induced hypothermia and 180 controlled normothermia. On day 90, 14 of the 159 patients in the hypothermia group had a CPC score of 1 or 2, as compared with 10 of the 180 patients in the normothermia group, with no significant difference (8.81% vs 5.56%, p = 0.24) (Table 3). Patients in the hypothermia group and the normothermia groups did not differ in terms of mortality on day 90 (83% vs 86%, p = 0.43, Table 4, HR 0.92, 95% CI 0.73-1.16, p = 0.46, Fig. 2).

Conclusion: Presence of a post-resuscitation shock at ICU admission after cardiac arrest in non-shockable rhythm is a major determinant of day-90 functional outcome. There is no interaction between post-resuscitation shock presence and benefits of induced hypothermia provided for patients with cardiac arrest in non-shockable rhythm as compared to controlled normothermia.

Compliance with ethics regulations: Yes in clinical research.

CO-32 Organ donation after out-of-hospital cardiac arrest: a population-based study

RENAUDIER Marie1,2, BINOIS Yannick1,2, DUMAS Florence1,2, LAMHAUT Lionel2,3, BEGANTON Frankie2, JOST Daniel2,4, CHARPENTIER Julien1, LESIEUR Olivier5, MARIJON Eloi2,6, JOUVEN Xavier2,6, CARIOU Alain1,2, BOUGOUIN Wulfran2,7

1Hôpital Cochin, Paris, France; 2Paris Sudden Death Expertise Center, Paris, France; 3Hôpital Necker Enfants-Malades, Paris, France; 4Brigade des Sapeurs Pompiers de Paris, Paris, France; 5Hôpital Saint-Louis, La Rochelle, France; 6Hôpital Européen Georges Pompidou, Paris, France; 7Hôpital Privé Jacques Cartier, Massy, France
Correspondence: Marie RENAUDIER (Mrenaudier@aol.com)

Annals of Intensive Care 2022, 12(1):CO-32

Rationale: Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area.

Patients and methods/Materials and methods: We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated but died in intensive care units in the Paris region in 2011–2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. A donation-likelihood score was established. One-year outcomes of transplants and transplant recipients were assessed using Cox and log-rank tests.

Results: Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e. 28% of the patients with brain death. Patients characteristics are described in the Table. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, predictors of organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6–27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1–1.6], P < 0.001); older age predicted absence of donation (OR/10-year increase, 0.7 [0.6–0.8], P < 0.001). In patients without post-resuscitation shock, the only predictor was neurological cause of OHCA (OR, 6.9 [3.0–15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7–1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2–0.7], P = 0.006) predicted absence of donation. Organ donation occurred in 3% of patients with a prediction score < 0 and 34% of those with a score > 0. One-year outcomes of kidney transplants and their recipients did not differ according to Utstein characteristics of the donor.

Conclusion: Organ donation should be considered in every patient with OHCA due to a neurological cause, independently from presence of post-resuscitation shock and from Utstein characteristics.

Compliance with ethics regulations: Yes in clinical research.

figure p

Table: Utstein characteristics of patients with out-of-hospital cardiac arrest

CO-33 Factors associated with circulatory death after cardiac arrest: a population-based, clustering analysis

BINOIS Yannick1,7, RENAUDIER Marie1,7, DUMAS Florence3,7,8, YOUSSFI Younès8,9, BEGANTON Frankie7,8, JOST Daniel5,7,8, LAMHAUT Lionel6,7,8, MARIJON Eloi4,7,8, JOUVEN Xavier4,7,8, CARIOU Alain1,7,8, BOUGOUIN Wulfran2,7

1Hôpital Cochin, ICU department, Paris, France; 2Hôpital Jacques Cartier, ICU department, Massy, France; 3Hôpital Cochin, Emergency department, Paris, France; 4Hôpital Georges Pompidou, Cardiology department, Paris, France; 5BSPP Paris, Paris, France; 6Hôpital Necker Enfants malades, ICU department, Paris, France; 7Université de Paris, INSERM U970 - PARCC, Paris, France; 8Paris Sudden Death Expertise Center, Paris, France; 9Center for Research in Economics and Statistics, Palaiseau, France
Correspondence: Yannick BINOIS (yannick.binois@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-33

Rationale: Out-of-hospital cardiac arrest (OHCA) is a common cause of death, with a very low survival rate. Early circulatory failure is the most common reason for death within the first 48 h after resuscitation. This study including intensive care unit (ICU) patients with OHCA was designed to identify and characterize clusters based on clinical and laboratory features and to determine the frequency of death from refractory post-resuscitation shock (RPRS) in each cluster.

Patients and methods/Materials and methods: We retrospectively identified adults who were admitted alive to ICUs after OHCA in 2011–2018 and recorded in a prospectively established registry for the Paris area (France). We identified patient clusters by performing an unsupervised hierarchical cluster analysis (without mode of death among the variables) based on Utstein clinical and laboratory variables. For each cluster, we used the Fine-and-Gray approach to estimate the hazard ratio (HRs) for RPRS (defined as post-resuscitation shock refractory to aggressive critical care). Inclusion was at ICU admission. The time-to-event analysis was censored on the date of death in the ICU or date of ICU discharge alive.

Results: Of the 4445 included patients, 1468 (33%) were discharged alive from the ICU and 2977 (67%) died in the ICU. We identified four clusters: initial shockable rhythm with short low-flow time (cluster 1), initial non-shockable rhythm with usual absence of ST-segment elevation (cluster 2), initial non-shockable rhythm with long no-flow time (cluster 3), and long low-flow time with high epinephrine dose (cluster 4). RPRS was significantly associated with this last cluster (HR, 5.51; 95% confidence interval, 4.51–6.74).

Conclusion: We identified patient clusters based on Utstein criteria, and one cluster was strongly associated with RPRS. This result may help to make decisions about using specific treatments after OHCA.

Compliance with ethics regulations: Yes in clinical research.

figure q

Heatmap + PCA

CO-34 Effect of moderate hypothermia vs normothermia on 30-day mortality in patients with cardiogenic shock receiving venoarterial extracorporeal membrane oxygenation: a randomized clinical trial

LEVY Bruno1, GIRERD Nicolas1, OUATTARA Alexandre2, COMBES Alain3

1CHU Nancy, Vandoeuvre Les Nancy, France; 2CHU Bordeaux, Department Of Anaesthesia And Critical Care, Magellan Medico-Surgical Centre, France; 3APHP, Paris La Pitie Salpetriere, Mir, France
Correspondence: Bruno LEVY (blevy@sfr.fr)

Annals of Intensive Care 2022, 12(1):CO-34

Rationale: The optimal approach to the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during cardiogenic shock is uncertain.

Patients and methods/Materials and methods: To determine whether early use of moderate hypothermia (33–34 °C) compared to strict normothermia (36–37 °C) improves mortality in patients with cardiogenic shock receiving VA-ECMO. Multicenter, unblinded, parallel-group, randomized clinical trial in the intensive care units (ICU) of 20 French Cardiac Shock Care Centers Patients were eligible if they were endotracheally intubated and had been receiving VA-ECMO for cardiogenic shock for < 6 h. Of 786 eligible patients, 374 were randomized. The primary outcome was mortality at 30 days. There were 21 secondary outcomes including mortality at days 7, 60, and 180; a composite outcome of death, cardiac transplant, stroke or escalation to left ventricular assist device (LVAD) at days 30, 60 and 180, ventilatory- and kidney replacement therapy-free days between inclusion and days 30, 60 and 180. Adverse events included rates of severe bleeding, sepsis and number of packed red blood cells transfused during VA-ECMO.

Results: 334 patients completed the trial (mean age, 57 [SD 12] years. At 30 days, 71 of the 168 patients (42%) in the moderate hypothermia group and 84 of the 166 patients (51%) in the normothermia group had died (adjusted odds-ratio = 0.71; 95% confidence interval 0.45–1.13, p = 0.15; risk difference -8.3% (− 16.3 to − 0.3%)). The odds-ratio of the composite outcome of death, cardiac transplant, escalation to LVAD and stroke in the hypothermia group, as compared with the control group, was 0.61 (95% CI 0.39–0.96, p = 0.03) at day 30 (risk difference − 11.5% (− 23.2 to 0.2%)). Of the 27 secondary outcomes, 26 were inconclusive. The incidence of severe or moderate bleeding was 34% in the hypothermia group and 36% in the normothermia group. The incidence of infections was 52% in both groups.

Conclusion: In patients with refractory cardiogenic shock treated with VA-ECMO, early application of moderate hypothermia for 24 h did not significantly increase survival compared with normothermia. However, because the confidence interval was wide and included a potentially clinical important effect size, these findings should be considered inconclusive.

Reference 1: Levy B et al. JAMA. 2022 Feb 1;327(5):442-453. https://doi.org/10.1001/jama.2021.24776.

Compliance with ethics regulations: Yes in clinical research.

figure r

Kaplan Meier survival estimates during the first 30 days of VA-ECMO patients treated with moderate hypothermia or normothermia. Median (IQR) of observation time was 8 (28, 30) days.

CO-35 Effects of mean arterial pressure target on mottling and arterial lactate normalization in patients with septic shock

FAGE Nicolas1,2, DEMISELLE Julien3,4, SEEGERS Valérie5, MERDJI Hamid3,4, GRELON Fabien6, MEGARBANE Bruno7, ANGUEL Nadia8, MIRA Jean-Paul9, DEQUIN Pierre-François10, GERGAUD Soizic11, WEISS Nicolas12, LEGAY François13, LE TULZO Yves14, CONRAD Marie15, COUDROY Rémi16, GONZALEZ Frédéric17, GUITTON Christophe18, TAMION Fabienne19, TONNELIER Jean-Marie20, BEDOS Jean Pierre21, VAN DER LINDEN Thierry22, VIEILLARD-BARON Antoine23,24, MARIOTTE Eric25, PRADEL Gaël26, LESIEUR Olivier27, RICARD Jean-Damien28, HERVE Fabien29, DU CHEYRON Damien30, GUERIN Claude31, MERCAT Alain1, TEBOUL Jean Louis8, RADERMACHER Peter32, ASFAR Pierre1

1Department of Medical Intensive Care, University Hospital of Angers, Angers, France; 2MITOVASC Laboratory UMR INSERM (French National Institute of Health and Medical Research), 1083 – CNRS 6015, University of Angers, Angers, France; 3Department of Intensive Care (Service de Médecine Intensive – Réanimation), Nouvel Hôpital Civil, University Hospital of Strasbourg, Strasbourg, France; 4INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS (Fédération de Médecine Translationnelle de Strasbourg), University of Strasbourg, Strasbourg, France; 5Service de Biométrie, Institut de Cancérologie de l'Ouest, Centre Paul Papin, Angers, France; 6Medical and Surgical Intensive Care Unit, Le Mans Hospital, Le Mans, France; 7Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France; 8Department of Medical Intensive Care, Bicêtre University Hospital, AP-HP, Paris-Saclay University, Le Kremlin Bicêtre, France; 9Department of Medical Intensive Care, Cochin University Hospital, Paris, France; 10Department of Medical Intensive Care, Tours University Hospital, Tours, France; 11Department of Surgical Intensive Care, University Hospital of Angers, Angers, France; 12Department of Medical Intensive Care, Georges Pompidou European Hospital, Assistance Publique – Hôpitaux de Paris, University of Paris, Paris, France; 13Medical and Surgical Intensive Care Unit, Saint Brieuc Hospital, Saint Brieuc, France; 14Department of Infectious Diseases and Medical Intensive Care, Rennes University Hospital, Rennes, France; 15Department of Medical Intensive Care, Nancy University Hospital, Nancy, France; 16Department of Medical Intensive Care, Université de Poitiers, CHU Poitiers, Poitiers, France; 17Department of Medical and Surgical Intensive Care, Avicenne Teaching Hospital, Bobigny, France; 18Department of Medical Intensive Care, Nantes University Hospital, Nantes, France; 19Department of Medical Intensive Care, Rouen University Hospital, Rouen, France; 20Department of Medical Intensive Care, Brest University Hospital, Brest, France; 21Intensive Care Unit, Versailles Hospital, Le Chesnay, France; 22Department of Intensive Care, Saint Philibert hospital, Catholic University of Lille, Lille, France; 23Department of Medical Intensive Care, University Hospital of Ambroise Paré, Boulogne Billancourt, France; 24Inserm U1018, Center for Research in Epidemiology and Population Health (CESP), Paris Saclay University, Villejuif, France; 25Department of Intensive Care, Saint Louis Hospital, Paris, France; 26Department of Intensive Care, Avignon Hospital, Avignon, France; 27Department of Medical and Surgical Intensive Care, La Rochelle Saint Louis Hospital, La Rochelle, France; 28Université de Paris, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive Réanimation, Colombes, France; 29Department of Medical and Surgical Intensive Care, Quimper Hospital, Quimper, France; 30Department of Medical Intensive Care, Caen University Hospital, Caen, France; 31Department of Medical Intensive Care, Edouard Herriot Hospital, Lyon, France; 32Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, Ulm, Allemagne
Correspondence: Nicolas FAGE (fage.nicolas@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-35

Rationale: In patients with septic shock, the impact of mean arterial pressure (MAP) target on the course of mottling remains uncertain. We investigated whether a low-MAP (between 65 and 70 mm Hg) or a high-MAP target (between 80 and 85 mm Hg) would affect the course of mottling and arterial lactate in patients with septic shock.

Patients and methods/Materials and methods: For this post hoc analysis of the SESPSISPAM trial (1), we included patients with at least one available data regarding mottling. Data that concerned mottling were considered until the discontinuation of catecholamine or for a maximum of 5 days under vasopressors. The presence or absence of mottling was recorded every 2 h from 2 h after inclusion to the catecholamine weaning. We compared time course of mottling and arterial lactate between the two MAP target groups. We then evaluated the patient’s outcome according to the presence or absence of mottling.

Results: We included 747 patients in this analysis: 374 were assigned to the low-MAP target group and 373 to the high-MAP target group. After adjustment for MAP target and confounding factors, the presence of mottling ≥ 6 h during the first 24 h was significantly associated with a higher risk of death at day 90 [Hazard Ratio (HR) 2.28 (1.74–3.00), p < 0.0001]. As compared with low MAP target, a high MAP target did not alter mottling course (Fig. 1) and arterial lactate normalization. Our results were similar when considering only patients who reached the criteria of the SEPSIS-3 definition of septic shock. In addition, when compared to arterial lactate at inclusion, mottling duration appeared to be a better microcirculatory marker of mortality risk. Indeed, patients without mottling or mottling during less than 6 h and with arterial lactate ≥ 2 mmol/l has a lower mortality [HR 1.56 (1.10–2.20)] than patients with mottling during more than 6 h and with arterial lactate < 2 mmol/L [HR of 2.77 (1.80–4.30) (p = 0.005)].

Conclusion: In this large-scale study, we showed that a MAP target between 80 and 85 mm Hg, achieved through increased vasopressor doses, did not alter the course of mottling nor arterial lactate normalization. In patients with septic shock, the presence of mottling ≥ 6 h was associated with higher mortality at day 28 and day 90. In addition, compared to arterial lactate at inclusion, mottling duration appears to be a stronger marker of mortality risk.

Reference 1: Asfar P, Meziani F, Hamel J-F et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med. 24 avr 2014;370(17):1583–93.

Compliance with ethics regulations: Yes in clinical research.

figure s

Course of mottling in patients with septic shock according to the mean arterial pressure target. Horizontal line represents a patient follow-up. Solid line corresponds to a period with mottling; hatched line corresponds to period without mottling

CO-36 Right ventricular failure is strongly associated with mortality in patients with moderate-to-severe COVID-19-related ARDS

EVRARD Bruno1, GOUDELIN Marine1, GIRAUDEAU Bruno2, BRIAT Charlotte1, FEDOU Anne-Laure1, DAIX Thomas1, VAIDIE Julien1, SANSON Amandine1, FRANCOIS Bruno1, VIGNON Philippe1

1CHU Limoges, Limoges, France; 2CHU de Tours, Tours, France
Correspondence: Bruno EVRARD (bruno.evrard@chu-limoges.fr)

Annals of Intensive Care 2022, 12(1):CO-36

Rationale: The incidence and prognostic value of new-onset right ventricular failure (RVF) in patients hospitalized in intensive care unit (ICU) for moderate-to-severe acute respiratory distress syndrome (ARDS) related to COVID-19 has been scarcely studied. Accordingly, the objective was to evaluate the association between the development of RVF during ICU stay and 90-day mortality in patients admitted for COVID-19 ARDS. Secondary objective was to evaluate the association between the new-onset RVF and variations of respiratory parameters.

Patients and methods/Materials and methods: In this single-center prospective observational study, ICU patients with COVID-19 moderate-to-severe ARDS were serially assessed using echocardiography. RVF was defined as the association of dilated RV (RV/left ventricular end-diastolic area > 0.6) and elevated central venous pressure (≥ 8 mmHg). Multivariate Cox model analysis accounting for new-onset RVF as time-dependent variable was used to identify parameters associated with mortality. In the subset of patients without RVF at baseline who subsequently developed RVF during the ICU stay, we compared respiratory parameters between the day of the RVF diagnosis and the day of the preceding CCE assessment using a Wilcoxon signed-rank test.

Results: Overall, 401 echocardiographic assessments were performed in 140 patients, 43 of whom died at day 90 (31%). RVF was identified within 72 h of ICU admission in 35 patients and secondarily in 40 patients. RVF was independently associated with 90-day mortality (adjusted hazard ratio: 8.17; 95% confidence intervals: 3.15–21.2; p < 0.001). Other independent risk factors were age (HR per 10 years: 1.84; 95% CI: 1.20–2.81; p = 0.005) and ischemic cardiomyopathy (HR: 2.26; 95% CI: 1.19–4.31; p = 0.013). Worsening of PaO2/FiO2 (median [quartiles]: 70 mmHg [57–126] vs. 96 mmHg [69–159]: p = 0.005), PaCO2 (60 mmHg [46–65] vs. 51 mmHg [35–61] p = 0.036), ventilatory ratio (2.73 [2.29–3.57] vs. 2.25 [1.51–2.92]: p = 0.004), and driving pressure (14 cm H2O [13–19] vs. 13 cm H2O [10–14]: p = 0.005) were associated with new-onset RVF.

Conclusion: The development of RVF during ICU stay was independently associated with a markedly higher risk of 90-days mortality and appeared associated with a worsening of respiratory parameters.

Compliance with ethics regulations: Yes in clinical research.

CO-37 Sedation-analgesia in pediatric ICU: PEDIASLEEP study

ALLARY Chloé1, RONCIN César1, MICHEL Fabrice1

1La Timone - Assistance Publique des Hôpitaux de Marseille, Marseille, France
Correspondence: Chloé ALLARY (chloe.allary@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-37

Rationale: Sedation in pediatric intensive care units (PICU) is balancing between endangerment patient and the risk of tachyphylaxis, withdrawal syndrome and delirium (1). The main objective was to describe sedation-analgesia procedures in France. The secondary objectives was to specify the use of drugs without marketing authorization, and to observe the drugs associations.

Patients and methods/Materials and methods: We conducted a multicentric, descriptive and prospective study in France, between May and July 2021. PICU were joined by the PICURE network or by the chief of department. The referring doctors answered a first online survey describing their unit. They answered a second online survey about each sedated patient on the days of the study. The included patients were hospitalized in PICU; aged between 38 weeks of amenorrhea (WA) and 18 years old; received drugs for sedation or withdrawal syndrome. Excluded patients received painkillers against pure nociceptive pain, or palliative or terminal sedation.

Results: Thirty PICU were included, between 8 and 34 beds. Fourteen centers (47%) used protocols. Nurses were autonomous to set dose of sedation according to protocol in 13 centers. Four hundred and two questionnaires were filed. Twelve were excluded: 5 because of age < 38 WA, 7 because they received pure analgesia. Patients ages were: neonates 19%, infant 39%, 2-6 years old 17%, 6–10 years old 5%, 10–14 years old 8%, and 14–17 years old 11%. Forty eight percent patients were in postoperative care, including 30% post cardiotomy; 74% had invasive ventilation, 4% extra corporeal membrane oxygenation, 5% hemodialysis. Sedation was scored in 291 (74%) patients mainly by Comfort Behavior Scale (55%). Pain was scored in 314 (80%) patients, mainly using the Comfort Behavior Scale (50%). Withdrawal was scored in 214 patients (55%), mainly using the Withdrawal Assessment Tool 1. Sixteen per cent patients received no opioids; 42% received Morphine, and 36% Sufentanil. Non-opioid antalgics were: Acetaminophen (78%), NSAIDs, Nefopam, Nalbuphine. While 22% patients didn’t received hypnotic, 57% received Midazolam, 34% alpha agonist, 18% Ketamine, 8,5% Propofol. Use of Pentothal, Levomepromazine and Sevoflurane was uncommon. Only 9% of patients received neuromuscular blocking agents, mainly Cisatracurium and Atracurium. Non-drug treatment was used in 77% cases: mainly parental presence, circadian rhythm observance, music therapy and cocooning.

Conclusion: The most frequent sedation includes an association between an opioid and a benzodiazepine. Non-drug cares are widely used. Though recommended, scores are not often used.

Reference 1: Harris et al. Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals, Intensive Care Med 2016 Jun;42(6):972–86.

Compliance with ethics regulations: Yes in clinical research.

CO-38 Retrospective study on prolonged sedation effects with inhaled agents in PICU

BERGER Léo1, MIATELO Jordi2, LÉGER Pierre-Louis1

1Hôpital Armand-Trousseau, Paris, France; 2Hôpital Bicêtre, Le Kremlin-Bicêtre, France
Correspondence: Léo BERGER (leo.berger@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-38

Rationale: In ICU, sedation-analgesia is a major therapeutic element to provide adequate comfort to the patient and to permit a good synchronization with the respirator. Currently, it is common to associate benzodiazepine with opioid. However, after prolonged sedation, effects of the sedative become exhausted, requiring an increase in doses, leading to an increased incidence of withdrawal syndrome, and delaying extubation. Since the beginning of the XXI century, there has been a growing interest in the use of halogenated gases in ICU, because of their hypnotic effects. Furthermore, there is little data on their use during prolonged sedation. Therefore, their efficacy and tolerance should be assessed. They could reduce the dosage of benzodiazepines and opioids, thereby reducing the incidence of withdrawal syndrome.

Patients and methods/Materials and methods: This is a retrospective, multicentric cohort study. 50 children (median age 2.2 years, [0.8–7.2]) admitted to PICU between January 2018 and December 2020 were included. All of them received multimodal prolonged sedation (> 72 h) for mechanical ventilation. They all benefited from volatile sedation (Isoflurane of Sevoflurane) for 24 h at least. The primary endpoint was a decrease superior to 20% in benzodiazepine dosages during the first 24 h after halogenated introduction. A 20% decrease in other hypnotics, NMBA, and opioids were also explored. The proportion of adverse events and withdrawal syndrome were collected.

Results: A statistically significant reduction in benzodiazepines dosages (μg/kg/h) was reported (118 [62.5; 200] vs 80.0 [32.5; 120], p < 0,01). The same results were found for other hypnotics (Ketamine: 2.00 [1.00; 2.00] vs 1.50 [1.00; 2.00], p = 0.036, mg/kg/h; Clonidine: 0.55 [0.35; 1.27] vs 0.20 [0.12; 0.43], p = 0.036, μg/kg/h). For opioids (μg/kg/h), only Sufentanil (0.80 [0.50; 1.00] VS 0.70 [0.35; 1.00]; p = 0.022) and Fentanyl (6.00 [4.00; 8.00] VS 5.75 [3.25; 6.00], p = 0.012) decreased significantly. No major adverse effects were reported. 26% of patients developed withdrawal syndrome.

Conclusion: Halogenated gases seem to be an interesting therapeutic to reduce dosages of different hypnotics and opioids used during multimodal prolonged sedations. Inhalation of halogenated gas via the ACD seems to be sure and easy to use. That appears to be a simple method for maintaining long-term sedation in PICU. Our results suggested IA sedation using the ACD to be an effective and safe alternative to the usual intravenous Propofol- or Midazolam-based regimen. Sevoflurane provided sedation quality comparable to Propofol and Midazolam, but with decreased wake-up and extubation times.

Compliance with ethics regulations: Yes in clinical research.

CO-39 3D and Thermography video research infrastructure for multi-modal image acquisition in the Pediatric Intensive Care Unit

SHCHERBAKOVA Monisha1, BOIVIN Vincent2, TIASSOU Edem1, WILLGENSS Priscilla2, VAIL Mariane3, SAUTHIER Michael1, JOUVET Philippe1, NOUMEIR Rita2

1CHU Sainte Justine, Montreal, Canada; 2Ecole de technologie supérieure, Montreal, Canada; 3HEC Montreal, Montreal, Canada
Correspondence: Monisha SHCHERBAKOVA (monisha.shcherbakova.hsj@ssss.gouv.qc.ca)

Annals of Intensive Care 2022, 12(1):CO-39

Rationale: Computer vision has promising potential for the diagnosis of vital distress in critically ill patients including neurological, respiratory and hemodynamic distress. For instance, measurement of respiratory rate using 3D videos in spontaneous breathing patients and correlation between low cardiac output and thermal distribution using infrared (IR) images were reported in several studies. The aim of our research was to setup a multi-modal video infrastructure to create a clinical video research database and pave the way to real-time vital distress video monitoring within a pediatric intensive care unit (PICU).

Patients and methods/Materials and methods: The specifications of the infrastructure were developed by an interdisciplinary team including clinicians, computer scientists, and hospital information technology personnel. These specifications took into account the requirements of the research ethics board: (1) a multimodal video system (MMVS) that is able to capture color (RGB) videos for neurological distress analysis, 3D videos for respiratory distress analysis and thermal videos for hemodynamic analysis; (2) a MMVS in each room on the ceiling above the patient’s bed; (3) security systems to only register videos of patients who have consented to the study; (4) automatic data storage on the hospital private servers; (5) synchronization of the videos with clinical data collected simultaneously; (6) data classification in a research database.

Results: The MMVS developed included a hardware and a software component (Fig. 1). The hardware component consisted of a NVIDIA Jetson Xavier NX mini-computer that has a built-in GPU (NVIDIA Corp, USA) connected to a Kinect Azure RGB-3D camera (Microsoft, USA) and a FLIR Lepton 3.5 thermal sensor (Teledyne FLIR, USA). Both cameras are pointed towards the patient and are placed in a 3D printed support. The software component included a web user interface for performing the acquisitions in the hospital intranet in a secure manner. The video research database currently includes more than 200 acquisitions and is being used in various studies to assess vital distress signs including facial expressions to estimate sedation level and consciousness using RGB videos, the refinement of tidal volume and respiratory rate measurements in patients using 3D videos, and estimation of the thermal gradient across various parts of the body using IR.

Conclusion: A multi-modal RGB 3D and thermography video infrastructure was successfully set up and a video research database of critically ill children was constructed and enabled algorithm development to assess various vital distress. This setup could be replicated in other PICUs.

Compliance with ethics regulations: Yes in clinical research.

CO-40 Volume per kg per transfusion of the first red blood cell (RBC) transfusion given to participants of the ABC-PICU randomized controlled trial, for the ABC-PICU Investigators, CCCTG, PALISI Network, BloodNet Network, and GFRUP

GALLAND Anne1, DU PONT-THIDODEAU Geneviève1, SPINELLA Philipp2, LETEURTRE Stéphane3, DUCRUET Thierry4, LACROIX Jacques1, TUCCI Marisa1

1Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada; 2Department of Surgery and Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Etats-Unis; 3Réanimation et Surveillance Continue Pédiatriques, Hôpital Jeanne de Flandre, CHRU Lille, Lille, France; 4Unité de recherches cliniques appliquées, Research Centre, CHU Sainte-Justine, Montreal, Canada
Correspondence: Jacques LACROIX (jlacroix052@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-40

Rationale: New et al1 completed a national cohort study in the United Kingdom (UK); all hospitals were invited to participate. Hospitalized children—not only those in pediatric intensive care units (PICU)—< 18 years old who received an RBC transfusion during a 3-month period in 2009 were eligible for inclusion. The median volume was 15.0 (IQR: 11.8–19.2) mL/kg per transfusion, with peaks of prescription volume at 10, 15 and 20 mL/kg. Almost no specific attention has been paid to the volume of RBC transfusion administered in PICU. We determined the volume/kg/transfusion of the first RBC transfusion given to participants in the Age of Blood in Children in PICU (ABC-PICU) trial.2 The hypothesis was that we would find the same variability in the volume/kg administered to PICU patients than reported by New in hospitalized children.

Patients and methods/Materials and methods: Patients enrolled in ABC-PICU were allocated to receive either fresh (stored <7 days) or standard-issue RBC (delivery of oldest compatible unit available in the blood bank). The volume of RBC unit per transfusion was not controlled in ABC-PICU. Cardiac patients were randomized before surgery; other patients were randomized in PICU. In the former, data on RBC transfusion were collected in the operating room and PICU while data in the latter were collected only in PICU.

Results: 1538 patients across 50 centers (US, Canada, France, Italy, Israel) were randomized between February 2014 and August 2018; 1474, including 1263 non-cardiac patients, received at least one RBC transfusion. Figure 1 reports the number of participants to ABC-PICU per range of volume of the first RBC transfusion administered after randomization. Among the 1474 participants, 105 (7.1%) received > 30 mL/kg/transfusion; most (82/105 = 78.1%) were cardiac patients who were first transfused while priming a cardio-pulmonary bypass. Among 1263 non-cardiac participants, 736 (58.3%) received between 9 and 16.99 mL/kg/transfusion; a significant proportion received < 9 or > 17 mL/kg/transfusion (286 or 22.6% and 241 or 19.1%, respectively).

Conclusion: There is an important variability in the volume/kg/transfusion given to participants in ABC-PICU. Data on bleeding status and on-site policy limiting volume per transfusion (e.g., not more than one unit per transfusion) were not collected in ABC-PICU, which limits the interpretation of the results reported in this abstract. Future studies taking into account patients’ bleeding status and site-specific policy on volume per transfusion must investigate what are the causes and the clinical impact of the variability that we observed in ABC-PICU participants.

Reference 1: New HV, Grant-Casey J, Lowe D, Kelleher A, Hennem S, Stanworth SJ. Red blood cell transfusion practice in children: current status and areas for improvement? A study of the use of red blood cell transfusions in children and infants. Transfusion 2014;54.

Reference 2: Spinella PC, Tucci M, Fergusson DA, Lacroix J, Hébert PC, Leteurtre S, et al. The age of transfused blood in critically ill children. JAMA 2019;322:2179–90.

Compliance with ethics regulations: Yes in clinical research.

figure t

Volume of first red cell transfusion given after randomization to 1263 non-cardiac and 211 cardiac participants to the ABC-PICU trial.

CO-41 In situ simulation training for parental presence during critical situations in PICU: an observational study

BORDESSOULE Alice1, FELICE-CIVITILLO Cristina1, GRAZIOLI Serge1, BARCOS Francisca1, HADDAD Kevin1, RIMENSBERGER Peter1, POLITO Angelo1

1HUG, Geneva, Suisse
Correspondence: Alice BORDESSOULE (alice.bordessoule@hcuge.ch)

Annals of Intensive Care 2022, 12(1):CO-41

Rationale: Family presence during invasive procedures or cardiopulmonary resuscitation (CPR) is a part of the family-centered approach in pediatric intensive care units (PICUs). We established a simulation program aiming at providing communication tools to healthcare professionals. The goal of this study was to evaluate the impact of this program on the stress of PICU professionals and its acceptance.

Patients and methods/Materials and methods: An observational study of a simulation program, with questionnaire, was used to measure pre- and post-simulation stress and the degree of satisfaction of the participants. Setting: PICU of Geneva Children’s Hospital, Switzerland. Forty simulations with four different simulation scenarios and various types of parental behavior, as imitated by professional actors, were completed during a 1-year period. Primary outcomes were the difference in perceived stress level before and after the simulation and the degree of satisfaction of healthcare professionals (nursing assistants, nurses, physicians). The impact of previous experience with family members during critical situations or CPR was evaluated by variation in perceived stress level.

Results: Overall, 201 questionnaires were analyzed. Perceived stress associated with parental presence decreased from a pre-simulation value of 6 (IQR, 4–7) to 4 (IQR, 2–5) post-simulation on a scale of 1–10. However, in 25.7% of cases, the individually perceived post-simulation stress level was higher than the pre-simulation one. Satisfaction of the participants was high with a median of 10 (IQR, 9–10) out of 10 (Fig. 1).

Discussion: Our study describes an in situ pediatric simulation program of critical situations in the presence of family members played by professional actors. The simulation program was explicitly aiming at the development of communication skills. The “in situ” setting and the possibility to debrief in the presence of a psychologist represent two innovative features of our study. The simulation generally, but not always, showed a reduction in healthcare professionals perceived stress caused by family presence during a critical situation in the PICU. To meet the demand of participants experiencing a high level of stress after the simulation, a pre-simulation video on potential benefits and pitfalls of family presence during critical situations as well as on ad-hoc communication tools is now available to all future participants.

Conclusion: A simulation program helps reduce PICU team emotional stress associated with the presence of family members during critical situations or CPR, and is welcomed by PICU team members.

Compliance with ethics regulations: Yes in clinical research.

figure u

Figure 1. Box plot showing overall pediatric intensive care team stress related to family member presence during cardiopulmonary resuscitation or other major interventions in the pediatric intensive care unit, before and after the simulation.

CO-42 Beta-lactam exposure and safety in intermittent or continuous infusion in critically ill children

DEBRAY Agathe3, CALLOT Delphine2, HIRT Deborah2, BILLE Emmanuelle1, RENOLLEAU Sylvain1, CHOUCHANA Laurent2, TRELUYER Jean-Marc1,2, OUALHA Mehdi1, BERANGER Agathe1

1Necker enfants malades, Paris, France; 2cochin, Paris, France; 3trousseau, Paris, France
Correspondence: Agathe BERANGER (agathe.beranger@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-42

Rationale: To assess the pharmacokinetic (PK) efficacy and clinical toxicity for three beta-lactams: cefotaxime, piperacillin/tazobactam and meropenem, depending on two administration modalities: continuous or intermittent infusions in critically ill children.

Patients and methods/Materials and methods: This single center observational prospective study was conducted in a pediatric intensive care unit. All hospitalized children who had one measured plasma concentration of the investigated antibiotics were included. Plasma antibiotic concentrations were interpreted by a pharmacologist, using a Bayesian approach based on previously published population pharmacokinetic models. Exposure was considered optimal, low, or high according to the PK target 100% fT > 4 × MIC and a trough concentration below the toxic concentration (50 mg.L−1 for cefotaxime, 150 mg.L−1 for piperacillin and 44 mg.L−1 for meropenem).

Results: Between May 2019 and January 2020, 80 patients were included and received 106 antibiotic courses: 74 (70%) were administered in intermittent infusion (II) and 32 (30%) in continuous infusion (CI). Compared to II, CI provided more optimal PK exposure (OR 1.2, 95% CI 1.01–1.5, p = 0.04), less underexposure (OR 0.7, 95% CI 0.6–0.84, p < 0.001) and more overexposure (OR 1.2, 95% CI 1.03–1.3, p = 0.01) (Fig. 1). Five adverse events have been reported during the study period, although none have been attributed to beta-lactam treatment.

Conclusion: Continuous infusion provided a higher probability to attain an optimal PK target compared to intermittent infusion, but also a higher risk for overexposure. Regular therapeutic drug monitoring is recommended in critically ill children receiving beta-lactams, regardless of the administration modality.

Compliance with ethics regulations: Yes in clinical research.

figure v

Description of the antibiotic exposure (underexposure, optimal exposure or overexposure) depending on the drug (A) or for the whole cohort (B), with respect to the administration route, intermittent infusion (II) or continuous infusion (CI).

CO-43 Incidence and risk factors of weaning-induced cardiac dysfunction: results from a multicenter, observational study

SHI Rui1, AYED Soufia1, TEBOUL Jean-Louis1, ANGUEL Nadia1, OSMAN David1, PHAM Tài1, MORETTO Francesca1, LAI Christopher1, BEUZELIN Marie2, PERSICHINI Romain3, LEGOUGE Marie4, DE VITA Nello5, LEVY Bruno6, BEURTON Alexandra7, MANGAL Kishore8, HULLIN Thomas9, LABBE Vincent10, GUILLOT Max11, HARROIS Anatole12, MONNET Xavier1

1Service de médecine intensive-réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France; 2Service de réanimation polyvalente, Centre hospitalier de Dieppe, Dieppe, France; 3Service de réanimation médicale, Hôpital Félix Guyon, Saint-Denis-De-La-Réunion, France; 4Service de d’anesthésie-réanimation adultes, Centre hospitalier d'Orléans, Orléans, France; 5Università del Piemonte Orientale, Dipartimento di Medicina Traslazionale, Novara, Italie; 6Service de réanimation médicale, Hôpital de Nancy-Brabois, Vandoeuvre-Lès-Nancy, France; 7AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive Réanimation (Département R3S), Paris, France; 8Department of Medicine and Critical Care, Eternal Hospital, Eternal Heart Care Centre & Research Institute, Jaipur, Inde; 9Service de réanimation polyvalente, Hôpital Sud-Essone, Etampes, France; 10Service de réanimation, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Tenon, Paris, France; 11Service de réanimation médicale, Hôpital de Strasbourg, Strasbourg, France; 12Service d'anesthésie-réanimation, Université Paris-Saclay, AP-HP, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
Correspondence: Rui SHI (rui.shi@u-psud.fr)

Annals of Intensive Care 2022, 12(1):CO-43

Rationale: Weaning-induced pulmonary edema (WiPO) is one of the main reasons for weaning failure. Nevertheless, the reported incidence of WiPO is variable mainly in monocentric studies with small sample size. We thus aimed to evaluate the incidence and risk factors of WiPO in a large mixed population of critically ill patients.

Patients and methods/Materials and methods: Adult critically ill patients receiving invasive ventilation were included once the attending physicians decided to perform a spontaneous breathing trial (SBT). Patients with tracheostomy were excluded. The duration and modalities of the SBT (T-tube/pressure support or others) were decided by attending physicians. The consensual diagnosis of WiPO was made a posteriori by five experts based on the patient characteristics, hemodynamic and echocardiographic variables, and biochemical results.

Results: From July 2019 to February 2021, 634 SBT performed in 500 patients (65 (55–74) y.o., 64% male) from twelve intensive care units, were prospectively included. The main indication for intubation was acute respiratory failure in 202 (40%) patients, neurological failure in 100 (20%) patients, interventional procedure in 74 (15%) patients, shock in 55 (11%) patients, resuscitated cardiac arrest in 10 (2%) patients, a mixture of previous reasons in 53 (11%) patients and miscellaneous reasons in 6 (1%) patients. SBT failed at 217 (34%) occurrences observed in 157 (31%) patients. WiPO was identified in 79 (36%) failed SBTs in 58 (37%) patients. We assessed WiPO according to the main indication for intubation, the prevalence of WiPO was 73% in patients intubated for acute respiratory failure/shock/sepsis, 13% in patients intubated for neurological failure, 9% in patients intubated after resuscitated cardiac arrest, and 5% in those intubated for an interventional procedure. Among 217 failed SBTs, WiPO occurred in 54 (25%) of SBTs performed with a T tube, 16 (7%) with pressure support ventilation, and 9 (4%) with other modalities. Compared to patients without WiPO (n = 98), patients with at least one WiPO (n = 58) had a higher prevalence of chronic obstructive pulmonary disease (COPD) (27% vs. 7%, respectively; p = 0.001), and previous cardiopathy (dilated and/or hypertrophic and/or valvular disease, 49% vs. 23%, respectively; p = 0.002). A logistic regression analysis found that, COPD (odds ratio (OR): 5.1, [95% confidence interval: 1.9–14.0]), and previous cardiopathy (OR: 2.9 [1.4–6.2]) were independent risk factors for developing WiPO.

Conclusion: In a large mixed population of critically ill patients, WiPO accounts for 36% of SBT failure. COPD and a previous cardiopathy were independent risk factors for developing WiPO.

Compliance with ethics regulations: Yes in clinical research.

CO-44 Plasma exchange are not associated with better outcome in MDA5 rapidly-progressive interstitial lung disease

BAY Pierre1, PINETON DE CHAMBRUN Marc2, ROTHSTEIN Vincent3, MAHEVAS Matthieu1, DE PROST Nicolas1, ROUX Antoine4, ZUBER Benjamin4, ISRAEL BIET Dominique5, HERVIER Baptiste6, TAZI Abdellatif6, MOUTHON Luc7, MEKINIAN Arsene9, DELIGNY Christophe15, BORIE Raphael8, MEURICE Jean Claude10, PRIOU Pascaline10, MEYER Alain12, SAVALE Laurent14, DE SAINT MARTIN Luc13, BRILLIET Pierre-Yves3, KHAFAGY Philippe3, BENVENISTE Olivier2, NUNES Hilario3, ALLENBACH Yves2, UZUNHAN Yurdagul3

1CHU Henri Mondor, Créteil, France; 2CHU Pitié Salpétrière, France, France; 3CHU Avicenne, Bobigny, France; 4Hopital Foch, Suresnes, France; 5Hopital Européen Georges Pompidou, Paris, France; 6CHU Saint Louis, Paris, France; 7CHU Cochin, Paris, France; 8CHU Bichat, Paris, France; 9CHU Saint Antoine, Paris, France; 10CHU Poitiers, Poitiers, France; 11CHU Angers, Angers, France; 12CHU Strasbourg, Strasbourg, France; 13CHU Brest, Brest, France; 14CHU Bicetre, Le Kremlin Bicetre, France; 15CHU Martinique, Fort De France, France

Correspondence: Pierre BAY (pierrebay53@yahoo.fr)

Annals of Intensive Care 2022, 12(1):CO-44

Rationale: Rapidly progressive interstitial lung disease (RP-ILD) is a frequent manifestation of anti-MDA5 dermatomyositis (DM) and is associated with a high mortality rate. The appropriate treatment regimen of anti-MDA5 RP-ILD is uncertain. A potential pathogenic role of MDA5 antibodies motivated plasma exchange (PLEX) but whether the effectiveness of this procedure is unknown. The aim of the study was to evaluate the outcome of patients undergoing PLEX for anti-MDA5 RP-ILD.

Patients and methods/Materials and methods: This French multicenter retrospective study was conducted from 2012 to 2021 in 18 hospitals and included all patients with anti-MDA5 RP-ILD. The primary endpoint was one-year mortality.

Results: 51 patients with anti-MDA5 RP-ILD (female 67%; mean age at disease onset: 51 ± 11.6 years) were included. 32 patients (62.7%) required mechanical ventilation. 25 patients (49%) received PLEX. Baseline characteristics were not different between PLEX+ and PLEX− patients. PLEX+ patients received more immunosuppressants and required more often mechanical ventilation (19 PLEX+ vs 13 PLEX−, p 0.05). One-year morality rate for PLEX+ and PLEX− patients was 64% and 42.6%, respectively. The Kaplan–Meier estimated probabilities of one-year survival were similar for PLEX+ vs. PLEX− patients (Fig. 1).

Conclusion: Anti-MDA5 RP-ILD is associated with a high 1-year mortality rate. The use of PLEX was not associated with a favorable outcome. Further studies are needed to evaluate their efficacy.

Compliance with ethics regulations: Yes in clinical research.

figure w

Kaplan–Meier Curves for the 1-year mortality status according to plasma exchange status.

CO-45 Spontaneous pneumomediastinum in critically ill COVID-19 patients

ELABBADI Alexandre1, TOMAS Urbina2, ENORA Berti3, CONTOU Damien 4, QUINTANA Soulier2, CARTEAU Guillaume3, VOIROT Guillaume1, FARTOUKH Muriel1, GIBELIN Aude1

1Hôpital Tenon, APHP, Paris, France; 2Hôpital Saint-Antoine, APHP, Paris, France; 3Hôpital Henri Mondor, Créteil, France; 4Centre Hospitalier Victor Dupouy, Argenteuil, France
Correspondence: Alexandre ELABBADI (alexandre.elabbadi@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-45

Rationale: Spontaneous pneumomediastinum (SP), defined by the presence of air within the mediastinum without traumatic lesion, has been described during ARDS, even in the era of protective ventilation. It has been also described in case series of COVID-19 with severe pneumonia in the absence of use of invasive mechanical ventilation. We aimed at describing the prevalence of spontaneous pneumomediastinum during severe COVID-19 pneumonia, and at investigating its prognostic impact

Patients and methods/Materials and methods: We conducted a retrospective multicenter observational study in 4 French intensive care units (ICUs) between August 2020 and April 2021. All patients with laboratory-confirmed COVID-19 with severe pneumonia were included. Spontaneous pneumomediastinum was diagnosed either on chest X-ray or chest CT-scan. The primary endpoint was to estimate the prevalence of SP during COVID-19 with severe pneumonia. Secondary endpoints were to investigate the prognostic impact of SP, using a composite criterion named “complicated course” including mechanical ventilation or death at day-28.

Results: During the study period, 672 patients with COVID-19 with severe pneumonia were included. Thirty-two patients (5%) developed a SP after 9 days [4–-13] of COVID-19 onset. A pneumothorax was associated in 10 patients (31%). Two-third of patients (n = 21; 66%) developed a SP after 6 days [4–12] of ICU admission, while they did not receive invasive mechanical ventilation (IMV). Finally, half of these patients (n = 11/21) required IMV after 1 day [0–3] of SP diagnosis. Although the proportion of patients requiring IMV was similar, the time to tracheal intubation was longer in the patients with SP (6 days vs. 2 days; p < 0.01), with a significantly higher first-line use of high-flow nasal oxygen therapy or non-invasive ventilation, and more awake prone positioning sessions. Although there was no difference in “complicated course”, the length of stay in the ICU was significantly higher in the SP group (18 vs 9 days, p = 0.01).

Conclusion: Prevalence of SP was not uncommon, affecting nearly 5% of all patients admitted to the ICU. Nearly two third of SP occur before or in the absence of IMV. This suggests that, barotrauma secondary to invasive mechanical ventilation, does not appear to be preponderant in the occurrence of pneumomediastinum in COVID-19. Mechanism is potentially carried-out by patient self-inflected lung injury and hyperinflation secondary to a prolonged respiratory failure, as underlined by a longer delay before invasive mechanical ventilation. Presence of a pneumomediastinum should alert the clinician in a spontaneously breathing patient to its tolerance and the need to use a more protective ventilation.

Compliance with ethics regulations: Yes in clinical research.

CO-46 Attributable mortality and population attributable fraction of death of ventilator-associated pneumonia among pandemic non-COVID-19 patients, and pandemic COVID-19 patients

VACHERON Charles-Hervé1, LEPAPE Alain1, SAVEY Anne1, MACHUT Anais1, TIMSIT Jean-Francois2, COURNO Gaelle4, VANHEMS Philippe5, LANDEL Verena5, LAVIGNE Thierry6, BAILLY Sebastien7, BETTEGA Francois7, COMPAROT Sylvie3, REA-REZO Study Group1, MAUCORT-BOULCH Delphine5, FRIGGERI Arnaud5

1CHU lyon sud, Lyon, France; 2APHP, Paris, France; 3CH Avignon, Avignon, France; 4CH Toulon, Toulon, France; 5CHU Lyon, Lyon, France; 6CHU Strasbourg, Strasbourg, France; 7CHU Grenoble, Grenoble, France
Correspondence: Charles-Hervé VACHERON (charles-herve.vacheron@chu-lyon.fr)

Annals of Intensive Care 2022, 12(1):CO-46

Rationale: Patients with a SARS-CoV-2 infection are at higher risk of Ventilator-Associated Pneumonia (VAP) and may have an increased Attributable Mortality (AM) and Population Attributable Fraction (PAF) of mortality related to VAP.

Patients and methods/Materials and methods: Using the REA-REZO surveillance network, 3 groups of adult medical ICU patients were computed: control group (patients admitted between 2016 and 2019), pandemic COVID-19 group (PandeCOV+), and pandemic non-COVID-19 group (PandeCOV−) admitted during 2020. The primary outcome was the estimation of AM and PAF related to VAP in these patients. Using multi-state modeling with causal inference, the outcomes related to VAP were also evaluated.

Results: A total of 64816 patients were included in the control group, 7442 in the PandeCOV−, and 1687 in the PandeCOV+ . The incidence of VAP was 14.2 (95% CI [13.9;14.6]), 18.3 (95% CI [17.3;19.4]), and 31.9 (95% CI [29.8;34.2]) VAP per 1000 ventilation-day, in each group, respectively. AM at 90 days was 3.15% (95% CI [2.04;3.43]), 2.91% (95% CI [− 0.21;5.02]), and 8.13% (95% CI [3.54–12.24]), and PAF of mortality at 90 days was 1.22% (95% CI [0.83;1.63]), 1.42% (95% CI [− 0.11–2.61]), and 9.17% (95% CI [3.54;12.24]) for the control, PandeCOV−, and PandeCOV+ .groups, respectively. Except for the higher risk of developing a VAP, the PandeCOV− group shared similar VAP characteristics with the control group. PandeCOV+ patients were at lower risk of death without VAP (HR 0.62, 95% CI [0.52;0.74]) and tended to have a higher risk of death after acquiring VAP (HR 1.07, 95% CI [0.86;1.33]) compared to the control group.

Conclusion: Patients admitted in ICUs during the pandemic, even without a diagnosis of COVID-19, were at higher risk of VAP. VAP attributable mortality was higher for COVID-19 patients, with more than 9% of the overall mortality related to VAP.

Compliance with ethics regulations: Yes in clinical research.

CO-47 FX06 to rescue acute respiratory distress syndrome during Covid-19 pneumonia. A randomized clinical trial

GUERIN Emmanuelle1, FRANCHINEAU Guillaume2, LE GUENNEC Loic1, FRAPARD Thomas1, LEFEVRE Lucie1, LUYT Charles-Edouard1, COMBES Alain1, HAYON Jan2, ASFAR Pierre3, BRECHOT Nicolas1

1CHU Pitié-Salpêtrière, Paris, France; 2CHI de POISSY, Saint-Germain-En-Laye, France; 3CHU d'ANGERS, Angers, France
Correspondence: Nicolas BRECHOT (nicolas.brechot@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-47

Rationale: Vascular leakage is a major feature of SARS-CoV-2 induced acute respiratory distress syndrome (ARDS). Its levels are associated with mortality, which remains as high as 50%. FX06, a drug under development containing fibrin-derived peptide beta15–42, stabilizes cell-cell interactions, thereby reducing vascular leak and mortality in several animal models of ARDS. It was successfully used as a rescue therapy in a patient exhibiting a severe ARDS following EBOLA virus infection. The aim of this study was to evaluate the efficacy of FX06 in reducing vascular leakage during SARS-CoV-2 induced ARDS.

Patients and methods/Materials and methods: We conducted a double-blinded placebo-controlled multicenter trial. Patients receiving invasive mechanical ventilation for less than 5 days for a SARS-CoV-2 induced ARDS were randomized to receive intravenous FX06, 400 mg per day during 5 days, or its placebo, on the top of usual care. The primary endpoint was the reduction of pulmonary vascular leakage from day 1 to day 7, evaluated by transpulmonary thermodilution-derived extra-vascular lung water index (EVLWi). All analyses were conducted on an intent-to-treat basis.

Results: After one consent withdrawal, 49 patients were enrolled and randomized, 25 in the FX06 group and 24 in the placebo group. Patients were very severe, with a median SAPS-II score of 57 [IQR 39; 66], a median PaO2:FiO2 ratio of 104 [69; 165], and a median static pulmonary compliance of 28 ml/cm of water [19; 35]. One third of them were equipped with veno-venous ECMO. Although EVLWi was elevated at baseline (15.6 ml/kg [13.5; 18.5]), the primary endpoint of its reduction from day 1 to day 7 was comparable between groups (− 1.9 ml/kg [− 3.3; − 0.5] in the FX06 group vs. − 0.8 ml/kg [− 5.5; − 1.1] in the placebo group, estimated effect − 0.8 [− 3.1; 2.4], p = 0.51). Cardiac index, pulmonary vascular permeability index, and fluid balance were also comparable between groups. PaO2:FiO2 ratio remained low and comparable between groups. Duration of mechanical ventilation and survival were also not affected by FX06 infusion, with 21 (84%) patients surviving at day 30 in the FX06 group and 17 (71%) in the placebo group (p = 0.27). Adverse events rates were comparable between groups, although patients receiving the drug experienced more ventilator-associated pneumonia (16/25 vs. 6/24, p = 0.009).

Conclusion: In this trial FX06 failed to reduce the level of SARS-CoV-2 induced pulmonary vascular leakage. Further studies are needed to evaluate its efficacy at earlier time points of the disease or using other dosing regimens.

Compliance with ethics regulations: Yes in clinical research.

CO-48 Quality of life and long-term assessment of survivors after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome due to COVID 19

CHOMMELOUX Juliette1, VALENTIN Simon2, ADDA Mélanie3, PINETON DE CHAMBRUN Marc1, MOYON Quentin1, MATHIAN Alexis1, CAPELLIER Gilles4, GUERVILLY Christophe3, LEVY Bruno2, JACQUET Pierre5, SONNEVILLE Romain5, VOIRIOT Guillaume6, DEMOULE Alexandre1, BOUSSOUAR Samia1, BRECHOT Nicolas1, LEBRETON Guillaume1, BARHOUM Pétra1, LEFÈVRE Lucie1, HEKIMIAN Guillaume1, LUYT Charles-Edouard1, COMBES Alain1, WINISZEWSKI Hadrien4, SCHMIDT Matthieu1

1Hôpital de la Pitié Salpêtrière, Paris, France; 2Centre Hospitalier Régional Universitaire de Nancy, Nancy, France; 3Hôpital Nord, Marseille, France; 4Centre Hospitalier Régional Universitaire de Besançon, Besançon, France; 5Hôpital Bichat, Paris, France; 6Hôpital Tenon, Paris, France
Correspondence: Juliette CHOMMELOUX (juliette.chommeloux@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-48

Rationale: Mortality of COVID- related acute respiratory distress syndrome (ARDS) treated with ECMO did not differ from other ARDS in the first wave of the pandemic. However, ECMO duration and hospital length of stay were much longer. We aimed to assess the long-term quality of life (QoL) and mortality of patients COVID 19 who received ECMO.

Patients and methods/Materials and methods: Survivors after ECMO-treated ARDS from March to June 2020 in 7 French Intensive Care Unit (ICU) were followed up at 6 and 12 months after ECMO onset. Pulmonary (CT scan, pulmonary function test, St George score), physical (MRC and examination), and psychological were assessed. QoL was compared to the age-matched French population and patients with non-COVID ARDS treated with ECMO.

Results: Eighty out of 132 patients with ECMO were discharged alive during that period. Eighteen patients were lost to follow-up and were not included in our study. The 62 studied survivors were predominantly male, median age 47 [40–55] years, and have very few comorbidities except obesity (BMI 32 [28–36] kg/m2). ECMO and mechanical ventilation duration were 18 [11–25] and 36 [27–62] days, respectively. Besides, their ICU and hospital length of stay were 43 [33–62] and 85 [29–112] days. At 1 year, only one patient was still in the hospital. Pulmonary function tests were good at 6 months except for a persistent impairment of the DLCO. However, 75% of patients had fibrotic-like patterns on the CT scan at that time. QoL, assessed by the SF-36, was impaired compared with the French age-matched population, but also with non-COVID ARDS treated with ECMO. Noticeably, QoL did not improve at 1 year of follow-up. At 1 year, 44% and 42% of the patients had signs of anxiety and depression, respectively, whereas 42% of survivors had symptoms of post-traumatic stress disorder. Lastly, only 38% of these patients returned to their initial work at 1 year.

Conclusion: Contrary to non-COVID ARDS, the long-term QoL of COVID patients treated with ECMO was still severely impaired at one year. Besides, a very large proportion of survivors still complained about anxiety, depression, and post-traumatic stress symptoms. These results emphasize the importance to integrate these young patients into customized, patient-centered, rehabilitation programs after ICU discharge.

Compliance with ethics regulations: Yes in clinical research.

figure x

Compared quality of life (SF-36) 6 and 12 months after ECMO for severe ARDS due to COVID 19 with non-COVID ARDS on ECMO and French-age matched population

CO-49 Late venovenous extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome due to SARS-CoV-2

NATIVEL Mathilde1, PUECH Bérénice1, VALANCE Dorothée1, CALLY Radj1, DANGERS Laurence1, JABOT Julien1, BRAUNBERGER Eric1, NIGOLEAN Alexandru1, ALLYN Jérôme1, ALLOU Nicolas1, VIDAL Charles1

1CHU Nord de La réunion, Saint-Denis, Reunion
Correspondence: Mathilde NATIVEL (mathildennativel@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-49

Rationale: Invasive mechanical ventilation (IMV) beyond 10 days is a relative contraindication to venovenous extracorporeal membrane oxygenation (VV-ECMO). Few studies have evaluated the prognosis of late VV-ECMO support in patients with acute respiratory distress syndrome (ARDS) due to SARS-CoV-2. The aim of our study was to evaluate the characteristics and prognosis of patients supported with late VV-ECMO for refractory ARDS due to SARS-CoV-2.

Patients and methods/Materials and methods: It was a multicenter, retrospective, observational study that evaluated all patients assisted with VV-ECMO between July 2020 and December 2021 for refractory ARDS related to SARS-CoV-2. We compared the characteristics of patients supported with late VV-ECMO (beyond 10 days of IMV) with those supported with early VV-ECMO (< 10 days).

Results: Over the study period, 467 patients were hospitalized in 4 intensive care units (ICU) for SARS-CoV-2 pneumonia. Among them 54 patients with a median age of 51 (42;57) years had required VV-ECMO support (12%). Of the 54 patients, 11 had late VV-ECMO (20%) with a median implantation time of 11 [11–14] days after the beginning of IMV (Table 1). Late implanted patients were less obese (p = 0.02), they tended to have less diabetes mellitus (p = 0.09) and to have a lower simplified acute physiology score (SAPS) II (p = 0.12). At the time of VV-ECMO implantation, significant differences were observed with higher lactatemia in the early implanted group (1.8 mmol/L vs. 1.2 mmol/L, p = 0.02) and higher capnia in the late VV-ECMO patients (67 mmHg vs. 53 mmHg, p < 0.01). Vasopressor support by norepinephrine was comparable between the two groups (p = 0.19). The in-ICU mortality was 56% without significant difference between the two groups (p = 1), even after adjustment for Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score (p = 0.64) or SAPS II (p = 0.99).

Conclusion: Late VV-ECMO implantation in patients with refractory ARDS related to SARS-CoV-2 does not appear to be associated with an excess risk of mortality, provided that patients were selected on their clinical characteristics at ICU admission (past medical history, SAPS II) and their severity at the time of implantation (associated organ failures). These results are consistent with other studies concerning SARS-CoV-2 associated ARDS [1,2]. The delay of IMV beyond 10 days should not be a contraindication to the implantation of VV-ECMO in patients with SARS-CoV-2 associated ARDS.

Reference 1: Olivier et al. Crit Care (2021) Prolonged time from intubation to cannulation in VV-ECMO for COVID-19: does it really matter? 25:385 https://doi.org/10.1186/s13054-021-03800-5.

Reference 2: Hermann et al. Annals of Intensive Care (2022) Duration of invasive mechanical ventilation prior to extracorporeal membrane oxygenation… 12:6 https://doi.org/10.1186/s13613-022-00980-3.

Compliance with ethics regulations: Yes in clinical research.

figure y

Table 1: Selected characteristics at implantation of the whole population and univariate analyses between early (< 10 days of mechanical ventilation) and late (beyond 10 days) VV-ECMO. Results are expressed as median ([Q25; 75] or number (%).

CO-50 DD ECMO: Prevalence and evolution of diaphragmatic dysfunction in patients with acute respiratory distress syndrome under veno-venous ECMO

GAUTIER Melchior1, JOUSSELIN Vincent1, DEMOULE Alexandre1, COMBES Alain1, SCHMIDT Matthieu1, DRES Martin1

1Pitié Salpetrière, Paris, France
Correspondence: Melchior GAUTIER (melchiorgautier25@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-50

Rationale: ECMO is currently part of care in severe acute respiratory distress syndrome (ARDS). Its use is frequently associated with prolonged deep sedation and neuromuscular blockades, that may lead to diaphragm dysfunction. This latter is associated with delayed mechanical ventilation weaning and poor outcomes. Our study aims to assess the prevalence of diaphragmatic dysfunction in a large population of severe ARDS on veno-venous ECMO. We hypothesize that diaphragmatic dysfunction is frequent, severe, and associated with prolonged mechanical ventilation and poor outcomes in that severe population.

Patients and methods/Materials and methods: We conducted a prospective, observational study in two medical intensive care units. All patients with SARS-CoV-2 related ARDS requiring veno-venous ECMO were included from February 1 to September 31, 2021. Diaphragmatic function was daily assessed by measuring diaphragm pressure generation in response to phrenic nerve stimulation (Ptr,stim) from ECMO initiation until ECMO weaning.

Results: Sixty-three patients were included with a median age of 53 (42–59) years old and after a median of 4 days (2–6) of mechanical ventilation. Diaphragmatic dysfunction upon inclusion (at day 1 of ECMO) was present in 38 patients (60%). Patients with diaphragmatic dysfunction at day 1 were older (55 years [43–60] vs. 48 years [40–55], p = 0.042) and had a higher LUS (Lung Ultrasound score as a surrogate of lung aeration loss) (26 vs. 24, p = 0.037). Diaphragmatic function did not significantly change over the study period (Fig. 1). 24 patients had a successful ECMO weaning, sixteen patients (67%) had diaphragmatic dysfunction the day of ECMO weaning. Besides, these patients had longer mechanical ventilation duration when compared to those without diaphragmatic dysfunction (62.9 vs 41.7 days).

Conclusion: Diaphragmatic dysfunction is frequent in ARDS patients undergoing ECMO for SARS-CoV-2 infection. When present at ECMO day-1, diaphragmatic dysfunction did not seem to evolve over time. However, it was associated with a longer duration of mechanical ventilation in patients successfully weaned from ECMO.

Compliance with ethics regulations: Yes in clinical research.

figure z

Figure 1: Time course of diaphragmatic function from D1 to ECMO weaning. Values are presented as medians with their standard deviations. The red line corresponds to the threshold of 11 cmH 2 O below which diaphragmatic dysfunction is defined.

CO-51 Impaired pharmacokinetics of amiodarone under veno-venous extracorporeal membrane oxygenation: from bench to bedside

LESCROART Mickael1, PRESSIAT Claire2, PEQUIGNOT Benjamin1, HÉBERT Jean-Louis3, ALSAGHEER Nassib1, SCALA BERTOLA Julien1, LEVY Bruno1

1CHRU Nancy, Vandoeuvre, France; 2CHRU Henri Mondor, Créteil, France; 3Hopital Pitié Salpétrière, Institut de cardiologie, Paris, France
Correspondence: Mickael LESCROART (dr.lescroart@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-51

Rationale: Adjusting drug therapy under Veno-Venous Extra-Corporeal-Membrane-Oxygenation (VV-ECMO) is challenging. Albeit impaired pharmacokinetics (PK) under VV-ECMO have been reported for sedative drugs and antibiotics, data about amiodarone are lacking. We assessed the PK of amiodarone under VV-ECMO in vitro and in vivo using a porcine model of cardiac arrest ongoing CPR previously injured with ARDS rescued by VV-ECMO.

Patients and methods/Materials and methods: In vitro: closed loop ECMO were used for studying amiodarone adsorption over a 120 min period versus a recipient control. Amiodarone bolus (100 and 300 mg) were studied. In vivo: ARDS was induced in 10 pigs. Animals were randomly assigned to control or VV-ECMO groups. Amiodarone 300 mg was injected once CPR started and twelve blood samples were drawn over a 12 min period. Pharmacokinetic analysis was performed with non-linear mixed effects modelling.

Results: In vitro study revealed a significant decrease in amiodarone concentrations after 10 min and a loss of 99.6% of amiodarone concentrations after 120 min. In vivo pharmacokinetics revealed a significant decrease of Cmax, with 123.5 mg/L (109.5–150.0) versus 61.7 mg/L (55.3–80.3) in the control vs ECMO groups (p = 0.02), respectively without delaying time to peak concentration with 90 s (60–90) versus 90 s (75–90), respectively (p = 1). VV-ECMO significantly modified central distribution volume and amiodarone clearance. Monte-Carlo simulations predicted that amiodarone 600 mg bolus under VV-ECMO could achieve the AUC observed in the control group.

Conclusion: This is the first study reporting pharmacokinetics of amiodarone under VV-ECMO in an animal model. We found significant alterations of drug delivery. Higher amiodarone doses might be considered for efficient pharmacokinetics under VV-ECMO.

Compliance with ethics regulations: Yes in animal testing.

figure aa

Panel A: experimental protocol. Panel B: Visual Predictive Check for amiodarone model. Left panel: control group. right panel: ECMO group. Panel C: Monte Carlo simulations to reach amiodarone AUC Q1–Q3 in the control group.

CO-52 Increasing sweep gas flow through the membrane lung reduces dyspnea and respiratory drive in veno-arterial ECMO patients– The DysCO 2 study

BUREAU Côme1, SCHMIDT Matthieu1, NIERAT Marie-Cécile1, DANGERS Laurence1, CLERC Sébastien1, JOUSSELLIN Vincent1, MAYAUX Julien1, MORAWIEC Elise1, COMBES Alain1, SIMILOWSKI Thomas1, DEMOULE Alexandre1

1Hôpital Universitaire Pitié-Salpêtrière, Paris, France
Correspondence: Côme BUREAU (come.bureau@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-52

Rationale: Patients with severe heart failure may benefit from veno-arterial extracorporeal membrane oxygenation vaECMO, which preserves systemic blood flow. In addition, the vaECMO oxygenation membrane ensures blood oxygenation and CO2 removal. In clinical practice, vaECMO patients may exhibit dyspnea despite adequate blood flow and the absence of blood gas abnormalities. Our objective was to evaluate, in vaECMO patients exhibiting significant dyspnea, the impact of an increase in sweep gas flow through the vaECMO membrane on dyspnea.

Patients and methods/Materials and methods: Patients with (1) vaECMO for cardiogenic shock and (2) a dyspnea ≥ 40 mm on a visual analog dyspnea scale (Dyspnea-VAS) from zero to 100 mm were included. Four conditions were studied: on inclusion and after three sweep gas flow increments of two liters per minute each. Dyspnea was assessed with the Dyspnea-VAS, the A1 score of the Multidimensional Dyspnea Profile and the Intensive Care Respiratory Distress Operating Scale (IC-RDOS). The respiratory drive was concomitantly assessed by the measure of the electromyographic activity of the Alea Nasi and parasternal muscles.

Results: We included 21 non-mechanically ventilated patients. Median (interquartile range) age was 40 years (30–55), 62% male and duration of ECMO was 3 days (2–4). Dyspnea-VAS was 50 (45–60) mm. Weinberg radiological pulmonary oedema score was 3 (0–5). Gas flow at inclusion was 1 L/min (0.5–2). Table 1 shows respiratory rate, PaCO2, Dyspnea-VAS, A1 score and IC-RDOS across the four conditions. PaCO2 decreased in response to the 2-L-per-minute increase in sweep, but it ceased to decrease after 6 L. Dyspnea did not decrease immediately but was significantly lower after 6 L of increased sweep regardless of the assessment score. The electromyographic activity of Alea nasi and parasternal muscles decreased significantly after sweep gas flow increment. There was a significant inverse correlation between the Dyspnea-VAS and the sweep gas flow (Rho = − 0.68, p < 0.0001) but not between Dyspnea-VAS and PaCO2 (Rho = 0.136, p = 0.236).

Conclusion: In critically ill patients with vaECMO, incrementation of sweep gas flow through the oxygenation membrane decreases dyspnea. It might be mediated by a decrease in respiratory drive, as suggests the concomitant decrease in respiratory rate and electromyographic activity of respiratory muscles.

Compliance with ethics regulations: Yes in clinical research.

figure ab

p < 0.05 compared to the Baseline condition, $ p < 0.05 compared to the + 2 condition, £ p < 0.05 compared to the + 4 condition

CO-53 Amniotic fluid embolism rescued by venoarterial extracorporeal membrane oxygenation

AISSI JAMES Sarah 1, KLEIN Thomas2, LEBRETON Guillaume 1, NIZARD Jacky1, CHOMMELOUX Juliette1, BRECHOT Nicolas1, PINETON DE CHAMBRUN Marc1, HEKIMIAN Guillaume1, LUYT Charles-Edouard1, LEVY Bruno2, KIMMOUN Antoine2, COMBES Alain1, SCHMIDT Matthieu1

1Hôpital Pitié Salpêtrière, Paris, France; 2CHRU, Nancy, France

Correspondence: Sarah AISSI JAMES (sarah.aissi@live.fr)

Annals of Intensive Care 2022, 12(1):CO-53

Rationale: Amniotic fluid embolism (AFE) is a rare but often catastrophic complication of pregnancy. The cardiopulmonary dysfunction associated with AFE being typically self-limited, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support has been reported in the most severe forms. Data available on AFE rescued by VA-ECMO were mainly described in single-case reports and concern can be raised about the bleeding risks with ECMO in that context. The objectives of this retrospective study were to report outcomes of ECMO-treated AFE; to describe their critical care management and in-ICU complications; and to report long-term maternal health-related quality of life (HRQOL).

Patients and methods/Materials and methods: This study included patients with AFE, according to Clark diagnostic criteria (1), rescued by VA-ECMO and hospitalized in two ECMO centers between August 2008 and February 2021. Clinical characteristics, peri-delivery resuscitative procedures and critical care management are detailed. Main outcome variables included survival to ICU discharge, days under ECMO therapy, ECMO-associated complications, time on mechanical ventilation, ICU length of stay. ICU survivors were assessed for long term HRQOL during a phone interview in May 2021 by completing the Short-Form 36 questionnaire and the Impact of Event Scale screening for Post-Traumatic Stress Disorder (PTSD)-related symptoms.

Results: During that 13-year study period, 10 patients with AFE were treated with VA-ECMO. Seven patients had a cardiac arrest before ECMO and two were cannulated under cardiopulmonary resuscitation. Pre-ECMO hemodynamic was severely impaired with an inotrope score at 370 (55–1530) μg/kg/min, a severe left ventricular ejection fraction at 14 (0–40) %, lactate at 12 (2–30) mmol/L, SAPS II at 69 (56–81) and massive blood transfusion requirement. 70% of these patients were alive at hospital discharge, 50% reported ECMO-related complications. Median durations of ECMO and mechanical ventilation support were respectively 4 (1–6) and 5 (1–13) days. The median ICU length of stay was 12 (1–25) days. All infants survived. HRQOL was lower than age-matched controls and still profoundly impaired in the role-physical, bodily pain, and general health components after a median of 44 months follow-up (Fig. 1). Four out of seven patients returned to their initial work.

Conclusion: In this rare per-delivery complication, our results support the use of VA-ECMO despite extreme initial severity, intense disseminated intravascular coagulation and ongoing bleeding. However, long-term physical and mental status were still impaired after long-term evaluation. Future studies should therefore focus on customized, patient-centered, rehabilitation programs to improve HRQOL.

Reference 1: Clark SL, Romero R, Dildy GA, Callaghan WM, Smiley RM, Bracey AW, et al. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol. 2016;215:408–12.

Compliance with ethics regulations: Yes in clinical research.

figure ac

Comparison of SF-36 scores of AFE survivors treated by ECMO after a median follow-up of 40 months after ICU discharge and their age- and sex-matched control subjects, 84 venovenous ECMO-treated ARDS survivors, and 32 septic shock rescued by VA-ECMO

CO-54 Extracorporeal life support allows lung transplant in anti-MDA5+ rapidly progressive-interstitial lung disease

BAY Pierre1, PINETON DE CHAMBRUN Marc2, ROUX Antoine4, BUNEL Vincent6, COMBES Alain2, ISRAËL BIET Dominique 5, ZUBER Benjamin4, NUNES Hilario3, ALLENBACH Yves2, UZUNHAN Yurdagul3

1Hopital Henri Mondor, Creteil, France; 2Hopital Pitié Salpétrière, Paris, France; 3Hopital Avicenne, Paris, France; 4Hopital Foch, Suresnes, France; 5Hopital Européen Georges Pompidou, Paris, France; 6Hopital Bichat, Paris, France
Correspondence: Pierre BAY (pierrebay53@yahoo.fr)

Annals of Intensive Care 2022, 12(1):CO-54

Rationale: Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5) dermatomyositis (DM) is a rare subtype of idiopathic inflammatory myopathy, associated with severe interstitial lung disease (ILD). A subset of anti-MDA5 DM patients with rapidly progressive ILD (RP-ILD) have a very poor prognosis with reported mortality rates reaching 80–84%. The use of extracorporeal life support (ECLS) is questionable, as reported in several studies that emphasize the futility of a bridge-to-recovery strategy. In this respect, emergency lung transplantation of previously unlisted patients on ECLS is under debate.

Patients and methods/Materials and methods: This French, multicenter, retrospective study, conducted from 2013 to 2021 included all patients with anti-MDA5 DM RP-ILD requiring ECLS.

Results: Fifteen patients requiring ECLS were included in the study: venovenous -ECMO n = 13, ECCO2R n = 1 and venoarterial-ECMO n = 1. The female-to-male ratio was 4 and the age at ICU admission was a mean of 50 [32–67] years. Two patients received ECLS support (1 ECMO VA, 1 ECMO VV) as a bridge-to-transplantation strategy and both underwent ECLS before mechanical ventilation. Five patients underwent lung transplantation after a median of 8 [4-20] days on ECMO, none previously listed for a lung transplantation. After a median follow-up of 25 [3–93] months, all transplanted patients were alive at the conclusion of the study (four discharged home, one still hospitalized) and no relapse of DM or ILD was noted. All other patients, not listed for lung transplantation, died after a median of 30 [4–52] days on ECMO (Fig. 1).

Discussion: The prognosis of anti-MDA5 RP-ILD seems inevitably poor despite aggressive immunosuppression and the use of ECLS. The results presented here provide crucial information for the management of anti-MDA5 RP-ILD. First, we highlight the refractory nature of the anti-MDA5 RP-ILD requiring ECLS. No anti-MDA5 RP-ILD patient, irrespective of the treatment regimen they receive, including the most recent biologics such as JAK inhibitors, should be weaned from the ECLS. Second, every patient that could be bridge-to-transplantation was discharged alive from ICU. None was previously listed for lung transplantation. Emergency lung transplantation was possible in patients treated with vasopressors, mechanical ventilation and ECLS.

Conclusion: The bridge-to-recovery strategy in anti-MDA5 RP-ILD patients requiring ECLS despite specific prior treatment leads to undesirable results, pointing to the drawbacks of this approach. In contrast, a bridge-to-emergency lung transplantation is not only feasible, but also associated with a favorable outcome and appears therefore as the sole hope of survival for patients requiring ECLS.

Reference 1: Vuillard C, Pineton de Chambrun M, de Prost N, Guérin C, Schmidt M, Dargent A, et al. Clinical features and outcome of patients with acute respiratory failure revealing anti-synthetase or anti-MDA-5 dermato-pulmonary syndrome: a French multicenter retrosp.

Reference 2: Rubin J, Black KE, Hallowell RW, Witkin AS, Lydston M, Shelton K, et al. Veno-Venous Extracorporeal Membrane Oxygenation (ECMO) for Myositis-Associated Rapidly Progressive Interstitial Lung Disease (RP-ILD). CHEST [Internet]. 2021 Jul 16 [cited 2021 Jul 1].

Compliance with ethics regulations: Yes in clinical research.

figure ad

Kaplan–Meier 120-days Survival Estimates according to lung transplantation status

CO-55 Trends in clinical characteristics and outcomes of Covid-19 critically ill adult patients in France: a national database study

NAOURI Diane6, BEDUNEAU Gaetan4, DRES Martin2, KIMMOUN Antoine5, COMBES Alain2, DEMOULE Alexandre2, MERCAT Alain3, PHAM Tai2, SCHMIDT Matthieu2, JAMME Matthieu1

1Hopital privé de l'ouest parisien, Trappes, France; 2Assistance publique hopitaux de Paris, Paris, France; 3CHU Angers, Angers, France; 4CHU Rouen, Rouen, France; 5CHU Nancy, Nancy, France; 6Direction de la recherche, des études, de l'évaluation et des statistiques (DREES), Paris, France
Correspondence: Matthieu JAMME (mat.jamme@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-55

Rationale: Data concerning the association between time-period of ICU hospitalization and prognosis of patients admitted for coronavirus disease 2019 (COVID-19) are scarce. We aimed to describe the characteristics and the outcomes over time of critically ill patients cared in ICU for COVID-19.

Patients and methods/Materials and methods: We conducted a retrospective cohort study using the French administrative health care database (Système National des Données de Santé, SNDS). All adult patient hospitalized in French ICUs from March 1, 2020, to June 30, 2021 with at least one ICD-10 diagnosis code of COVID-19 was included. Three time-period corresponding to surge of COVID-19 ICU admission were defined: the first one between March 1, and June 30, 2020; the second between July 1, and December 31, 2020; and the third from January 1, to June 30, 2021. Risk factors of mortality and invasive mechanical ventilation (iMV) were identified by multivariate logistic regression models.

Results: 105979 COVID-19 patients were admitted in ICU during the study period with respectively 25150, 32689, and 48140 patients during the first, second, and third surge. First surge was remarkable with the highest proportion of iMV (42%, 32% and 31% for respectively surge 1, 2 and 3; p < 0.001), of renal replacement therapy (RRT) (9%, 7% and 5% for respectively surge 1, 2 and 3; p < 0.001) and use of vasopressors (36%, 26% and 24% for respectively surge 1, 2 and 3; p < 0.001). Second wave was composed with older patients (respectively 50% of more than 70 years vs 41% for wave 1 and 3) and higher IGS-2 score at ICU admission (33 [26–42]). Multivariate model identified age, male gender, Charlson score, IGS 2 score and ICU admission after the first wave as risk factors of in-hospital death. After stratification on age, the odds ratios of in-hospital death were higher only in patients older than 70 years for the third wave (aOR = 1.30; 95% CI = 1.23–1.37) and the second wave (aOR = 1.15; 95%CI = 1.08–1.22), compared to those younger than 69 years old. During the third wave, 4971 (9%) patients had been vaccinated at ICU admission. Vaccination was associated with a lower likelihood of invasive mechanical ventilation (OR = 0.50, 95% CI = 0.40–0.63) and death (OR = 0.74, 95% CI = 0.60–0.90).

Conclusion: Between March 2020 and July 2021, we reported a decline in iMV, vasopressors and RRT use for ICU patients admitted for COVID-19. Second and third wave were associated with in-hospital mortality for patients with 70 years and more. Finally, vaccination was associated with a lower likelihood of iMV and death.

Compliance with ethics regulations: Yes in clinical research.

CO-56 Comparison of SARS-CoV-2 variants of concern Alpha (B.1.1.7) versus Beta (B.1.351) in critically ill patients: a multicenter cohort study in the northeast of France

LOUIS Guillaume1, BELVEYRE Thibaut2, GIBOT Sebastien3, GOETZ Christophe5, DUNAND Paul4, GACI Rostane1, CONRAD Marie3, CADOZ Cyril1, GETTE Sebastien1,4, PEREZ Pascale6, OUAMARA Nadia5, PICARD Yoann1, MELLATI Nouchan1

1Intensive Care Unit, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France, Metz, France; 2Department of Anesthesiology and Intensive Care Medicine, University Hospital of Nancy, Vandoeuvre-Lès-Nancy, France, Vandoeuvre-Les-Nancy, France; 3Medical Intensive Care Unit, University Hospital of Nancy, Nancy, France, Nancy, France; 4Intensive Care Unit, Metz-Thionville Regional Hospital, Bel Air Hospital, Thionville, France, Thionville, France; 5Clinical research support Unit, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France, Metz, France; 6Department of Virology, Metz-Thionville Regional Hospital, Mercy Hospital, Metz, France, Metz, France
Correspondence: Guillaume LOUIS (gus_louis@yahoo.fr)

Annals of Intensive Care 2022, 12(1):CO-56

Rationale: The clinical outcomes of the Beta (B.1.351) variant of concern (VOC) of the SARS-CoV-2 virus remain poorly understood. In early 2021, northeastern France experienced an outbreak of Beta that was not observed elsewhere. This outbreak slightly preceded and then overlapped with a second outbreak of the better understood VOC Alpha (B.1.1.7) in the region. This situation allowed us to contemporaneously compare Alpha and Beta in terms of the characteristics, management, and outcomes of critically ill patients.

Patients and methods/Materials and methods: A multicenter cohort study was conducted on all consecutive adult patients who had laboratory confirmed SARS CoV-2 infection, underwent variant screening, and were admitted to one of four intensive care units for acute respiratory failure between January 9th and May 15th 2021. Primary outcome was 60-day mortality. Differences between Alpha and Beta in terms of other outcomes, patient variables, management, and vaccination characteristics were also explored by univariate analysis. The factors that associated with 60-day death in Alpha- and Beta-infected patients were examined with logistic regression analysis.

Results: In total, 333 patients (median age, 63 years) were enrolled. Of these, 174 and 159 had Alpha and Beta, respectively. The two groups did not differ significantly in terms of 60-day mortality (19% vs. 23%), need for mechanical ventilation (60% vs. 61%), mechanical ventilation duration (14 vs. 15 days), other management variables, patient demographic variables, comorbidities, or clinical variables on ICU admission. The vast majority of patients were unvaccinated (94%). The remaining 18 patients had received a partial vaccine course and 2 were fully vaccinated. The vaccinated patients were equally likely to have Alpha and Beta.

Discussion: To date, this is one of the largest studies to compare the characteristics and outcomes of critically ill patients who were infected with either of two simultaneously circulating VOCs and who underwent similar treatment regimens in the same settings. A recent meta-analysis suggests an increased mortality of Beta variant compared to wild type strain. Plus, the Beta and Delta variants were described as risker than the Alpha and Gamma variants (1). Nevertheless, none of the studies cited in the meta-analysis was specific to critically ill patient or compare variants with each other. Plus, the Beta variant proportion was quite low compared to other variants in these studies (Alpha particularly).

Conclusion: Beta did not differ from Alpha in terms of patient characteristics, management, or outcomes in critically ill patients. Better understanding of these variants including ongoing and future ones is essential.

Reference 1: Lin L, Liu Y, Tang X, He D. The Disease Severity and Clinical Outcomes of the SARS-CoV-2 Variants of Concern. Frontiers in Public Health (2021) 9: https://www.frontiersin.org/article/10.3389/fpubh.2021.775224 [Accessed January 26, 2022].

Compliance with ethics regulations: Yes in clinical research.

figure ae

Kaplan–Meier survival curves of the patients who were admitted to an ICU for an infection with Alpha or Beta (n = 333).

CO-57 Critically ill patients with SARS-Cov2 pneumonia after vaccination: a multicenter cohort

FRIOL Alice1, MOREAU Anne-Sophie4, JUNG Boris5, JULLIEN Edouard6, BUREAU Côme7, DJIBRÉ Michel8, DE PROST Nicolas9, ZAFRANI Lara10, ARGAUD Laurent11, REUTER Danielle12, CALVET Laure13, DE MONTMOLLIN Etienne14, BENGHANEM Sarah15, PICHEREAU Claire16, PHAM Tai17, CACOUB Patrice2, BIARD Lucie3, SAADOUN David2, MIROUSE Adrien2

1Institut Cochin - INSERM U1016 - CNRS UMR 8104 - Université de Paris, APHP, Paris, France; 2Département de Médecine Interne et Immunologie Clinique - hôpital Pitié Salpêtrière, APHP, Paris, France; 3Département de biostatistiques, hôpital Saint-Louis, APHP, Paris, France; 4Service de réanimation polyvalente, CHRU de Lille - hôpital Roger Salengro, Lille, France; 5Service de médecine intensive réanimation, CHU de Montpellier, Montpellier, France; 6Service de médecine intensive réanimation, hôpital Ambroise Paré, APHP, Boulogne, France; 7Service de médecine intensive réanimation, hôpital Pitié-Salpêtrière, APHP, Paris, France; 8Service de médecine intensive réanimation, hôpital Tenon, APHP, Paris, France; 9Service de médecine intensive réanimation, hôpital Henri Mondor, APHP, Créteil, France; 10Service de médecine intensive réanimation, hôpital Saint-Louis, APHP, Paris, France; 11Service de médecine intensive réanimation, hospices civils de Lyon, Lyon, France; 12Service de réanimation polyvalente, CH Sud-Francilien, Corbeil-Essonnes, France; 13Service de médecine intensive réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France; 14Service de médecine intensive réanimation, hôpital Bichat, APHP, Paris, France; 15Service de médecine intensive réanimation, hôpital Cochin, APHP, Paris, France; 16Service de réanimation polyvalente, CH Pontoise, Pontoise, France; 17Service de médecine intensive réanimation, hôpital de Bicêtre, Paris, France
Correspondence: Alice FRIOL (alice.friol@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-57

Rationale: Vaccination reduces risk of infection, hospitalization and death due to SARS-Cov2. Vaccinated patients may experience severe SARS-Cov2 disease.

Patients and methods/Materials and methods: Multicenter cohort study of patients with severe SARS-Cov2 disease admitted in 15 intensive care units in France between January and September 2021. Vaccinated patients were compared to a large European cohort of wave 2/3 critically ill SARS-Cov2 patients.

Results: One hundred patients (68 (68%) men, median age 64 [57–71]) were included. Immunosuppression was reported in 38 (38%) patients. Among available serology at intensive care unit (ICU) admission, 64% exhibited an optimal antibody level. Median SOFA score at ICU admission was 4 [4–6.25] and median PaO2/FiO2 ratio was 84 [69–128] mmHg. High flow nasal oxygen and non-invasive mechanical ventilation were implemented in 79 (79%) and 18 (18%) patients, respectively. Mechanical ventilation was initiated in 48 (48%) with a median duration of 11 [5–19] days. During a median ICU length-of-stay of 8 [4–20] days, 31 (31%) patients died. Age (OR 1.07 CI95% [1.00–1.13] per year, p = 0.035), and SOFA at ICU admission (OR 1.40 CI95% [1.14–1.72] per point, p = 0.002) were independently associated with mortality. Vaccinated patients exhibited less frequently diabetes (16 [16%] vs. 351 [27%], p = 0.029) but more frequently immunosuppression (20 [20%] vs. 109 (8.3%), p < 0.0001), chronic kidney disease (24 [24%] vs. 89 (6.8%), p < 0.0001), chronic heart failure (16 [16%] vs. 58 [4.4%], p < 0.0001), and chronic liver disease (3 [3%] vs. 8 [0.6%], p = 0.04) compared to unvaccinated patients. Despite similar severity, vaccinated patients required less frequently invasive mechanical ventilation at ICU-day 1 and during ICU stay (23 [23%] vs. 785 [59.7%], p < 0.0001, and 48 [48%] vs. 930 [70.7%], p < 0.0001, respectively). There was no difference concerning ICU mortality (31 [31%] vs. 379 [28.8%], p = 0.76).

Conclusion: Severe SARS-Cov2 infection occurs post-vaccination essentially in patients with immunosuppression, chronic kidney, heart or liver failure. Age and disease severity are independently associated with mortality. Vaccination might inflect the disease course, even in critically-ill patients.

Compliance with ethics regulations: Yes in clinical research.

CO-58 Auto-antibodies against type I interferons in critically ill COVID-19 patients: a prospective multicentre study

ARRESTIER Romain1,2,3, BASTARD Paul4, BELMONDO Thibault5, VOIRIOT Guillaume6, URBINA Tomas7, LUYT Charles-Edouard8,9, BELLAÏCHE Raphaël10, PHAM Tai11, AIT-HAMOU Zakaria12, ROUX Damien13, CLERE-JEHL Raphaël14, AZOULAY Elie14, GAUDRY Stéphane15, MAYAUX Julien16, MONCOMBLE Elsa1,2, PARFAIT Mélodie1, MEKONTSO-DESSAP Armand1,2,3, SEGAUX Lauriane3,17, CANOUI-POITRINE Florence3,17, CASANOVA Jean-Laurent4, HUE Sophie3,5, DE PROST Nicolas1,2,3

1Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Créteil, France; 2Groupe de Recherche Clinique CARMAS, Faculté de Santé de Créteil, Université Paris Est Créteil, France; 3INSERM, IMRB, Université Paris Est Créteil, Créteil, France; 4Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, Paris, France; Imagine Institute, University of Paris, Paris, France; St. Giles Laboratory of Human Genetics of Infectious Diseases, Rocke, New York, Etats-Unis; 5Département d'Hématologie et d'Immunologie Biologiques, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalo-Universitaire Chenevier Mondor, Créteil, France; 6Service de Médecine Intensive-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France; 7Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France; 8Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; 9INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris, France; 10Service d'Anesthésie-Réanimation Chirurgicale, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France; 11Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France; 12Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université de Paris, Paris, France; 13Médecine Intensive Réanimation, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Colombes, France; 14Service de médecine intensive et réanimation, Hôpital Saint-Louis, Assistance Publique Des Hôpitaux de Paris, Paris, France; 15Département de réanimation médico-chirurgicale, APHP Hôpital Avicenne, Bobigny, France; 16Groupe Hospitalier Pitié Salpêtrière, Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Réanimation Médicale, Paris, France; 17Unité de Recherche Clinique AP-HP, Hôpitaux Henri-Mondor, Créteil, France; 18Service de Médecine intensive Réanimation, APHP.Sorbonne Université, Hôpital Pitie Salpêtriere, Paris, France
Correspondence: Romain ARRESTIER (romain.arrestier@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-58

Rationale: SARS-CoV-2 infection leads to a broad spectrum of symptoms with a large inter-individual variability. Impaired interferon (IFN) type I response seems to be involved in patients with severe SARS-CoV-2 infection. Auto-antibodies (auto-Abs) neutralizing type I IFN-α2 and IFN-ω were found in 10% of severe COVID-19 cases compared with 0% in mildly or asymptomatic cases. Dertermining whether auto-Abs neutralizing type I IFNs are associated with outcomes in critically ill patients with COVID-19 could lead to individualized therapeutic interventions.

Patients and methods/Materials and methods: We conducted a prospective multicentre study including 11 intensive care units (ICU). Patients hospitalized in ICU with proven SARS-CoV-2 infection and acute respiratory failure requiring oxygen or mechanical ventilation support were included. Our objectives were to compare the mortality of patients with versus without auto-Abs neutralizing type I IFNs, to assess the rate of positivity of auto-Abs and the factors associated with their positivity.

Results: 925 critically ill COVID-19 patients were included in the study between March 2020 and May 2021. Auto-Abs neutralizing type I IFN were found in 96 patients (10.3%): 78.3% had auto-Abs against IFN-α2, 74% against IFN-ω and 12.5% against IFN-β. Baseline characteristics did not differ between patients with and without auto-Abs (Table 1). At ICU admission, positive patients required a higher FiO2 (100% (70–100) vs 90% (60–100), p = 0.01), and more frequently met the diagnosis criteria for the acute respiratory distress syndrome (92.7% vs 77.6%, p = 0.0005). Mortality at day 28 was not different between groups (18.7% vs 23.7%, p = 0.279). In multivariable analysis, age (adjusted odds ratio (aOR) = 1.06 [1.04–1.08], p < 0.001), SOFA score (aOR = 1.18 [1.12–1.23], p < 0.001) and immunosuppression (aOR = 1.82 [1.1–3.0], p = 0.02) were associated with 28-days mortality, but auto-Abs positivity was not (aOR = 0.69 [0.38–1.26], p = 0.23). There was a non-significant trend towards a higher proportion of men among positive patients (78 vs 70%) contrasting with the previous finding that auto-Abs were almost uniquely detected in men (94%)1. Compared to women without auto-Abs, positive women were significantly younger (45 (24–62) vs 60 years (45.5–67.5)) and more frequently displayed an auto-immune background with more frequent positive anti-nuclear antibody (28% vs 4%, p = 0.003). They required more frequent invasive mechanical ventilation (71% vs 47%, p = 0.04) at ICU admission but 28-days mortality was not different.

Conclusion: In ICU patients, auto-Abs against type I IFNs are present in 10% of patients but are not associated with higher 28 days mortality. Positive women seem to have an auto-immune background and more frequently required mechanical ventilation.

Reference 1: Bastard, P. et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science 370, eabd4585 (2020).

Compliance with ethics regulations: Yes in clinical research.

figure af

Demographics and characteristics of patients with severe SARS-CoV-2 infection (n = 925) at intensive care unit admission and ICU management and outcomes according to the presence of antibodies against type I IFNs

CO-59 Monocytic expression of HLA-DR independently anticipates the clinical course of undifferentiated patients with SARS-Cov-2 in Emergency Department

LAFON Thomas1, GUÉRIN Estelle1, CHAPUIS Nicolas2, DAIX Thomas1, FONTENAY Michaela2, VIGNON Philippe1, FRANÇOIS Bruno1, FEUILLARD Jean1

1CHU Dupuytren, Limoges, France; 2Hôpital Cochin, AP-HP, Paris, France
Correspondence: Thomas LAFON (thomas.lafon@chu-limoges.fr)

Annals of Intensive Care 2022, 12(1):CO-59

Rationale: Assessing the prognosis of patients with SARS-Cov-2 related pneumonia is fundamental in Emergency Department (ED) to manage the flow of patients. Previous cohort of patients highlighted that 1/3 of patients worsened after their admission. Standard scores and biomarkers used in ED are strongly associated with immediate severity but their prognostic performance to predict clinical course of patients is limited. COVID-19 leads to immunological impairment with lymphopenia, low expression of HLA-DR on monocytes and high neutrophil count. We evaluated the prognostic performance of immunological parameters (circulating lymphocyte subsets, neutrophils and immature granulocytes, MO1 immature to M3 inflammatory stage based on CD16 and CD14 expression, and mHLA-DR) to anticipate the clinical evolution of undifferentiated COVID-19 patients in ED.

Patients and methods/Materials and methods: We conducted a prospective multicenter study during 5 months in two ED: one for exploratory cohort and one for consolidation. In addition to clinical, biological and radiological parameters, circulating lymphocyte subsets, mature and immature granulocytes and mHLA-DR were analyzed using routine flow cytometry on the first blood sample. The primary endpoint was the non-deterioration determined by 3 clinicians who were blinded from cytometry results and defined from a composite criterion: (i) need for high flow oxygen, (ii) ICU admission, (iii) in-hospital mortality related to SARS-COV-2, (iiii) readmission within 5 days. Sample size of 245 patients (estimated deterioration = 20%).

Results: 284 patients were analyzed (men = 56%; mean age = 63 ± 17 yrs; onset of symptoms 7 ± 4 days, SpO2 = 95 ± 4%, respiratory rate = 23 ± 7 breaths/min) including 72 patients (25%) who were assigned to the deterioration group (high flow oxygen 86%, ICU admission 35%, in-hospital mortality 40%, readmission 8%). On the first series of 180 patients, among the 27 clinical and biological parameters tested, the 3 independent variables were P/F ratio (adjusted OR = 2.8, LCI = 1.2, UCI = 6.4, p = 0.014), lymphocyte count (adjusted OR = 4.2, LCI = 1.7, UCI = 10.2, p = 0.0019) and mHLA-DR (adjusted OR = 4.5, LCI = 2, UCI = 10.3, p = 0.0003). On the consolidating series of 104 patients, the independent variables were also P/F ratio (adjusted OR = 9.2, LCI = 3, UCI = 19, p = 0.0001), lymphocyte count (adjusted OR = 4, LCI = 1, UCI = 16, p = 0.049) and mHLA-DR (adjusted OR = 4.1, LCI = 1.2, UCI = 13.7, p = 0.02). A score that included P/F ratio > 300, lymphocyte count > 1.1 G/L and HLA DR intensity > 15 000 reached 100% of PPV for non-deterioration.

Conclusion: With the P/F ratio and the lymphocyte count, absence of DR loss on monocytes was strongly independently and robustly associated with clinical non-deterioration. A simple predictive score ratio seems interesting to allow safe rule-out, over-triage reduction and better allocation of hospital resources.

Compliance with ethics regulations: Yes in clinical research.

CO-60 Incidence and outcome of invasive pulmonary aspergillosis in critically-ill COVID-19 patients: a French multicenter experience

DESMEDT Luc1, RAYMOND Matthieu1, ASFAR Pierre2, DARREAU Cedric14, REIZINE Florian3, COLIN Gwenhaël4, AUCHABIE Johann13, LACOMBE Béatrice12, KERGOAT Pierre11, HOURMANT Baptiste6, DELBOVE Agathe7, FRÉROU Aurélien8, MORIN Jean15, ERGRETEAU Pierre Yves9, SEGUIN Philippe10, REIGNIER Jean1, LASCARROU Jean-Baptiste1, CANET Emmanuel1

1Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France; 2Service de Médecine Intensive Réanimation, CHU d'Angers, Angers, France; 3Service de Médecine Intensive Réanimation, CHU de Rennes, Rennes, France; 4Service de Réanimation Polyvalente, CHD La Roche Sur Yon, La Roche Sur Yon, France; 5Service de Réanimation Polyvalente, CH Saint Nazaire, Saint Nazaire, France; 6Service de Réanimation Polyvalente, CHU de Brest, Brest, France; 7Service de Réanimation Polyvalente, CH de Vannes, Vannes, France; 8Service de Réanimation Polyvalente, CH de Saint Malo, Saint Malo, France; 9Service de Réanimation Polyvalente, CH de Morlaix, Morlaix, France; 10Service de Réanimation chirurgicale, CHU de Rennes, Rennes, France; 11Service de Réanimation Polyvalente, CH de Cornouille, Quimper, France; 12Service de Réanimation Polyvalente, CH Bretagne Sud, Lorient, France; 13Service de Réanimation Polyvalente, CH Cholet, Cholet, France; 14Service de Réanimation Polyvalente, CH du Mans, Le Mans, France; 15Unité de soins intensifs de Pneumologie, Nantes, France
Correspondence: Luc DESMEDT (Luc.desmedt@live.fr)

Annals of Intensive Care 2022, 12(1):CO-60

Rationale: Recent studies identified coronavirus disease 2019 (COVID-19) as a risk factor for invasive pulmonary aspergillosis (IPA), with conflicting data on prevalence and impact on patients’ outcomes. We aimed to determine the incidence and outcome of COVID-19 associated pulmonary aspergillosis (CAPA) in mechanically ventilated COVID-19 patients.

Patients and methods/Materials and methods: We conducted a multicenter observational study. All Covid-19 patients admitted to 15 ICUs from Pays-de-la-Loire and Bretagne regions between February 1st 2020 and December 31th 2020 and treated with mechanical ventilation were included. The main objective was to assess the incidence and mortality of CAPA in COVID-19 patients with acute respiratory distress syndrome (ARDS). Each case of CAPA reported by local investigators was reviewed by an adjudication committee of 3 independent experts. CAPA were diagnosed and graded according to the 2020 ECMM/ISHAM consensus criteria [1].

Results: Among the 15 participating centers, 2 (13%) had a screening strategy for Aspergillus in mechanically ventilated patients, while in the other 13 (87%) centers CAPA was investigated in case of respiratory deterioration. During the study period, 644 mechanically ventilated patients were included (mean age 65 (SD 11) years-old; 523 (74%) men). Mean duration of mechanical ventilation was 21 (19) days and 90-day mortality rate was 34%. According to the EORTC criteria, 114 (16%) patients had underlying immunosuppression. Overall, 348 (49%) patients were treated with corticosteroids and no patients received Tocilizumab. Overall, 35 (5%) patients had proven/probable/possible CAPA. Among them, 18 (3%) patients fulfilled the criteria for probable CAPA and 17 (3%) patients met the criteria for possible CAPA (3%). No case of histologically proven CAPA was reported. Patients with probable CAPA were 70 (7) years-old and 4 (22%) were immunocompromised. Patients with possible CAPA were 68.64 (8.62) years-old and 3 (17.6%) were immunocompromised. Probable CAPA were diagnosed after 8 [4.25–21.75] days of mechanical ventilation and possible CAPA after 6 [1–10] days. At day-90, 16 (46%) of the 35 patients with CAPA were dead. Among the 18 patients with probable CAPA, the mortality at day-90 was 55% (n = 10) and the duration of mechanical ventilation was 27 [18–33.5] days. Patients with possible CAPA had a mortality rate at day-90 of 35% (n = 6) and a duration of mechanical ventilation of 16 [13–23] days.

Conclusion: In our study, the incidence of IPA in ARDS-Covid-19 patients treated with mechanical ventilation was low, and only probable CAPA was associated with a higher mortality at day-90.

Reference 1: Koehler, Philipp, Matteo Bassetti, Arunaloke Chakrabarti, Sharon C A Chen, Arnaldo Lopes Colombo, Martin Hoenigl, Nikolay Klimko, et al. « Defining and managing COVID-19-associated pulmonary aspergillosis: the 2020 ECMM/ISHAM consensus criteria for research and clinical guidance. Lancet Infect Dis 2021; 21: e149–e162.

Compliance with ethics regulations: Yes in clinical research.

CO-61 Psychotraumatic impact of the child's visit to the adult intensive care unit: first results of the ENVIFAR study

NGUYEN Stéphanie1, VANGI Marie-Aude2, FOURNIER Alicia1, SOUPPART Virginie4, PILI FLOURY Sébastien5, QUENOT Jean Pierre6, DUBOST Jean-Louis7, BOUHEMAD Belaid8, CAPELLIER Gilles9, LAURENT Alexandra2,10

1Université Bourgogne Franche-Comté, Dijon, France; 2 CHU Dijon, Réanimation Chirurgicale, Dijon, France; 3 Université Bourgogne Franche-Comté, Laboratoire Psy-DREPI, Dijon, France; 4APHP Saint Louis, Médecine Intensive Réanimation, Paris, France; 5CHU Besançon, Réanimation Chirurgicale, Besançon, France; 6CHU Dijon, Médecine Intensive Réanimation, Dijon, France; 7CH Pontoise, Réanimation Médico-Chirurgicale,, Pontoise, France; 8CHU Dijon, Réanimation Chirurgicale, Dijon, France; 9CHU Besançon, Réanimation Médicale, Besançon, France; 10Université Bourgogne Franche-Comté, Laboratoire Psy-DREPI, Dijon, France
Correspondence: Stéphanie NGUYEN (stephanielaurent@gmx.fr)

Annals of Intensive Care 2022, 12(1):CO-61

Rationale: While Intensive Care Units (ICU) have widely opened their doors to relatives, the presence of visiting children and adolescents in ICU remains a sensitive issue. In a desire to protect the child from a potentially traumatic environment, some units refuse or restrict visits to children (Laurent et al., 2019). The aim of this study is to measure the psychotraumatic impact of a child’s visit to adult ICU and to identify the influence of the accompanying parent on the child’s visit.

Patients and methods/Materials and methods: This study was conducted in six ICU with 22 children, 15 accompanying parents. The psychotraumatic impact of the visit on the child was measured at 7 and 30 days of the visit using the CRIES-8 (Children’s revised impact of event scale, CRIES-8). We also measured the anxiety-depression of the accompanying parent during the visit using the HADS (REF). We complemented the quantitative approach with semi-structured interviews to capture the experience of the visit at 7 days.

Results: Of the 22 children included, 15 children were able to complete questionnaires at 7 days of the visit and 21 at 30 days. At 7 days of the visit, 9 out of 15 children showed acute stress. One month after, 9 out of 21 children suffered from a potential post-traumatic stress disorder. The thematic analysis shows that the visit is indeed disturbing for most of children. However, children expressed that this visit was reassuring to them. Certain dimensions are identified as a source of distress and can explain the CRIES-8 scores: the absence of the hospitalized parent, the distress of the accompanying parent, and the disruption of daily life. In the same sense, our study shows a positive trend correlation between the HADS scores of the accompanying parents and the CRIES-8 score of the children (r2 = .24, p = .062) at 7 days. Thus, the higher the anxiety-depressive symptomatology of the parents, the higher the acute stress symptomatology of the children tended to be.

Conclusion: More than the visit itself, these initial results show the importance of considering the visiting parent's experience during the child’s visit.

Reference 1: Laurent A., Leclerc P., Nguyen S., Capellier G. (2019) The effect visiting relatives in the adult ICU has on children. Intensive Care Medicine. https://doi.org/10.1007/s00134-019-05690-2.

Reference 2: Laurent A., Nguyen S., Leclerc P., Capellier G. (2020) L’enfant visiteur en réanimation adulte: vécu psychologique de la visite et dispositifs d’accompagnement. Pratiques psychologiques (2020).

Compliance with ethics regulations: Yes in clinical research.

CO-62 Measuring ethical decision-making climate before and after the implementation of therapeutic perspective meetings—CLIMETHIC study

VALBRUN Jean-David1, NGUYEN Yên-Lan2

1Gustave Roussy, Villejuif, France; 2CHU Cochin, Paris, France
Correspondence: Jean-David VALBRUN (jean-david.valbrun@orange.fr)

Annals of Intensive Care 2022, 12(1):CO-62

Rationale: The perception of inappropriate care in end-of-life situations can be a source of conflict and burnout among caregivers. The purpose of this study is to describe caregivers' perceptions of end-of-life care in the surgical intensive care unit and intermediate care unit of our hospital before and after the implementation of therapeutic perspective meetings (TPMs).

Patients and methods/Materials and methods: Caregivers in the ICU were invited to participate in this survey before (August to October 2018) and after (August to October 2019) the implementation of TPMs. The “ethical decision-making climate” self-questionnaire was used. It explores 3 dimensions: working conditions, managerial skills and end-of-life decision making. Descriptive and analytical analyses were performed. This study was approved by the SFAR ethics commission (opinion n° IRB 00010254-2017-133).

Results: The implementation of TPMs improved caregivers’ perception of the existence of regular meetings to discuss projects (2 vs 3, p < 0.0001) and the quality of care delivered (2 vs 3, p < 0.0026). TPMs improved caregivers' perception of expressing disagreement with opinions or values (3 vs. 3, p = 0.02), nurses' presence during end-of-life interviews (3 vs. 3.5; p = 0.003) and nurses' involvement in these decisions (2 vs. 3, p < 0.0001). The TPMs did not change caregivers’ perception on the medical team management, on the realization of formalized debriefings after a difficult care or end-of-life situation, on the temporality of end-of-life decisions or on the admissions of patients with minimal chances of recovery.

Conclusion: The implementation of TPMs has improved the perception of caregivers regarding communication between caregivers on patient management, particularly for end-of-life situations, and has encouraged the involvement of nurses in these decisions as well as their presence during interviews with the families. There was no impact on perceptions of the temporality of end-of-life decision-making or on admissions of patients with minimal chance of recovery. Further studies are needed to assess the impact of TPMs on the prevalence of conflict, risk of burnout, and quality of care delivered.

Reference 1: Piers et coll., JAMA, 2011.

Reference 2: Bo Van den Bulcke et coll. BMJ, 2018.

Compliance with ethics regulations: Yes in clinical research.

figure ag

Comparaison avant-après

CO-63 Intensivists’ differential ethical perceptions about withholding and withdrawing of treatment (Wh&Wd) decisions: a clinical ethics empirical investigation

SPRANZI Marta1

1AP-HP, Paris, France
Correspondence: Marta SPRANZI (marta.spranzi-ext@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-63

Rationale: Intensive care professional societies have issued policy recommendations regarding Wh&Wd decisions that consistently classify them as ethically equivalent and ethically neutral insofar as they correspond to “passive” actions. However, on the ground some are perceived as more “active” than others most notably Wd as opposed to Wh decisions. Recent studies also show that there is a personal “variability” in the way such decisions are made, and that further investigation is needed. Therefore it seemed necessary to explore intensivists’ differential ethical perceptions about Wh&Wd decisions and the ethical reasons underlying their spontaneous judgments.

Patients and methods/Materials and methods: A qualitative retrospective and multicentered study was initiated in 7 AP-HP intensive care units. In-depth interviews were conducted with 39 intensivists of different age groups and levels of professional experience, and with 5 department heads. We used an inductive (“grounded theory” inspired), multidisciplinary clinical ethics approach, aimed at eliciting and retrieving practitioners’ ethical intuitions about different Wh&Wd decisions. Interview transcripts were analyzed using a “thematic analysis” approach.

Results: Practitioners’ perceptions of Wh&Wd decisions vary along two continuous dimensions: “active”/passive and ethically problematic/unproblematic. Three groups have been identified and described: those who tend to consider Wh&Wd decisions (1) as passive and unproblematic, (2) as active and problematic, and (3) as active and unproblematic. More interestingly, these groups are differently correlated with three other ethically relevant variables: the role of consensus during the collegial procedure, the difference between withholding and withdrawing decisions, and the definition of one’s own overarching goal as professional.

Discussion: The study results confirm what is now called practitioners’ “variability” and the moral complexity of Wh&Wd decisions. Moreover, it shows that, contrary to the “moral neutrality” doctrine, practitioners consider different Wh&Wd decisions as more or less morally problematic along a continuum from passive to “very active”, although Wd&Wh practices are mostly described as different from euthanasia. It also shows that practitioners’ “variability” does not simply correspond to sociological variables which could be easily erased, but has deep-seated ethical roots.

Conclusion: Practitioners’ perception and ethical reasons about Wh&Wd decisions have never been analyzed in depth. Our results allow for the recognition of intensivists’ moral distress about Wh&Wd decisions, and open up new perspectives to deal with their deep-rooted variability, most notably by working on the rationale and format of the collegial procedure.

Reference 1: Nadig, N. R., & Ford, D. W. (2019). A Consensus: Everyone Agrees Collectively but No One Believes Individually. Critical care medicine, 47(10), 1470–1472.

Reference 2: Wilkinson, D. J., & Truog, R. D. (2013). The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive care medicine, 39(6), 1128–1132.

Compliance with ethics regulations: N/A.

figure ah

Ethical perceptions of WD&Wh decisions and intensivists'values

CO-64 Association of nursing team composition with mortality in critically ill patients: a multicenter observational studY

GUÉRIN Claude1,5, PAYET Cécile5, BABOI Loredana3, ALLAOUCHICHE Bernard2, ARGAUD Laurent1, AUBRUN Fréderic3, BOHÉ Julien2, DAILLER Frédéric4, FELLAHI Jean-Luc4, LEHOT Jean-Jacques5, PIRIOU Vincent2, RIMMELÉ Thomas1, POLAZZI Stéphanie5, DUCLOS Antoine5

1Hôpital Edouard Herriot Hospices Civils de Lyon, Lyon, France, France; 2Groupement hospitalier Lyon Sud, Lyon, France; 3Groupement hospitalier nord, Lyon, France; 4Groupement hospitalier Est, Lyon, France; 5Université de Lyon, Lyon, France
Correspondence: Claude GUÉRIN (claude.guerin@chu-lyon.fr)

Annals of Intensive Care 2022, 12(1):CO-64

Rationale: In the Intensive Care Unit (ICU), patient-to-nurse ratio is associated with patient outcomes but little is known about the habit among staff members of working together. The goal of present study is to investigate the role of nursing team composition on patient ICU mortality.

Patients and methods/Materials and methods: Retrospective multicentre observational study in eight adult ICUs from the Greater Lyon area in France, analysing all patients present between January 1st 2011 and December 31st 2016. The team composition was evaluated using the familiarity among the ICU caregivers, which was measured by shift (from 7:00 am to 6:59 pm and from 7:00 pm to 6:59 am) as the mean number of previous collaborations between each nursing team member during previous shifts within the given ICU. Suboptimal collaboration was defined as less than 50. The patient-to-nurse ratio and patient-to-auxiliary nurse ratio were also considered (suboptimal ratio defined as higher than 0.5 and 0.25, respectively), as well as individual length of experience in ICU for every caregiver (suboptimal defined as less than 400 previous shifts with collaboration). The primary outcome was inpatient death at the time of ICU discharge, excluding patients for whom a decision to forego life-sustaining therapy was made. Inpatient death during the shift at admission was secondarily considered. A multiple Poisson regression was computed to identify the determinants of ICU mortality per shift, taking into account the ICU site, patients’ characteristics, and caregivers’ workload.

Results: A total of 43,479 patients were admitted to the ICUs of whom 3,311 (7.6%) died, corresponding to 8.8% shifts (3,101/35,072) with at least one death. The adjusted model showed an increased risk of patient mortality during shifts exposed to suboptimal team familiarity lower than 50 previous collaborations (Relative Risk 1.06, 95% Confidence Intervals [1.04–1.09]) and simultaneously with suboptimal patient-to-staffing ratio (RR 1.13, IC95% [1.07–1.19]). Suboptimal team composition reflected a total of 172 [116–241] shifts with potentially avoidable death, corresponding to 7.5% of all ICU shifts with occurrence of inpatient death. The risk of death at admission was also higher in case of suboptimal team composition (RR 1.27, IC95% [1.13–1.43]).

Conclusion: In conclusion, the familiarity between ICU nursing staff is significantly associated with inpatient death additionally to patient-to-caregiver ratio. Improving team composition should be a management goal in ICU.

Compliance with ethics regulations: Yes in clinical research.

figure ai

Figure 1

CO-65 Healthcare workers cost awareness in intensive care unit: a prospective multicentric study

GABARRE Paul1, MAYLIN Rima1, STUDER Antoine2, GUITTON Christophe3, ANTIGNAC Marie1, DE PROST Nicolas4, URBINA Tomas1, BONNY Vincent1, MISSRI Louai1, EHRMINGER Sebastien1, BAUDEL Jean-Luc1, JOFFRE Jérémie1, AIT OUFELLA Hafid1, MAURY Eric1

1Hôpital Saint Antoine, Paris, France; 2CHRU Strasbourg, Strasbourg, France; 3Centre Hospitalier du Mans, Le Mans, France; 4Hôpital Henri Mondor, Créteil, France
Correspondence: Paul GABARRE (paulgabarre@hotmail.com)

Annals of Intensive Care 2022, 12(1):CO-65

Rationale: Physicians play an important role in controlling health care spending, by prescribing more or less expensive treatments. The aim of this study was to evaluate the knowledge of health care workers of the cost of the treatments they daily use in ICU.

Patients and methods/Materials and methods: We conducted a prospective, multicenter, volunteer-based study. A survey was delivered and completed anonymously by healthcare workers (HCWs) of four French ICUs, three university affiliated and one non-university affiliated. The survey proposed to estimate the price of 37 treatments frequently used in critical care. Cost estimations were expressed as percentage of the real cost; an estimation was considered correct if it was ± 50% of the true prices

Results: 158 HCWs answered to the survey, including 75 nurses and 82 physicians. Medical staff was composed of 36 seniors and 45 juniors. Median age of the respondents was 29 [25–36] years. They provided 5798 answers. Only 18% of estimations were within 50% of the real cost. In univariate analysis, Medical staff was more likely to respond correctly than nurses, with 20% vs. 16,8% of correct cost estimations (p = 0,001). Unsurprisingly, among the medical staff, seniors were better at evaluating the prices than juniors, with 22,58% of good answers vs. 18,3% p = 0,0051. There was no difference between university affiliated and non-university affiliated hospital’s HCWs. Antibiotics were the most often well estimated treatments, with 25% of correct estimations, followed by fluids (24%), vasopressors (19%), sedative drugs (14%), chemotherapy and immunosuppressive treatments (13%). Interestingly, the most expensive treatments prices were under evaluated whereas the cheapest ones were overvalued. For example, median estimation of the cost of eculizumab was only 9 [2.5–29]% of its real price.

Conclusion: ICU health care workers have a poor knowledge of the price of treatments frequently used in the ICU.

Compliance with ethics regulations: N/A.

CO-66 How subjective determinants influence antibiotic prescribing behaviors among intensivists in French ICUs? A nation-wide cross-sectional survey

GIANNOLI Alice1, BAUDOT Amandine1, THIERY Guillaume1

1CHU Nord Saint-Etienne, Saint Etienne, France
Correspondence: Alice GIANNOLI (alice.giannoli@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-66

Rationale: In order to improve antibiotic’s use, strategies, such as stewardship programs, have been developed. However, their efficacy remains flawed and antibiotics remain overused. One of the reasons lies in subjective determinants of the prescription. The aim of our study is to explore personal, social, cultural and contextual factors that can influence antibiotic prescribing behaviour in the ICU.

Patients and methods/Materials and methods: For this nation-wide study, we designed a questionnaire to explore 4 domains that may influence antibiotic prescription: demographic characteristics, knowledge and medical practice, social interactions, and psychological factors. The questionnaire was distributed to all ICUs in France through a personal email sent to the head of each ICU, asking them to send the questionnaire to doctors and residents of their team. Two reminders were sent, at 2 and 4 months.

Results: We received 803 responses (55% senior physicians, 15% fellows, 5% academic physicians and 25% residents). Primaries specialties was anesthesiology (47%), medical specialty (38%), emergency medicine (8%) and intensive care (DESMIR, 7%). Fifty-two percent worked in university hospitals, 41% had a combined activity. The population is comparable to the global demography in French ICUs (1). A large majority (84%) of the respondents felt concerned by antibiotic resistance, but 45% didn’t believe that a restrictive use could decrease it. Only 54% of the responders shared the statement “we must always seek the narrowest spectrum”. The decision to not initiate an antibiotic treatment was perceived as more difficult that initiating, adapting of interrupting it (p < 0.0001). For 85% of the responders, antibiotic prescription is a team decision. However, 30% declare that they don’t ask any advice and 22% report a large variability within their team. Twenty-two percent of the responders don’t hesitate to modify a prescription of their college and 13% of their boss if considered inappropriate. Seventy-eight percent of the responders consider themselves as “restrictive prescribers”. More academic physicians, senior physicians and physician having validated the subspecialisation in intensive care (DESC) declared themselves as “restrictive prescribers”, whereas more residents declared themselves “liberal prescribers”. Analysis of these “liberal prescribers” reveals that they are significantly more inexperienced, anxious and insecure, with a limited ability to take a step back.

Conclusion: This work confirms that subjective determinants hinder reasoned antibiotic prescribing. Factors such as prescriber anxiety and lack of self-confidence, linked in particular to a lack of knowledge, stand out. The fear of missing a septic etiology pushes the physician to prevail the short-term benefit taking over the long-term consequences.

Compliance with ethics regulations: Yes in clinical research.

CO-67 Assessment of new methods for bedside measurement of airway opening pressure without the need for low-flow insufflation

HAUDEBOURG Anne-Fleur1,3, DELAMAIRE Flora2, LOUIS Bruno3, MEKONTSO DESSAP Armand1,3, CARTEAUX Guillaume1,3

1C.H.U. HENRI MONDOR, Creteil, France; 2HÔPITAL PONTCHAILLOU, Rennes, France; 3INSTITUT MONDOR DE RECHERCHE BIOMEDICALE (IMRB), Creteil, France
Correspondence: Anne-Fleur HAUDEBOURG (annefleur.maignant@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-67

Rationale: The gold standard method proposed to detect and measure airway opening pressure (AOP) in patients with acute respiratory distress syndrome (ARDS) requires a low-flow insufflation (i.e., 5 L/min). This ensures that the resistive pressure is negligible but might potentially be poorly tolerated. Theoretically, during usual constant flow insufflation (i.e., 30 to 60 L/min), the delta pressure comprised between the PEEP and the first inflection point of the airway pressure waveforme, subsequently called “conductive pressure”, comprises resistive pressure and potential AOP (Fig. 1). We assessed the accuracy and tolerance of calculating AOP as the conductive pressure minus resistive pressure during usual constant flow insufflation. We also assessed an automated computer-based detection of AOP.

Patients and methods/Materials and methods: AOP was measured in ARDS patients using three different methods: 1: gold standard: low-flow insufflation (5 L/min); 2: visual waveform analysis during standard ventilation with a constant flow rate of 30 and 60 L/min: AOP was identified as the conductive pressure minus the resistive pressure; 3: automated computer-based detection of the rupture of the airway pressure slope. We compared methods 2 and 3 to the gold standard and collected the lowest SpO2 during each measurement to assess the tolerance.

Results: 25 ARDS patients were included so far, of whom 13 (52%) had an AOP > 5 cmH2O with a median value of 7 cmH2O [6–8]. AOP obtained by visual waveform analysis during ventilation with usual flow rate showed a very strong correlation with reference value (r = 0.8 at flow 30 L/min and r = 0.93 at flow 60 L/min, p < 0.001, Fig. 1). Bland–Altman plot for visual waveform analysis at 60 L/min showed a bias of 0.08 with agreement limits between − 1.87 and 2.03 cmH2O. AOP obtained by computer-based detection showed a strong correlation with reference value (r = 0.66 at 30 L/min and r = 0.70 L/min, p < 0.001) but with a trend toward overestimation of AOP. Visual or computer-based waveform analysis during ventilation with usual flow rate was better tolerated than gold standard method (decrease in SpO2: − 0.5% [− 2–0] and 0% [− 2–0] at 30 and 60 L/min respectively versus − 2% [− 4.8 to − 1] at 5 L/min, p < 0.001).

Conclusion: These preliminary data suggest that measuring AOP is feasible at standard insufflation flow rate with a simple, quick and safe method based on visual inspection of airway pressure waveform.

Compliance with ethics regulations: Yes in clinical research.

figure aj

Figure 1: Spearman correlation between AOP obtained by visual waveform analysis during standard ventilation at 60 L/min and gold standard at low-flow insufflation (full line: linear regression line).

CO-68 Detection and respiratory mechanic assessment of asymmetrical acute respiratory distress syndrome with electrical impedance tomography

ROZE Hadrien1, BONNARDEL Eline1, BOISSELIER Clément1, GRESS Gauthier1, REPUSSEAU Benjamin1, PERRIER Virginie1, CHRISTELLE Pellerin1, OUATTARA Alexandre1

1CHU de Bordeaux, Bordeaux, France
Correspondence: Hadrien ROZE (hadrien.roze@chu-bordeaux.fr)

Annals of Intensive Care 2022, 12(1):CO-68

Rationale: ARDS is a heterogeneous syndrome involving different phenotypes with distinct clinical and outcome characteristics. Low flow pressure volume (PV) curve reflects the global behavior of the lungs and can be misleading in ARDS. With Electrical Impedance Tomography (EIT) it is possible to measure the distribution of ventilation in each lung in order to describe asymmetrical lung injury. Moreover, each lung respiratory mechanic and PV curve can be assessed with an EIT derived method. In the present study, we hypothesized that some patients may have asymmetrical ARDS where EIT would provide different information from those obtained from global P-V curves.

Patients and methods/Materials and methods: Prospective study (NCT04386720). We recorded the low flow PV curve without PEEP of the ventilator in order to assess airway closure and the recruited volume.1 AT the same time with EIT we analyzed the derived PV curves of each lung.2 A difference of tidal ventilation of at least 20% between the 2 lungs was considered as asymmetrical ARDS. We compared respiratory mechanic between the 2 lungs in patients with asymmetrical ARDS.

Results: We analyzed 26 patients, 18 patients had asymmetrical lung injury, the most injured lung received 28.5 ± 8.0% of the tidal ventilation, its compliance was significantly lower than the less injured lung: 11.9 ± 7.8 vs 28.8 ± 14.3 ml cmH2O-1p < 0.0001 respectively. Thirteen patients had airway closure with an airway opening pressure > 4 cmH2O; Global PV curve AOP was 6.6 ± 3.4 cmH2O, similar to the less injured lung with 6.6 ± 3.3 cmH2O, whereas the most injured lung had a significantly higher AOP of 10 ± 3.9, p = 0.003. The PEEP recruited volume VREC was significantly lower in the most injured lung: 67 [43–123] vs 120 [57–225] ml, p = 0.015. The compliance of the recruited lung (Crec) in the more injured lung was not different from the less injured 22.0 [5.6–32.3] vs 24.0 [11.8–41.0] ml.cmH2O−1 respectively, p = 0.460.

Conclusion: EIT can show asymmetrical ARDS and assess respiratory mechanic of each lung. Personalizing ventilator management in asymmetrical lung injury entails assessing each lung-specific risk of VILI with repeated opening and collapse of the most injured lung and overdistension in the less injured lung. A specific compromise between PEEP and VT in asymmetrical ARDS could attenuate these opposite risk of VILI.

Reference 1: AJRCCM 2018 197:132–136.

Reference 2: AJRCCM 2021;203:511–515.

Compliance with ethics regulations: Yes in clinical research.

figure ak

Airway Opening Pressure measured with EIT in each lung

CO-69 Response to PEEP assessed on computed tomography in COVID-19 ECMO patients

RICHARD Jean-Christophe1,2, YONIS Hodane1, SIGAUD Florian3, MEZIDI Mehdi1, DAVILA SERRANO Eduardo2, ORKISZ Maciej2, ROUX Emmanuel2, GAILLET Maxime1, BAYAT Sam3, TERZI Nicolas3, BITKER Laurent1,2

1Hopital de la Croix-Rousse, Lyon, France; 2Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Lyon, France; 3CHU Grenoble Alpes, Grenoble, France
Correspondence: Jean-Christophe RICHARD (j-christophe.richard@chu-lyon.fr)

Annals of Intensive Care 2022, 12(1):CO-69

Rationale: Lung potential for recruitment of COVID-19 ARDS is a matter of debate, and may be patient-dependent, favoring individualization of PEEP setting. PEEP selection in severe COVID-19 patients under ECMO may be more challenging as no study has assessed recruitment potential in this setting. The aim of the study was to compare potential for recruitment and the impact of PEEP on lung aeration with computed tomography (CT) in moderate, severe without ECMO and severe under ECMO ARDS patients.

Patients and methods/Materials and methods: We conducted a two-center prospective observational study in adult COVID-19 related ARDS patients who had an indication for CT. Main exclusion criteria were ARDS onset > 72 h in non-ECMO patients or ECMO onset > 72 h. Four low-dose CT acquisitions were performed at both end-expiration and end-inspiration at PEEP selected by attending physician, and at end-expiration at both PEEP 5 and 15 cmH2O.

Results: 99 patients (76% male, age 62 [54–71] year) were included, of whom 24 had severe ARDS under ECMO, 59 severe ARDS without ECMO and 16 moderate ARDS. ECMO patients were ventilated with significantly lower tidal volume (1.0 [1.0–1.0] vs 6.0 [5.9–6.0] ml/kg predicted body weight (PBW) and higher PEEP (15 [13–15] vs. 10 [5–10] cmH2O. The median amount of recruitable lung between PEEP 5 and 15 cmH2O was 6.2 [4.0–9.9]% of lung weight, and tidal hyperinflation amounted to 0.3 [0.1–1.0] ml/kg PBW. Tidal hyperinflation > 1 ml/kg PBW was observed in 19 (25%) non-ECMO patients and 0 (0%) ECMO patients. Non-inflated lung at PEEP 5 was significantly greater in ECMO than in non-ECMO patients (Fig. 1). End-expiratory aerated lung volume (EELV) at PEEP 5 was significantly lower in ECMO patients. Recruitment induced by PEEP increase from 5 to 15 cmH2O was not significantly different between groups, while PEEP-induced hyperinflation was significantly lower in the ECMO group and virtually inexistent. Tidal hyperinflation was significantly lower in ECMO patients. Compliance of the aerated lung between 5 and 15 cmH2O corrected for lung recruitability (CompliancePEEP5-15) was significantly lower in ECMO patients and was independently related to lung aeration at PEEP5 in multivariate analysis.

Conclusion: Lung recruitability of COVID-19 pneumonia is not significantly different among class of ARDS severity. ECMO patients exhibits lower hyperinflation levels of already aerated lung with PEEP increase from 5 to 15 cmH2O, as a consequence of compliance decrease of the baby lung at low end-expiratory lung volume. This suggests that PEEP higher than 15 could be safely applied in COVID-19 severe ARDS ECMO patients.

Compliance with ethics regulations: Yes in clinical research.

figure al

Figure 1

CO-70 Physiological effects of positive end-expiratory pressure titration strategies based on electrical impedance tomography in patients with COVID-19 associated acute respiratory distress syndrome

COURTAIS Antonin1, CHEAN Dara1, PAVLOVSKY Bertrand1, LESIMPLE Arnaud1, RICHARD Jean Christophe1, MERCAT Alain1, BELONCLE François1

1CHU Angers, Angers, France
Correspondence: Antonin COURTAIS (courtais.antonin@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-70

Rationale: Electrical Impedance Tomography (EIT) allows to provide an imaging of the gas distribution in the lung during ventilation. Various EIT-based strategies have been proposed to titrate positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). This study aimed to compare the physiological effects of two distinct EIT-based and one respiratory system mechanics-based PEEP titration strategies.

Patients and methods/Materials and methods: It was a randomized cross-over monocentric study. Patients with moderate to severe COVID-19 associated ARDS were enrolled within 72 h after intubation. Patients were ventilated in volume-controlled ventilation (tidal volume = 6 mL/kg predicted body weight). A decremental PEEP trial (PEEP from 20 to 5 cmH2O by steps of 3 cmH2O every 3 min) was performed in order to determine the PEEP levels associated with i the lowest Global Inhomogeneity index with a plateau pressure lower than 30 cmH2O (GI strategy) ii a percentage of collapsed lung tissue lower than 15% and the lowest hyperdistension percentage (OD-CL strategy) and iii with a plateau pressure between 28 and 30 cmH20 (Express strategy). The PEEP level determined according to the three tested strategies was then applied in a randomized order (three periods of 45 min). Gas exchange, respiratory mechanics including airway and esophageal pressure measurements, hemodynamic and gas distribution using EIT were assessed at the end of each period.

Results: Twenty patients have been included in the analysis. PEEP levels determined by the OD-CL strategy were lower than those determined by GI and Express strategies (median [interquartile range], 11 [8–14] cmH2O, 20 [17–20] cmH2O, 17 [15–18] cmH2O, respectively, p < 0.001). PaO2/FiO2 ratio was higher with GI and Express strategies compared to OD-CL strategy (173 [133–224] mmHg, 158 [135–203] mmHg, 137 [113–172] respectively, p < 0.001). Respiratory system compliance and cardiac output (CO) did not differ between the three PEEP titration strategies. The expiratory transpulmonary pressure was ≤ 2 cmH2O in seven patients (35%) with OD-CL strategy and three with Express and GI strategies (p = 0.2). The inspiratory transpulmonary pressure calculated according to the elastance ratio was > 22 cmH2O in four patients with OD-CL strategy and five patients (25%) with Express and GI strategies (p = 0.9).

Conclusion: OD-CL strategy lead to lower PEEP levels than the Express and GI strategies. OD-CL strategy is associated with decreased oxygenation but similar respiratory mechanics and hemodynamic parameters.

Compliance with ethics regulations: Yes in clinical research.

CO-71 Global Ventilation-Perfusion mismatch improvement related to PEEP increase in patients with highly recruitable lungs

PAVLOVSKY Bertrand1,2, PESENTI Antonio2, SPINELLI Elena2, SCARAMUZZO Gaetano3, MARONGIÙ Ines2, TAGLIABUE Paola2, SPADARO Savino2, GRASSELLI Giacomo2, MERCAT Alain1, MAURI Tommaso2

1CHU Angers, Angers, France; 2Fundazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italie; 3Ospedale Universitario Sant'Anna, Ferrara, Italie
Correspondence: Bertrand PAVLOVSKY (bertrand.pavlovsky@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-71

Rationale: The Acute Respiratory Distress Syndrome (ARDS) is characterized by an important Ventilation-Perfusion (V/Q) mismatch. By recruiting the collapsed lung areas, Positive End Expiratory Pressure (PEEP) may enhance V/Q coupling, by decreasing shunt and allowing a redistribution of ventilation through perfused regions. We hypothesized that higher PEEP may improve V/Q mismatch in ARDS patients with highly recruitable lungs.

Patients and methods/Materials and methods: We enrolled fifteen patients with moderate or severe ARDS in this study, within 2 [2–5] days from intubation. Two PEEP levels (5 and 15 cmH2O) were applied in a random order. Gas exchange and respiratory mechanics were assessed at each step. V/Q mismatch was evaluated by the Electrical Impedance Tomography (EIT) 5% NaCl bolus method at each PEEP level. Respective fractions of ventilation and perfusion across all V/Q ratios were built, leading to precise assessment of their distribution throughout different V/Q mismatch compartments. The amount of wasted ventilation and perfusion were computed according to this model as follows: sum of (log(V/Q) * V or Q), for all pixels in the functional EIT image within each ROI, including only units with V/Q ratio < 1 and > 1, respectively for wasted ventilation and wasted perfusion. Recruitment between the two PEEP levels was measured by the recruitment-to-inflation ratio (R/I) method.

Results: Median age was 60 [48–68] years, and body mass index 27.3 [25.7–35.4] kg.m−2. Between PEEP 5 and 15 cmH2O, PaO2/FiO2 increased from 125 [69–194] to 162 [90–198] mmHg (p = 0.011), while PaCO2 decreased, albeit non significantly (49.8 [42.0–61.0] vs. 48.0 [42.0–52.1] mmHg, p = 0.403). Respiratory system compliance remained stable (36 [25–50] vs. 32 [24–42] mL.cmH2O−1, p = 0.164). Patients were characterized by an elevated lung recruitability (R/I ratio 1.29 [1.01–1.53]). In the global population V/Q mismatch improved, as shown by the mean distributions of ventilation and perfusion fractions (Figure, panel A). Both wasted ventilation (17 [14–20] vs. 14 [10–18] %, p = 0.109) and wasted perfusion (16 [13–22] vs. 14 [9–17] %, p = 0.005) decreased at higher PEEP levels. There was a correlation between the R/I ratio and the amount of decrease in both variables from PEEP 5 to 15 cmH2O (Figure, Panel B and C).

Conclusion: In patients with highly recruitable lungs, V/Q mismatch is improved by higher PEEP levels. This effect is correlated with lung recruitability.

Compliance with ethics regulations: Yes in clinical research.

figure am

Distribution of the fraction of ventilation (blue) and perfusion (red) across all V/Q ratios at PEEP 5 and 15 cmH 2 O (A). Correlations between R/I ratio and the improvement in Wasted Ventilation (B) and Perfusion (C) between PEEP 5 and 15 cmH 2 O.

CO-72 Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial in ICU: Physiological effects on alveolar recruitment

COUDROY Rémi1, LEJARS Alice1, RODRIGUEZ Maeva1, ARRIVÉ François1, REYNAUD Faustine1, BOISSIER Florence1, VEINSTEIN Anne1, CHATELLIER Delphine1, ROBERT René1, FRAT Jean-Pierre1, THILLE Arnaud W.1

1CHU de Poitiers, Poitiers, France

Correspondence: Rémi COUDROY (remi.coudroy@chu-poitiers.fr)

Annals of Intensive Care 2022, 12(1):CO-72

Rationale: After a successful spontaneous breathing trial (SBT), reconnection to mechanical ventilation for 1 h is associated with lower reintubation rates than direct extubation1. However, physiological explanations leading to this clinical effect remain unclear. We hypothesized that reconnection to mechanical ventilation for 1 h after a successful SBT induces alveolar recruitment. Our primary aim was to compare end-expiratory lung volume (EELV) at the end of a successful SBT and 1 h after reconnection to mechanical ventilation.

Patients and methods/Materials and methods: This is an ancillary study of a multicenter randomized controlled trial comparing T-piece versus pressure-support (pressure support of 8 cmH2O without positive end-expiratory pressure) for SBT before extubation. All patients included were at high-risk of extubation failure, i.e. intubated at least 24 h and older than 65 years or having underlying chronic cardiac or lung disease.2 In this physiological single-center study, EELV was measured using the nitrogen washin-washout technique before the SBT under mechanical ventilation, at the end of the SBT, and then 10 min, and 1 h after reconnection to mechanical ventilation. Regional ventilation using electrical impedance tomography was continuously recorded during the study. SBT was performed for around 1 h using T-piece or low pressure-support levels according to the randomization.

Results: From the 25 patients analyzed, 11 (44%) had SBTs performed using T-piece and 14 (56%) using pressure-support. Median age was 71 years [interquartile range 67–75] and duration of mechanical ventilation was 8 days [4–13]. All in all, median EELV was 1938 mL [IQR, 1370–2514] before SBT and decreased by 30% [95 CI, 23–37] at the end of the SBT (p < 0.001). The decrease in EELV at the end of the SBT was greater using T-piece than using pressure-support (decrease by 43% [95% CI, 35–51] vs. 20 [95% CI, 13–26], p < 0.001). EELV significantly re-increased from 1305 mL [IQR, 1074–1703] at the end of the SBT to 1927 mL [IQR, 1377–2470] after 1 h of reconnection to mechanical ventilation (mean difference of 587 mL [95% CI, 406–767], p < 0.001). After only 10 min of reconnection to mechanical ventilation, 101% [95% CI, 64–137] of this increased EELV had already been recovered. Regional ventilation was mainly distributed in the non-dependent lung regions and did not differ between T-piece and pressure-support.

Conclusion: SBT induced a marked alveolar derecruitment which was significantly greater after SBT using T-piece than using pressure-support. This lung volume loss was almost completely recovered after 10 min of reconnection to mechanical ventilation regardless the type of SBT.

Reference 1: Fernandez MM, González-Castro A, Magret M, Bouza MT, Ibañez M, García C, et al. Reconnection to mechanical ventilation for 1 h after a successful spontaneous breathing trial reduces reintubation in critically ill patients: a multicenter randomized control.

Reference 2: Thille AW, Coudroy R, Gacouin A, Ehrmann S, Contou D, Dangers L, et al. T-piece versus pressure-support ventilation for spontaneous breathing trials before extubation in patients at high risk of reintubation: protocol for a multicentre, randomised control.

Compliance with ethics regulations: Yes in clinical research.

CO-73 Impact of extra-respiratory stimulations on dyspnea in critically ill mechanically ventilated patient—The sensopnea 2 study

BUREAU Côme1, NIÉRAT Marie-Cécile1, DECAVÈLE Maxens1, DANGERS Laurence1, CANTIER Marie1, VIROLLE Sara1, DELERIS Robin1, DELEMAZURE Julie1, MAYAUX Julien1, DRES Martin1, SIMILOWSKI Thomas1, DEMOULE Alexandre1

1Hôpital Universitaire Pitié-Salpêtrière, Paris, France

Correspondence: Côme BUREAU (come.bureau@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-73

Rationale: Half of patients undergoing mechanical ventilation (MV) in the intensive care unit report a dyspnea of moderate to severe intensity, which causes immediate suffering and post-traumatic stress disorders. Dyspnea has two distinct components, a sensory component and an emotional component. Our objective was to evaluate and to compare the respective impact of a modulation of the sensory component (respiratory afferents) and the emotional component (extra respiratory auditory and sensory stimulations) on the intensity of dyspnea in critically ill patients undergoing MV, either invasive or non-invasive.

Patients and methods/Materials and methods: Patients MV for more than 48 h with a dyspnea intensity ≥ 40 mm on a visual analog dyspnea scale (Dyspnea-VAS) were included. We studied the following interventions: (1) increase of pressure support level by 5 cmH2O vs. baseline ventilator settings as a control (sensory component), (2) a relaxing standardized music piece vs. a “pink” noise as a control (emotional component), and (3) fresh air directed toward the face vs. the thigh as a control (emotional component). A washout period separated each condition. Dyspnea was assessed with the Dyspnea-VAS and the A1 score of the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the P0.1 and electromyographic activity of the Alea Nasi and parasternal muscles.

Results: We included 46 patients, 19 tracheostomized, 18 intubated and 9 under non-invasive ventilation. Median (interquartile range) age was 63 years (54–73) and duration of mechanical ventilation was 33 days (7–49). Compared to their respective control group the three intervention decreased Dyspnea-VAS: 1) pressure support increment 20 [20–40] mm vs. 70 [60–80], p < 0.0001, 2) auditory stimulation 40 [20–40] vs. 70 [60–80], p < 0.0001 and 3) sensory stimulation 40 [30–50] vs. 60 [50–80], p < 0.0001). Compared to their respective control group the three interventions decreased A1: 1) pressure support increment 5 [4–6] vs. 7 [6–8], p < 0.0001, 2) auditory stimulation 2 [0–2] vs. 7 [6–8], p < 0.0001 and 3) sensory stimulation 3 [2–4] vs. 7 [6–8], p < 0.0001. The electromyographic activity of Alea nasi and parasternal muscles decreased significantly after pressure support increment (p < 0.0001 for both) but did not change during auditory and sensory stimulation. P0.1 decreased more markedly with pressure support increment (3.7 [2.7–5.1] cmH2O vs. 6.5 [6.0–8.1], p < 0.0001) than with auditory (6.0 [5.7–7.4] vs. 6.3 [6.0–7.7], p = 0.002) and sensory (6.0 [5.3–7.6] vs. 6.5 [5.7–7.7], p = 0.001) stimulation.

Conclusion: In critically ill MV patients, auditory and sensory extra-respiratory stimulations decreased dyspnea without decreasing respiratory drive, suggesting a mechanism involving a modulation of the emotional component.

Compliance with ethics regulations: Yes in clinical research.

CO-74 Accuracy of pulse oximetry (SpO2) with different oximeters—Oxygap study

BLANCHET Marie-Anne1, MERCIER Gabriel1, DELOBEL Antoine1, NAYET Emi1, BOUCHARD Pierre-Alexandre1, LELLOUCHE François1

1Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
Correspondence: Marie-Anne BLANCHET (marie-anne.blanchet.2@ulaval.ca)

Annals of Intensive Care 2022, 12(1):CO-74

Rationale: An accurate SpO2 value is critical in order to optimally titrate the O2 flow or FiO2 delivered to patients under oxygen support and to follow oxygenation guidelines. It has been shown with closed-loop oxygen titration that small variations in SpO2 target greatly affect the oxygen flow required, which may have a relevant impact on clinical decisions. However, the oximeters’ accuracy appears to vary widely from model to model, leading to an underestimation or an overestimation of actual SaO2 values. This variability may represent an obstacle to an optimal delivery of oxygen therapy, including the implementation of guidelines. The objective of this study was to assess the accuracy and bias of the SpO2 value measured by several oximeters compared to the reference value, arterial oxygen saturation (SaO2) measured by arterial gases in intubated and spontaneously breathing patients in the intensive care unit.

Patients and methods/Materials and methods: (ClinicalTrials.gov ID: NCT04772183) The study was approved by the local ethics board with a waiver of consent. We included stable patients hospitalized in the ICU with an arterial catheter in place. Main exclusion criteria were: respiratory instability, poor SpO2 signal, infectious isolation, SpO2 > 96%. We evaluated six oximeters: Nonin (Plymouth, MN), Massimo (Irvine, CA), Philips (Eindhoven, Netherlands), Nellcor (Pleasanton, CA), Fingers were randomized at each patient. Arterial blood gases were drawn and simultaneously, SpO2 values for all oximeters were collected. SpO2 value were compared to the reference (SaO2 value) to determine bias and accuracy. The ability for oximeters to detect hypoxemia and the impact of oximeters on oxygen titration were evaluated.

Results: We included 210 patients (153 men; 57 women, mean age 66.3 ± 11.2 years). The skin pigmentation evaluated by Fitzpatrick showed 96.2% of patients were type 1 or 2. One oximeter overestimated SaO2 (Philips, + 0.9%) while the three others underestimated SaO2 (Nonin − 3.1%, Nellcor − 0.3%, Masimo − 0.2%). Oxygen saturation was underestimated with Nonin oximeter in 91.3% of the cases while it was overestimated in 55.2% of the cases with Philips oximeter. Hypoxemia was detected in 100%, 26%, 37% and 11% of the cases with Nonin, Nellcor, Masimo and Philips respectively (Table 1).

Conclusion: We found large systematic and random errors between the tested oximeters and the arterial blood gases, in the studied population. These discrepancies may have important clinical impact on the detection of hypoxemia or management of oxygen.

Compliance with ethics regulations: Yes in clinical research

figure an

Table 1. Main features of evaluated oximeters. Mean, standard deviation, percentage of over and underestimation of the SaO 2 and detection of hypoxemia for tested oximeters.

CO-75 Effective FiO2 delivered by a new frugal CPAP system with low oxygen requirements: first clinical observations

DE BEAUFORT Eloïse1,7,8, MORIN François2, CARTEAUX Guillaume3,7,8, BOUJELBEN Mohamed2,7,8, BROC Alexandre1, LESIMPLE Arnaud1,9, TAILLANTOU-CANDAU Mathilde2, BIZOUARD Thomas2, SAVARY Dominique2,4, MERCAT Alain2, BELONCLE François2, BROCHARD Laurent5,6, RICHARD Jean-Christophe1,2, MEKONTSO-DESSAP Armand3,7,8

1Air Liquide Medical Systems, Antony, France; 2Centre Hospitalier Angers, Angers, France; 3Centre Hospitalier Henri Mondor, Créteil, France; 4École des hautes études en santé publique, Rennes, France; 5St. Michael’s Hospital, Toronto, Canada; 6Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; 7Institut Mondor de Recherche Biomédicale, Créteil, France; 8Université Paris-Est Créteil, Créteil, France; 9Institut MITOVASC, Angers, France
Correspondence: Eloïse DE BEAUFORT (eloise.debeaufort@airliquide.com)

Annals of Intensive Care 2022, 12(1):CO-75

Rationale: In patients with COVID-19 related de novo acute respiratory failure, the application of continuous positive airway pressure (CPAP) improves respiratory mechanics, gas exchange and outcome [1]. In the context of a pandemic with a massive influx of hypoxemic patients, the high oxygen consumption required to achieve optimal inspired oxygen (FiO2) may jeopardize health care organization and oxygen delivery hospital capabilities. Within the framework of frugal innovation [2], we have designed a new Bag-CPAP device aiming at meeting oxygen delivery constraints. The aim of these clinical observations was to evaluate the performances of the Bag-CPAP in terms of FiO2 actually delivered, oxygen consumption, airway pressure and clinical tolerance.

Patients and methods/Materials and methods: The Bag-CPAP is intended to deliver a positive end expiratory pressure (PEEP of 5–10 cmH2O) with two levels of FiO2: moderate (50%–60%) or high (90%–100%) obtained with an oxygen flow rate of 5 and 15 L/min, respectively. The system operates with a 30L reservoir for gas accumulation to reduce oxygen consumption and guarantee FiO2 irrespective of respiratory demand.

After ANSM authorization, the clinical observation was conducted in two university hospitals in France, on 20 adult patients with de novo acute respiratory failure. PEEP level was adjusted at 7.5 cmH2O in all patients and FiO2 (moderate or high) was selected according to patients’ needs. Actual FiO2 and PEEP were regularly measured along with respiratory pattern and dyspnea score. Quantitative data are expressed as median [interquartile range], a P value < 0.05 was considered statistically significant.

Results: Median FiO2 were 53% [52%–53%] for moderate FiO2 target and 94% [93%–96%] for high FiO2 target with an oxygen flow rate of 8 [7–9] L/min and 15 [15–16] L/min respectively (Fig. 1). 98% of FiO2 values were within the expected target ranges for both moderate and high FiO2. Median PEEP was 7 [5–7] cmH2O. SpO2 significantly increased and Borg dyspnea Scale significantly decreased since the first hour of Bag-CPAP application (93% [90%–97%] vs. 97% [95%–98%], p = 0.001 and 4 [2–7] vs. 3 [2–4], p = 0.017, respectively). No significant effect was observed on respiratory rate.

Conclusion: This pilot clinical experience shows that the Bag-CPAP is well tolerated while allowing reaching high FiO2 with low oxygen consumption: greater than 50% and 90% with an oxygen flow rate of at least 5 [5 to 10] L/min and 15 [10 to 20] L/min respectively.

Reference 1: G. D. Perkins et al., « An adaptive randomized controlled trial of non-invasive respiratory strategies in acute respiratory failure patients with COVID-19», août 2021. https://doi.org/10.1101/2021.08.02.21261379.

Reference 2: A. Mekontso Dessap, « Frugal innovation for critical care», Intensive Care Med., vol. 45, no 2, p. 252?254, févr. 2019, https://doi.org/10.1007/s00134-018-5391-6.

Compliance with ethics regulations: Yes in clinical research.

figure ao

FiO 2 measurements according to oxygen flow rate during Bag-CPAP treatment and FiO 2 target range (moderate: green or high: pink)

CO-76 Comparison of positive end-expiratory pressure titration strategies based on measured end-expiratory transpulmonary pressure and calculated end-inspiratory transpulmonary pressure in acute respiratory distress syndrome: a physiological study

CHEAN Dara1, COURTAIS Antonin1, PAVLOVSKY Bertrand1, YVIN Elise1, DESPREZ Christophe1, TAILLANTOU-CANDAU Mathilde1, RICHARD Jean-Christophe1, MERCAT Alain1, BELONCLE François1

1CHU ANGERS, Angers, France
Correspondence: Dara CHEAN (dara.chean@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-76

Rationale: The optimal positive end-expiratory pressure (PEEP) titration strategy for patients with acute respiratory distress syndrome (ARDS) is still a matter of debate. Esophageal pressure monitoring allows to estimate pleural and transpulmonary pressures. Two distinct strategies based on measured end-expiratory transpulmonary pressure (PL, exp) or calculated end-inspiratory transpulmonary pressure (PL, insp calc) have been described but their physiological effects have never been compared to each other. This study aimed at comparing the short-term ventilatory and hemodynamic effects of these two strategies in patients with ARDS.

Patients and methods/Materials and methods: PL, exp was computed as the difference between total PEEP and esophageal pressure measured at end-expiration. In PL, exp-based PEEP titration strategy, PEEP was set to maintain PL, exp between 0 and 6 cmH2O using a PL, exp-FiO2 table1. In PL, insp calc-based PEEP titration strategy, PL, insp calc was estimated using the lung to respiratory system elastance ratio and PEEP was set to achieve a PL, insp calc between 20 and 22 cmH2O2. PL, exp-based and PL, insp calc-based strategies were consecutively applied in a randomized order in patients with moderate to severe ARDS. Gas exchange, respiratory mechanics, hemodynamics and ventilation regional distribution assessed with electrical impedance tomography were evaluated 45 min after the application of each PEEP titration strategy.

Results: Twenty patients were included in this study. Twelve (60%) patients had SARS-CoV2 associated pneumonia. The two different PEEP titration strategies led to similar median levels of PEEP (median [interquartile range], 14 [9–17] cmH2O with PL, exp-based strategy vs 16 [12–18] cmH2O with PL, insp calc-based strategy, p = 0.11) but 14 (70%) patients presented a difference of at least 3 cmH2O between the two determined PEEP levels. PaO2/FiO2, shunt fraction, dead-space, cardiac index and oxygen delivery were similar between the two strategies. The 12 (60%) patients for whom PL, insp calc-based strategy was associated with higher PEEP levels than PL, exp-based strategy were characterized by a lower body mass index. Compared to PL, exp-based strategy, PL, insp calc-based strategy was associated, in these patients, with better oxygenation but lower cardiac output, higher transpulmonary driving pressure, lower respiratory system compliance and lower non-dependant regional compliance, suggesting lung overdistension.

Conclusion: PEEP levels defined by the two distinct esophageal pressure measurements-based strategies differed of at least 3 cmH2O in 70% of ARDS patients. PL, insp calc-based strategy may be associated with lung overdistension in some patients.

Reference 1: Talmor, D. et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N. Engl. J. Med. 359, 2095–2104 (2008).

Reference 2: Grasso, S. et al. ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med 38, 395–403 (2012).

Compliance with ethics regulations: Yes in clinical research.

CO-77 Respiratory effects of lung recruitment maneuvers depend on the recruitment-to-inflation ratio

ZERBIB Yoann1, LAMBOUR Alexis1, MAIZEL Julien1, KONTAR Loay1, DE CAGNY Bertrand1, SOUPISON Thierry1, BRADIER Thomas1, SLAMA Michel1, BRAULT Clément1

1CHU Amiens-Picardie, Amiens, France

Correspondence: Clément BRAULT (brault.clement@chu-amiens.fr)

Annals of Intensive Care 2022, 12(1):CO-77

Rationale: In the context of acute respiratory distress syndrome (ARDS), the response to lung recruitment maneuvers (LRM) varies considerably from one patient to another. The LRM can be harmful, especially in patients with low recruitability, inducing lung overdistention and cardiac dysfunction. Recently, a single-breath maneuver with measurement of the recruitment-to-inflation (R/I) ratio has been developed to assess lung recruitability and identify patients who could benefit from the application of positive pressure. Here, we determined whether or not the R/I ratio could differentiate between patients according to the change in lung mechanics during LRM.

Patients and methods/Materials and methods: We included all adults patients admitted with a diagnosis of ARDS and an arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio lower than 150 mmHg. Starting at 20 cmH2O, the PEEP was increased in 5 cmH2O steps to 40 cmH2O, with each step lasting 2 min. We evaluated the changes in gas exchange, respiratory mechanics, and hemodynamic parameters induced by a stepwise LRM at a constant driving pressure of 15 cmH2O during pressure-controlled ventilation. Patients were dichotomized with regard to the median R/I ratio.

Results: We included 30 patients with a median [interquartile range] R/I ratio of 0.62 [0.42-0.83]. The PaO2/FiO2 ratio increased significantly after LRM in patients with low and high lung recruitability (Table 1). However, the mechanisms behind this improvement in oxygenation depend on each patient’s potential for alveolar recruitment, as measured by the R/I ratio. In patients with high recruitability (R/I ratio ≥ 0.62), the static respiratory system compliance (Crs) increased significantly after the LRM (33 [27–42] vs. 42 [35–60] mL/cmH2O; p < 0.001). There was a moderate but significant positive correlation between the change in Crs during the LRM and the R/I ratio (r = 0.56; p = 0.001). In patients with low recruitability (R/I ratio < 0.62), the increase in PaO2/FiO2 ratio was associated with a significant decrease in pulse pressure (70 [55–85] vs. 50 [51–67] mmHg; p = 0.01) but not with a significant change in Crs (33 [24–47] vs. 35 [25–47] mL/cmH2O; p = 0.74).

Conclusion: During an LRM, the mechanisms related to an increase in oxygenation depend on the potential for lung recruitment. Patients with high recruitability presented a significant increase in Crs (indicating a gain in ventilated area), while those with low recruitability presented a decrease in pulse pressure suggesting a drop in cardiac output and therefore in intrapulmonary shunt. The R/I ratio might help clinicians to identify patients in whom an LRM will lead to an increase in Crs.

Compliance with ethics regulations: Yes in clinical research.

figure ap

Respiratory and hemodynamic parameters before and after the LRM, as a function of the patients’ lung recruitability

CO-78 Chest electrical impedance tomography and lung ultrasound to monitor extubation

JOUSSELLIN Vincent1,2, JANIAK Vincent3,4, BONNY Vincent1,2, CLERC Sébastien1, MAYAUX Julien1, MORAWIEC Elise1, TALLEC Gwendolyne4, SALEEM Umar4, PINNA Andrea3, DRES Martin1,2

1AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive – Réanimation (Département "R3S"), Paris, France; 2Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; 3Sorbonne Université, CNRS, LIP6, Paris, France; 4Bioserenity, Paris, France
Correspondence: Vincent JOUSSELLIN (vincent.joussellin@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-78

Rationale: Chest Electrical Impedance Tomography (EIT) is a non-invasive technique that produces continuous cross-sectional images of regional lung ventilation. This study investigated the use of chest EIT and lung ultrasound in patients extubated after a successful spontaneous breathing trial. The hypothesis was that patients with extubation failure may exhibit early regional lung ventilation disturbances and higher lung ultrasound score (LUS) as compared to patients with extubation success.

Patients and methods/Materials and methods: Patients at high risk of extubation failure (> 65 years old, chronic cardiac or pulmonary disease) were included after a successful spontaneous breathing trail and after extubation was planned by the physicians. Lung ultrasound (with calculation of LUS score as a surrogate of loss of lung aeration) and chest EIT (with calculation of derived indices, such as Global inhomogeneity index (GI), front-back Centre of ventilation (CoV), Regional ventilation delay (RVD) and Surface available for ventilation) were performed before (H0) and two hours and six hours after extubation (H2 and H6 respectively). The primary outcome was the proportion of patients who presented extubation failure (defined as acute respiratory failure requiring re-intubation or not or death within 48 h after extubation).

Results: Thirty-four patients were included, of whom 10 (29%) were considered with extubation failure. Before extubation, the LUS score was higher in the extubation failure group as compared to patients who were successfully extubated (20 vs 11, p < 0,01). However, EIT derived indices were not different between groups. After extubation, GI index, RVD and LUS score were higher in the extubation failure group, whereas Surface was lower and the CoV didn’t change (See an example in Fig. 1).

Conclusion: Before extubation, a loss of lung aeration was observed in patients who developed extubation failure afterwards. After extubation, this loss persisted with adjunction of heterogeneity in air distribution observed with EIT.

Compliance with ethics regulations: Yes in clinical research.

figure aq

EIT derived indices in a patient who presented extubation failure 24 h after extubation compared to a patient who were successfully extubated GI index: Global inhomogeneity index; RVD: Regional ventilation delay; H0: just before extubation; H2 and H6:

CO-79 Clinical and microbiological features of drowning associated pneumonia: a multicenter cohort study

REIZINE Florian1, AGATHE Delbove2, DOS SANTOS Alexandre3, BODENES Laetitia4, BOUJU Pierre5, FILLÂTRE Pierre6, FRÉROU Aurélien7, HALLEY Guillaume8, LESIEUR Olivier9, COUROUBLE Patricia 10, BERTEAU Florian11, MORIN Jean12, DELAMAIRE Flora1, MARNAI Rémy13, LE MEUR Anthony14, AUBRON Cécile4, REIGNIER Jean12, GACOUIN Arnaud1, TADIÉ Jean-Marc1

1CHU de Rennes, Rennes, France; 2CH Vannes, Vannes, France; 3CH La Roche sur Yon, La Roche Sur Yon, France; 4CHU Brest, Brest, France; 5CH Lorient, Lorient, France; 6CH Saint Brieuc, Saint Brieuc, France; 7CH Saint Malo, Saint Malo, France; 8CH Quimper, Quimper, France; 9CH La Rochelle, La Rochelle, France; 10CH Saint Nazaire, Saint Nazaire, France; 11CH Morlaix, Morlaix, France; 12CHU Nantes, Nantes, France; 13CH Le Mans, Le Mans, France; 14CH Cholet, Cholet, France
Correspondence: Florian REIZINE (florian.reizine@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-79

Rationale: Pneumonia is the most frequent infectious complication among drowning patients requiring ICU admission. However, clinical and microbiological data on such pneumonia are scarce.

Patients and methods/Materials and methods: We conducted a retrospective multicenter study (2013–2020) of 270 consecutive patients admitted for drowning to 14 ICUs in the west of France. Baseline characteristics as well as clinical course of patients were compared according to the occurrence of drowning associated pneumonia (DAP) (diagnosed within 48 h of ICU admission). Pneumonia microbiological features and therapeutic strategies were also analyzed.

Results: Among the 270 patients admitted to the ICUs for drowning, 101 (37.4%) experienced pneumonia. Suicidal etiology of drowning, psychiatric comorbidities, and need for mechanical ventilation appeared to be risk factors for drowning associated pneumonia (DAP). DAP occurred less frequently in patients initially treated by antibiotics. Pneumonia occurrence was associated with higher severity scores at ICU admission (Median SAPS 2 score 34 [Interquartile range 25–55] versus 45 [28–67]; p = 0.006), longer ICU LOS (2 days [1–3] versus 4 [2–7]; p < 0.001), mechanical ventilation duration (2 days [1–4] versus 4.5 days [2–8]; p < 0.001), higher SOFA score at day 3 (1 [0-3] versus 5 [1–10]; p = 0.001) These patients also experienced acute respiratory distress syndrome (ARDS) more frequently (28.4% versus 53.5%; p < 0.001). Survival at day-28 appeared lower among these patients particularly in patients developing microbiologically proven pneumonia (14/33 versus 201/237; p < 0.0001). Interestingly, microbiological analysis of respiratory samples showed a high proportion of gram-negative bacilli (39.6%) that did not differ according to water salinity. Empirical antimicrobial management seemed frequently inappropriate (30.3%) mostly due to high proportions of resistance to Amoxicillin–Clavulanate on isolates (39.4%).

Conclusion: Pneumonia occurrence was found to be a common complication in critical drowning patients that worsen patients’ clinical courses. Due to a high proportion of resistant gram-negative bacilli among isolated pathogens, initial empirical antimicrobial strategy with Amoxicillin–Clavulanate should be discouraged.

Compliance with ethics regulations: Yes in clinical research.

CO-80 Prognosis of adult patients hospitalized with respiratory syncytial virus infection: a multicenter retrospective observational cohort study

CELANTE Héloïse1, OUBAYA Nadia1, LAYESE Richard1, DE PROST Nicolas1

1Hôpital Henri-Mondor, Creteil, France
Correspondence: Héloïse CELANTE (heloise.celante@aphp.fr)

Annals of Intensive Care 2022, 12(1):CO-80

Rationale: Respiratory syncytial virus (RSV) is a common agent of viral respiratory infections. It causes significant morbidity and mortality in adults, especially in those with cardiorespiratory comorbidities and immunosuppression. Although there is a high burden of RSV respiratory infections in frail adults, few data are available in hospitalized patients. We set up a retrospective multicenter cohort to obtain large-scale data aiming at better depicting the clinical profile and prognosis of patients hospitalized with RSV infection.

Patients and methods/Materials and methods: Retrospective multicenter observational cohort study conducted in all Assistance Publique-Hôpitaux de Paris (AP-HP) hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 for documented respiratory RSV infection. Data were extracted from the AP-HP Health Data Warehouse (EDS). The selection of patients and the procedures performed in intensive care units (ICUs, n = 13) were identified using International Classification of Disease (ICD) 10 and CCAM (Classification Commune des Actes Médicaux) coding. The primary endpoint was in-hospital mortality.

Results: 1168 patients were hospitalized for RSV infection, including 880 patients admitted to 14 conventional inpatient units and 288 patients who required ICU admission. The median age of patients was 75 years, 54% of them were women. Patients frequently had comorbidities, most often cardiovascular (hypertension: 46.4%; heart failure: 34.4%), respiratory (28.6%), or immunodepression (29.5%). In-hospital mortality was 6.6% (n = 77/1168) in the whole cohort and 12.8% (n = 37/288) in ICU patients. By multivariable logistic regression, the factors associated with hospital mortality were age (adjusted odds ratio (aOR) = 1.03 95% CI [1.01–1.06], p = 0.006), presence of an acute respiratory failure at ICU admission (aOR = 2.35 [1.30–4.25], p = 0.04), acute respiratory distress syndrome (aOR = 6.49 [2.96-14.21], p < 0,001) and neutropenia (aOR = 5.57 [1.54–20.19], p = 0,009). 30% of patients admitted to the ICU required invasive mechanical ventilation support. Risk factors for intubation were age (aOR = 0.98 [0.96–0.99], p = 0.002), a previous chronic respiratory failure (aOR = 2.83 [1.72–4.65], p < 0,001), chronic heart disease (aOR = 1.90 [1.15–3.13], p = 0.012), obesity (aOR = 1.94 [1.09–3.45], p = 0.025) and the documentation of a bacterial co-infection (aOR = 2.51 [1.55–4.07], p < 0.001). A bacterial co-infection was documented in 18.2% of patients. Streptococcus pneumoniae and Pseudomonas aeruginosawere the two most frequently isolated bacteria.

Conclusion: In this large multicenter retrospective study of patients hospitalized with RSV infection, we found a mortality rate of 6.6%. Risk factors associated with mortality were age, the presence of acute respiratory distress, ARDS and neutropenia.

Compliance with ethics regulations: N/A.

CO-81 Differences in clinical characteristics and outcomes between Covid-19 and influenza in critically ill adult patients: a national database study

NAOURI Diane6, PHAM Tai2, DEMOULE Alexandre2, MERCAT Alain5, BEDUNEAU Gaetan3, COMBES Alain2, KIMMOUN Antoine4, SCHMIDT Matthieu2, DRES Martin2, JAMME Matthieu1

1Hopital privé de l'ouest parisien, Trappes, France; 2Assistance publique hopitaux de Paris, Paris, France; 3CHU Rouen, Rouen, France; 4CHU Nancy, Nancy, France; 5CHU Angers, Angers, France; 6Direction de la recherche, des études, de l'évaluation et des statistiques, Paris, France
Correspondence: Matthieu JAMME (mat.jamme@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-81

Rationale: Until March 2020 and the emergence of coronavirus disease 2019 (COVID-19), influenza was the leading cause of viral acute respiratory failure observed in ICU. While a few studies have compared flu patients vs. COVID-19, none of them have focused on the most severe forms. The aim of this study is to compare ICU patients admitted for COVID-19 vs. those admitted with influenza.

Patients and methods/Materials and methods: We conducted a retrospective cohort study using the French administrative health database (Système National des Données de Santé, SNDS). We included all adult patients hospitalised in French ICUs for whom a complete hospital history was available from 1 March 2020 to 30 June 2021. For the comparative group (influenza cohort), all adult patients hospitalised in ICUs from 1 January 2014 to 31 December 2019 were included. To be included in one of these two groups, the patient had to have an ICD-10 diagnosis code of COVID-19 or influenza regardless of its position in the hospital stay summary. The Chi-square test, Student’s t test or Wilcoxon test were used, as appropriate, to compare characteristics between patients with COVID-19 and influenza. To identify risk factors for invasive mechanical ventilation (IMV) and in-hospital death, we performed multivariate logistic regression models.

Results: Our study cohort included 105.979 COVID-19 patients and 18.763 influenza patients. Compared to influenza patients, COVID-19 patients were younger (p < 0.0001), more often male (p < 0.0001), and had a lower SAPS II score at ICU admission (p < 0.0001). During the ICU stay, patients with influenza more frequently required the use of iMV (47% versus 34%, p < 0.001), vasopressors (40% versus 27%, p < 0.001) and renal replacement therapy (22% versus 7%, p < 0.001). In-hospital mortality was higher in COVID-19 patients (25% vs. 21%, p < 0.001), especially in patients with iMV (40% vs. 33%, p < 0.001). After adjustment, while we did not observe an association between virus type and iMV use, we found a strong association between COVID-19 and in-hospital mortality compared to influenza (aOR = 1.92 [1.83–2.00], p < 0.001).

Discussion:

Conclusion: Using a very large cohort study, patients admitted for COVID-19 have a high probability of in-hospital death compared to patients admitted for influenza. This excess mortality does not appear to be related to a higher proportion of organ failure, particularly with respect to iMV use.

Compliance with ethics regulations: Yes in clinical research.

CO-82 Lung microbiome in critical care: evolution and risk factors of VAP

FROMENTIN Mélanie1,2, MULLAERT Jimmy2, BRIDIER-NAHMIAS Antoine2, MERCIER-DELARUE Séverine4, VUILLARD Constance2, DO VALE Julien2, SALMONA Maud4, LE GOFF Jerome4, RICARD Jean-Damien2,3, ROUX Damien2,3

1Ramsay Santé, Hopital privé Paul d'Egine, Champigny-Sur-Marne, France; 2Université de Paris, INSERM, U 1137 IAME Infection Antimicrobials Modelling Evolution, Paris, France; 3AP_HP, Hopital universitaire Louis Mourier, Colombes, France; 4Université de Paris, INSERM, U 976, HIPI Human Immunology, Pathophysiology & Immunotherapy, Paris, France
Correspondence: Mélanie FROMENTIN (mfromentin.anesthesierea@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-82

Rationale: We aimed to characterize and compare the temporal changes of lung bacterial microbiome whether ICU patients develop ventilator-associated pneumonia (VAP) or not. Our main objective was to identify early specific bacterial markers in the airway microbiome associated with the risk of ventilator-associated pneumonia (VAP) occurrence.

Patients and methods/Materials and methods: We conducted a case-control study based on a prospective cohort of mechanically ventilated (MV) patients. Controls were matched to VAP patients according to known risk factors of lung microbiota changes. We sequenced the specific V4 hypervariable region of 16S rRNA gene in samples collected every 72 h from oropharynx (OPS = oropharyngeal swabs) and lungs (ETA = endotracheal aspiration). The co-evolution of lung and oropharyngeal microbiota were described using non-linear mixed effects models.

Results: Nineteen VAP patients and 19 matched controls were included. We identified 281 taxa or operational taxonomic unit in 293 samples distributed in four predominant phyla. The dynamic evolution of the lung microbiota highlighted a constant increase in relative abundance of Bacteroidetes whereas these of Firmicutes decreased under mechanical ventilation (MV) (Fig. 1). On ICU admission, the Bacteroidetes phylum (p = 0.017) and the Bacteroidia class (p = 0.018) were more represented in patients who eventually developed a VAP. For all patients, the dynamic study highlighted a highly significant positive correlation between changes in lung and oropharyngeal microbiota for diversity (r = 0.87 (0.42;1), p < 0.001), for relative abundance of Bacilli (r = 0.91 (0.77;1), p < 0.001) and for relative abundance of Bacteroidia (r = 0.99 (0.94;1), p < 0.001). There was a significant decrease of the alpha diversity in both OPS (p < 0.001) and ETA during MV (p = 0,006), and a significant decrease of relative abundance of Bacilli in ETA (p < 0.001). On average, the relative abundance of Bacteroidia in the lungs was increased by an additional 14% per day of MV in VAP patients compared to controls (p = 0.025). The RA of Bacilli in the oropharynx decreased by an additional 9% per day of MV in VAP patients compared to controls (p = 0.049).

Conclusion: A lower initial RA of Bacteroidia, a faster decrease of Bacilli within the oropharynx as well as a faster increase of Bacteroidia within the lungs were associated with VAP development. This could represent a dysbiosis pattern that predisposed ICU patients to VAP. We aimed to characterize and compare the temporal changes of lung bacterial microbiome whether ICU patients develop ventilator-associated pneumonia (VAP) or not.

Compliance with ethics regulations: Yes in clinical research.

figure ar

Evolution of relative abundance of the four main phyla identified in the respiratory microbiota

CO-83 Involvement of lung epithelium in sepsis-induced immunosuppression

MALHERBE Jolan1, LADJEMI Maha Zohra1, ROUSSEAU Christophe1, PÉJU Edwige1,2, LLITJOS Jean-François1, BOULANT Léa1, MARTIN Clémence1,3, BURGEL Pierre-Régis1,3, PÈNE Frédéric1,2

1Institut Cochin, Inserm U1016, CNRS UMR8104, Université de Paris, Paris, France; 2Service de Médecine intensive & Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; 3Service de Pneumologie & Centre National de Référence Mucoviscidose, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
Correspondence: Jolan MALHERBE (jolan.malherbe@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-83

Rationale: Ventilator-associated pneumonia accounts for a leading cause of death in patients with septic shock. Altered lung immunity in post-septic hosts has been consistently ascribed to both quantitative and functional defects in most hematopoietic immune cells. In contrast, the role of airway epithelium has not been investigated in this setting despite its key role in first-line lung defense through various functions of physical barrier, tissue repair, pathogen sensing and crosstalk with immune cells. We raised the hypothesis that sepsis-induced alterations in airway epithelium contribute to defective lung defense towards secondary bacterial pneumonia. Our main goal was to assess the morphological and functional alterations of airway epithelium following non-pulmonary polymicrobial sepsis.

Patients and methods/Materials and methods: C57BL/6J female mice were used for the experiments. Mice were subjected to double-hit infectious insults through polymicrobial peritonitis induced by cecal ligation and puncture (CLP) or control sham surgery, followed eight days after by intratracheal instillation of Pseudomonas aeruginosa. The morphology and functions of lung epithelium were studied by immunohistochemistry and flow cytometry on days 3 and 7 after surgery, prior to any secondary bacterial challenge.

Results: As compared to sham-operated controls, post-CLP mice exhibited increased mortality towards secondary P. aeruginosa pneumonia, associated with increased systemic spread of the pathogen. Lung sections from post-CLP and sham-operated mice were subjected to histological analyses. Post-CLP mice exhibited reduced thickness of bronchial epithelium on day 3, associated with decreased proliferative capacity (as assessed by Ki67 immunostaining). However, bronchial epithelium became hypertrophied in post-CLP mice at delayed time point (day 7), thereby suggesting altered tissue repair. Tissue barrier functions were also altered as suggested by reduced epithelial expression of tight and adherens junctions (as assessed by Zonula occludens 1 and E-cadherin immunostainings). Increased expression of immune checkpoint inhibitors (day 3 post-sepsis) and Toll-like receptors 2 and 5 (day 7) were also observed in bronchial and alveolar epithelial cells from post-septic mice.

Conclusion: Our results suggest that non-pulmonary sepsis may modulate the main functions of airway epithelial cells and may thereby impact on lung compartmentalization. How this may affect mucosal immunity, possibly in relation with local dysbiosis, should now be investigated.

Compliance with ethics regulations: Yes in animal testing.

CO-84 Risk factors and outcomes of recurrent ventilator associated pneumonia in COVID-19 patients: a retrospective multicentric study

GRAGUEB CHATTI Ines1, HYVERNAT Herve2, LOPEZ Alexandre1, AGARD Geoffray1, PAPAZIAN Laurent1, DELLAMONICA Jean2, LEONE Marc1, HRAIECH Sami1

1APHM, Marseille, France; 2CHU L'Archet, Nice, France
Correspondence: Sami HRAIECH (sami.hraiech@ap-hm.fr)

Annals of Intensive Care 2022, 12(1):CO-84

Rationale: High incidence of ventilator associated pneumonia (VAP) has been reported among critically ill patients with COVID-19. Among these patients, we aimed to specifically assess the frequency, risk factors and outcomes of recurrences of VAP.

Patients and methods/Materials and methods: We conducted an observational retrospective study in 3 French intensive care units (ICUs). Patients admitted for a documented COVID-19 from March 2020 to May 2021 and requiring mechanical ventilation (MV) for ≥ 48 h were included. The study main outcome was the rate of VAP recurrence. Secondary outcomes were the risk factors for recurrence, the Day-28 and Day-60 ventilator-free days (VFD), the ICU and hospital length of stay and the Day-90 mortality.

Results: From 26th February 2020 to 21th May 2021, 398 patients were included in the analysis. Among them, 236 (59%) presented at least one VAP and 109 (27%) presented more than one VAP during the ICU stay (VAP recurrence). The overall ICU mortality rate was 27.9%, and day-90 mortality was 28.6%. After 90 days follow-up, the day-90 mortality rate of patients without VAP was significatively lower than mortality of patients with one VAP or more (p = 0.021). In contrast, there was no day-90 mortality difference between patients with one VAP or more than one (recurrence) (36.2% vs 31.2%). Patients with VAP recurence had a longer duration of mechanical ventilation, less VFD at day-28 and day-60, a longer ICU and hospital length of stay. In multivariate analysis, a bacterial co-infection at ICU admsision, the use of dexamethasone, the association of 2 immunosuppressive therapies or more during the ICU stay, the duration of antibiotic therapy, the type of bacteria responsible for the 1st occurence of VAP were not significantly associated with VAP recurrence.

Conclusion: VAP recurrences are frequent among COVID-19 ICU patients and are associated with a longer MV duration, ICU and hospital length of stay but not a higher mortality as compared with patients that had only one VAP. Bacterial co-infection at ICU admsision, the use of dexamethasone, the association of 2 immunosuppressive therapies or more during the ICU stay, the duration of antibiotic therapy or the type of bacteria responsible for the 1st occurence of VAP were not identified as independant risk factors of VAP recurrence in our cohort.

Compliance with ethics regulations: Yes in clinical research.

CO-85 Severe acute kidney injury in severe SARS COV2: “For a time they are a-changin’” For the Kidney Injury Working Initiative in Critically ill eurOpean patients during Coronavirus Outbreak (KIWI COCO)

CHAÏBI Khalil1, LOUIS Guillaume4, BOUBAYA Marouane1, BONNET Nicolas1, PAVOT Arthur2, ROUX Damien5, PICARD Yoann5, MELLATI Nouchan4, PHAM Tài2, GUMUCIO Victor Daniel3, DI PAOLO Fabio A.3, COHEN Yves1, DREYFUSS Didier5, PÉREZ-FERNANDEZ Xosé Luis3, GAUDRY Stephane1

1CHU Avicenne, Bobigny, France; 2CHU Kremlin Bicêtre, Kremlin Bicêtre, France; 3Bellvitge University Hospital, Barcelone, Espagne; 4CHR Metz Thionvile, Metz, France; 5CHU Louis Mourier, Colombes, France
Correspondence: Khalil CHAÏBI (khalilchaibi@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-85

Rationale: Severe acute kidney injury (AKI) is frequent among critically-ill patients with SARS-COV2 infection and associated with high mortality[1]. The epidemiological changes in the rate of severe AKI according to the epidemic waves remain unclear. We evaluated the differences in incidence, risk factors and outcome of severe AKI in patients with SARS-CoV-2 infection between the first and third wave of COVID-19.

Patients and methods/Materials and methods: We performed a European multicenter, retrospective observational study in five hospitals in France and Spain from March 1 to March 31, 2020 (first wave) and from March 1 to March 31, 2021 (third wave). We included consecutive adult patients with acute respiratory distress syndrome (ARDS) and testing positive for SARS-CoV-2 in respiratory fluids. Patients with end-stage renal disease or who had sustained cardiac arrest before ICU admission were not included. We reviewed clinical electronic medical records, nursing records, laboratory findings, demographic data, comorbidities, ICU usual parameters, occurrence of severe AKI (defined by KDIGO stage 3) in the first 7 days after ICU admission and survival outcome 28 days after ICU admission.

Results: A total of 445 patients with severe SARS COV2 pneumonia met the inclusion criteria of whom 293 (66%) were admitted during the first wave and 152 (34%) during the third wave. Patients admitted during the third wave had respectively more chronic kidney disease (CKD) at baseline (16.6% VS 7.2% p = 0.020), received more iodinated contrast media (56.6% VS 3.1%), more aminoglycosides (3.9% VS 0.3% p = 0.007) but were less severely ill (SOFA 5 VS 7 p = 0.006). One hundred two (23%) patients experienced severe AKI in the first 7 days of ICU admission. Its cumulative incidence was higher during the first wave than the third (26.8% VS 16.8% p = 0.029) (Fig. 1). In a multivariate Fine and Gray analysis, BMI ≥ 30 was a risk factor of severe AKI during the first (SHR [95CI%] 1.29 [0.81–2.04] p = 0.28) and third wave (SHR [95CI%] 3.35 [1.16–9.64] p = 0.025) whereas CKD was a risk factor only during the first wave (SHR [95CI%] 2.56 [1.23–5.31] p = 0.012). Steroid’s administration was not associated with the occurrence of severe AKI.

Conclusion: In this multicenter retrospective study including COVID-19 patients with ARDS, severe AKI was more frequent during the first epidemic wave compared to the third one. This may be explained by improvement in critical care delivery and a greater attention to renal impairment.

Reference 1:. Chaibi K, Dao M, Pham T, Gumucio-Sanguino VD, Di Paolo FA, Pavot A, et al. Severe Acute Kidney Injury in Patients with COVID-19 and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2020;202:1299–301.

Compliance with ethics regulations: Yes in clinical research.

figure as

Cumulative incidence of severe AKI in the first days after ICU admission according to the first and third wave

CO-86 Impact of dexamethasone use in severe COVID-19-induced acute kidney injury

ORIEUX Arthur1, LOUIS Guillaume3, GARRIC Antoine2, PICARD Yoann3, MELLATI Nouchan3, PREVEL Renaud1, GRUSON Didier1,4, RUBIN Sébastien2,5, BOYER Alexandre1,4

1Médecine Intensive Réanimation - CHU de Bordeaux, Bordeaux, France; 2Néphrologie, Transplantation, Dialyse - Aphérèse - CHU de Bordeaux, Bordeaux, France; 3Réanimation Polyvalente - CHR Metz - Thionville - Hôpital de Mercy, Metz - Thionville, France; 4Unité INSERM U1045, Université de Bordeaux, Bordeaux, France., Bordeaux, France; 5Unité INSERM U1034, Université de Bordeaux, Bordeaux, France., Bordeaux, France
Correspondence: Arthur ORIEUX (arthur.orieux@chu-bordeaux.fr)

Annals of Intensive Care 2022, 12(1):CO-86

Rationale: Since the first wave of COVID-19, the management of patients with severe SARS-CoV-2 infection in intensive care unit (ICU) has changed with the use of dexamethasone (DXM)1. Acute kidney injury (AKI) in ICU patients with severe COVID-19 was frequent (> 50%). Specific inflammatory process was previously suggested in AKI pathogenesis and could be improved by DXM. A previous study (n = 100 patients) reported a potential protective effect of DXM in AKI incidence2. The aim of this study was to investigate in a prospective multicentric study, the impact of DXM in severe COVID-19-induced AKI.

Patients and methods/Materials and methods: We carried out a prospective multicentric study in two French ICU from March 1st, 2020 to August 21st, 2021. All patients admitted for a severe COVID-19 in ICU were included. DXM was exclusively used from the second wave. AKI was defined according to the KDIGO classification. Acute kidney disease (AKD) was the persistence of the KDIGO criteria for AKI for ≥ 7 days.

Results: 1014 patients were included. 284/1014 patients (28%) were hospitalized in ICU1 and 730/1014 (72%) in ICU2. Mean age was 62.9 ± 12.2 years, 520/1014 (51%) patients had hypertension, 75/1014 (7%) suffered from previous chronic kidney disease (CKD) and 385/1014 (38%) required invasive mechanical ventilation (MV) in the first 24 h. Mean SAPSII was 38.9 ± 15.8 and non-renal SOFA was 4.2 ± 2.4. ICU mortality was 264/1014 (26%). AKI was present in 741/1014 (73%) patients: 266/741 (36%), 173/741 (23%) and 302/741 (41%) had respectively AKI KDIGO 1, 2 and 3 and 88/741 (12%) patients required renal replacement therapy. AKD was observed in 397/741 (54%) of AKI patients. In univariate analysis, DXM exposure decreased AKI incidence: 411/635 (65%) patients vs. 330/379 (87%) patients; OR = 0.27 [0.19–0.38]. In multivariate analysis, DXM use was independently associated with AKI: OR = 0.24 [0.11-0.53] (Table 1). After excluding patients who developed AKI before DXM exposure (n = 186 patients), DXM use remained independently associated with AKI in a similar multivariate model; OR = 0.26 [0.17–0.41]. In univariate analysis, DXM exposure decreased AKD incidence: 207/411 (50%) vs.190/330 (58%) patients; OR = 0.74 [0.55–0.99] but this effect did not persist in a similar multivariate analysis; OR = 1.17 [0.83–1.66].

Conclusion: In our study, DXM exposure decrease AKI incidence in severe COVID-19 patients. These results support the hypothesis that DXM can reduce “inflammatory” AKI incidence (specific of COVID-19 infection) but has no impact on “maladaptive repair” lesions secondary to AKI that can lead to an AKD.

Reference 1: The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N. Engl. J. Med. 384, 693–704 (2021).

Reference 2: Orieux, A., Khan, P., Prevel, R. et al. Impact of dexamethasone use to prevent from severe COVID-19-induced acute kidney injury. Crit Care 25, 249 (2021).

Compliance with ethics regulations: Yes in clinical research.

figure at

Table 1. Multivariate analysis for AKI development

CO-87 KUNGFU-ECMO Study, kidney upgrades net global filtration under ECMO

PENAUD Victor1, DUBURCQ Thibault4, BUREAU Côme2, SALMON-GANDONNIERE Charlotte5, ARRESTIER Romain6, HENRI Samuel4, DRES Martin2, JACQUIER Sophie5, DE PROST Nicolas6, GIRAUD Raphael3, RICARD Jean-Damien1, ROUX Damien1, UHEL Fabrice1, LEGOUIS David3, VERNEY Charles1

1AP-HP, Hôpital Louis Mourier, Colombes, France; 2AP-HP, Hôpital Pitié Salpêtrière, Paris, France; 3Hôpitaux Universitaires de Genève, Genève, Suisse; 4Centre Hospitalier Universitaire de Lille, Lille, France; 5Centre Hospitalier Régional Universitaire de Tours, Tours, France; 6AP-HP, Hôpital Henri Mondor, Créteil, France
Correspondence: Charles VERNEY (charlesverney@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-87

Rationale: Acute kidney injury (AKI) is frequently observed in acute respiratory distress syndrome (ARDS). Risk factors for AKI include positive end expiratory pressure (PEEP), severity of ARDS and fluid overload, possibly linked to renal congestion. There is no data on the evolution of renal function in patients presenting severe ARDS and requiring extra-corporeal membrane oxygenation (ECMO) implantation. Veino-veinous ECMO (VV-ECMO) could prevent AKI by alleviating this renal congestion with the aspiration of the femoral canula. We aim to study how a VV-ECMO modified the renal function in this population.

Patients and methods/Materials and methods: We performed a multicentre retrospective study, between 2011 and 2021, in six intensive care units in France and Switzerland. Inclusion criteria were: adult patients presenting a severe ARDS requiring VV-ECMO, with available data regarding daily urine output and blood tests 2 days before and three days after implantation. Patients receiving renal replacement therapy (RRT) before day three or veino-arterial ECMO or those who did not agree to participate were excluded. The primary outcome was the evolution of the serum creatinine level after VV-ECMO implantation. Daily urine output and evolution of biochemical parameters in urine samples after implantation were the secondary outcomes.

Results: Ninety-nine patients were included, with a median age of 53 years, of which 30% were women. ECMO implantation occurred after a median duration of mechanical ventilation of 6 days. COVID-19 was the main cause in 72% of ARDS. The evolution of the serum creatinine level did not significantly differ before and after implantation (p = 0.2). In contrast, ECMO implantation was associated with a significant increase in daily urine output (+ 6.3 mL/kg/day, p < 0.001), even after adjustment for potential confounding factors (including PEEP, duration of mechanical ventilation, fluid balance, cause of ARDS, and diuretics). Fractional excretion of urea and natriuresis were also significantly increased after ECMO implantation (respectively + 10%, p < 0.001 et + 20 mmol/L, p < 0.001). Finally, the increase in urine output under ECMO was negatively associated with the risk to receive RRT after day three (p = 0.047).

Conclusion: VV-ECMO implantation for severe ARDS is associated with an increase in daily urine output and natriuresis. This diuretic like effect does not modify the glomerular filtration following implantation. Prospective studies are necessary to better define renal hemodynamic and tubular modifications occurring under VV-ECMO, and the potential improvement in the management of fluid overload in this context.

Compliance with ethics regulations: Yes in clinical research.

figure au

Evolution of serum creatinine level, daily urine output, Fractional excretion or urea, mesured creatinine clearance with UV/P formula and natriuresis, between 2 days before and 3 days after implantation of VV-ECMO.

CO-88 Urinary CCL14 biomarker to predict renal replacement therapy initiation in critically ill patients with severe acute kidney injury?

CHAÏBI Khalil1, PLACIER Sandrine2, LOUIS Guillaume3, MARTIN-LEFEVRE Laurent4, TITECA Dimitri5, LACOMBE Béatrice6, BESSET Sébastien7, BADIE Julio8, CHEVREL Guillaume9, CHUDEAU Nicolas10, BARBAR Saber11, VINSONNEAU Christophe12, FOREL Jean-Marie13, THEVENIN Didier14, LACAVE Guillaume15, NSEIR Saad16, POIRSON Florent1, MAYAUX Julen17, KLOUCHE Kada18, REIGNIER Jean20, QUENOT Jean-Pierre21, HADCHOUEL Juliette2, DREYFUSS Didier2, GAUDRY Stéphane1

1CHU Avicenne, Bobigny, France; 2INSERM CORAKID UMRS1155, Paris, France; 3CHR Metz-Thionville Hôpital de Mercy, Metz, France; 4CHR départementale La Roche Sur Yon, La Roche Sur Yon, France; 5CHU d’Amiens Picardie, Amiens, France; 6CH de Bretagne Sud, Lorient, France; 7Hôpital Louis Mourier, Colombes, France; 8Hôpital Nord Franche-Comte, Belfort, France; 9CH Sud Francilien, Corbeil Essones, France; 10CH du Mans, Le Mans, France; 11Hôpital Caremeau, Nimes, France; 12CH Bethune Beuvry – Bermont et Gauthier, Bethune, France; 13Hôpital Nord, Marseille, France; 14CH Dr Schaffner, Lens, France; 15Hôpital André Mignot, Versailles, France; 16CHRU de Lille, Hôpital Roger Salengro, Lille, France; 17Hôpital Pitié Salpêtrière, Paris, France; 18Hôpital Lapeyronnie, Montpellier, France; 19Hôpital Avicenne, Bobigny, France; 20Hôtel Dieu, Nantes, France; 21François Mitterrand University Hospital, Dijon, France
Correspondence: Khalil CHAÏBI (khalilchaibi@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-88

Rationale: Recent trials confirmed that an early renal replacement therapy (RRT) initiation does not confer any survival benefice compared with a delayed one during severe acute kidney injury (AKI) when no severe complications are present. Tools to enable personalized management are still needed and evidence for biomarkers guided RRT initiation are lacking[1]. In a cohort of critically ill patients with AKI, an elevation in urinary CCL14 could predict the persistence/progression of AKI [2]. We aimed to assess the utility of urinary CCL14 for the prediction of RRT initiation in a conservative approach in Intensive Care Unit (ICU).

Patients and methods/Materials and methods: In an ancillary study of AKIKI2 (Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury), we included ICU patients with severe AKI (stage 3 KDIGO) and available urinary sample at the first day of severe AKI. We did not include patients with chronic kidney disease. CCL14 was measured by enzyme-linked immunosorbent assay (ELISA) in urinary samples at D0. The primary endpoint was the occurrence of a criteria for RRT (according to a conservative approach of RRT initiation) within the 72 h after severe AKI. Those criteria were: life threatening complication of AKI, or oliguria/anuria (urine output < 0·3 mL/kg per h or < 500 mL/day) for more than 72 h, or serum urea concentration of 40 mmol/L or more.

Results: A total of 230 patients were enrolled. Ninety patients (39.1%) met the primary endpoint. Urinary CCL14 was not associated with serum creatinine concentration at D0 (Pearson correlation r2 = 0.024). Median urinary CCL14 was 15.03 (IQR 24.88) mg/ml in patients reaching the primary endpoint and 5.8 (IQR 12.18) mg/ml in patients who did not (p < 0.001). In multivariate analysis, urinary CCL14 (OR = 1.02, [1.01;1.04], p = 0.0021) was associated with higher rate of occurrence of a criteria of RRT initiation. The area under the ROC curve was 0.701 (95% CI: [0.633;0.770]) for urinary CCL14 to predict the occurrence of a criteria of RRT initiation within 72 h after severe AKI (Fig. 1).

Conclusion: Although interesting, urinary CCL14 alone might not be precise enough to discriminate patients with RRT initiation criteria in a conservative approach. However, it might be useful when used in combination with other clinical or biological variables.

Reference 1: Ostermann M, Lumlertgul N. Wait and see for acute dialysis: but for how long? The Lancet. 2021;397:1241–3.

Reference 2: Hoste E, Bihorac A, Al-Khafaji A, Ortega LM, Ostermann M, Haase M, et al. Identification and validation of biomarkers of persistent acute kidney injury: the RUBY study. Intensive Care Med. 2020;46:943–53.

Compliance with ethics regulations: Yes in clinical research.

figure av

Receiver operating characteristic (ROC) curve for prediction of RRT initiation criteria with urinary CCL14

CO-89 Concurrent treatment with angiotensin 1-7 in septic shock

GARCIA Bruno1, ANNONI Filippo1, SU Fuhong1, HERPAIN Antoine1, TACCONE Fabio1, CRETEUR Jacques1

1Laboratoire experimental des soins intensifs de l'hôpital Erasme, Bruxelles, Belgique
Correspondence: Bruno GARCIA (br.garcia@icloud.com)

Annals of Intensive Care 2022, 12(1):CO-89

Rationale: Renin-angiotensin system is activated during sepsis and septic shock. Its main effector, angiotensin II, is responsible for pro-inflammatory effects and endothelial dysfunction. Angiotensin (1–7) (Ang (1–7)), an active peptide produced by angiotensin-converting enzyme type 2 (ACE2), has opposite effects and has been reported to prevent organ damage during sepsis in mice. Our study aimed to assess the effect of concurrent treatment with ang (1–7) on sepsis outcome.

Patients and methods/Materials and methods: Sepsis was induced by fecal peritonitis in sixteen mechanically ventilated, hemodynamically monitored female sheep. Animals were randomized to two groups: control or concurrent treatment group (n = 8 each) after surgical preparation and stabilization. Angiotensin (1–7) at 10 mcg/kg/h was started at sepsis inducement in the concurrent treatment group. Four hours after feces injection, fluid resuscitation (pulse pressure variation ≤ 13%), antibiotherapy, and peritoneal lavage were administrated, and norepinephrine was given to maintain mean arterial blood pressure ≥ 65 mmHg if necessary. The experiment lasted for 24 h.

Results: No difference was found among groups regarding baseline demography. During the first 4 h, MAP was dropped significantly in the control group. All the animals in the control group developed a septic shock. A significantly lower dose of norepinephrine was utilized in the concurrent treatment group. Creatinine, platelet count, PaO2/FiO2, pH, and lactate levels were significantly lower in the concurrent treatment group. Two animals died in the control group before the end of the experiment.

Discussion: In this mechanical ventilated, hemodynamically monitored sepsis model; concurrent treatment with ang (1–7) significantly reduced norepinephrine requirements and attenuated organ dysfunction. Ang (1–7) can reduce inflammation by the activation of the Mas receptor, and reduce cytokine storm. However, the risk of the effects on the immune system is not well described in the literature and could expose to secondary infections. This is the first use of Ang (1–7) in a large clinically relevant animal model characterized by fluid resuscitation based on dynamic parameters, broad-spectrum antibiotherapy, peritoneal lavage, and vasopressors. Polymicrobial sepsis, induced by feces injection, was able to develop a severe septic shock with organ dysfunction. The protocol followed the recent guidelines on septic shock resuscitation and guidelines for Minimum Quality Threshold in Pre-Clinical Sepsis Studies (MQTiPSS).

Conclusion: Concurrent treatment with Ang (1–7) reduced severity of septic shock. Further studies are needed to assess the timing of administration, dose and duration of Ang (1–7) in sepsis.

Compliance with ethics regulations: Yes in animal testing.

figure aw

Results

CO-90 Renal prognosis of elderly TTP patients on caplacizumab therapy (the Repeto-capla study)

CARNIATO Flavie1, LESCROART Mickael1, ZAFRANI Lara1, AZOULAY Elie1, VEYRADIER Agnès2, COPPO Paul3, MARIOTTE Eric1

1Hôpital Saint-Louis, Paris 10E, France; 2Hôpital Lariboisière, Paris 10E, France; 3Hôpital Saint-Antoine, Paris 12E, France
Correspondence: Flavie CARNIATO (flavie.carniato@gmail.com)

Annals of Intensive Care 2022, 12(1):CO-90

Rationale: Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy caused by a severe ADAMTS13 activity deficiency. Mortality in TTP sharply decreased with the introduction of emergency therapeutic plasma exchanges (TPE) and immunomodulation; however, elderly patients remain at high risk of mortality and severe organ involvements, including acute renal failure. More recently, the adjunction of Caplacizumab has improved time to recovery in TTP patients. The association of caplacizumab administration with improved renal function in elderly patients with TTP is unknown.

Patients and methods/Materials and methods: In this retrospective study, we described the characteristics and outcome of TTP patients aged over 60 years. They were enrolled from 2000 to 2021 in the French national reference center for thrombotic microangiopathy registry according to treatment with standard of care (SOC, consisting of TPE, steroids and for most rituximab) with or without Caplacizumab (C+ and C− groups). Results are presented as number (%) or median (interquartile range). Comparisons were made using Chi2 or Mann–Whitney tests as appropriate.

Results: Sixty-three patients met inclusion criteria, including 35 females (55%) aged 70 yo (65–75). Thirty-four (54%) patients received C− and 28 C+. Patients’ medical history and baseline characteristics were similar between both groups, including frequency of chronic kidney disease (14%), neurological involvement (79%), platelet rate (16G/L(9-24)), hemoglobin level (8.9 g/dL(8–10)), elevated troponin (68%) and Glomerular Filtration Rate (GFR, 51 ml/min/1.73 m2(35–77)). All C+ patients received Rituximab versus 65% of C− (p < 0.05). Caplacizumab was administered 2 (1.5–7.5) days after admission, for 30 (21–37) days, with frequent adverse effects (53%). Time to platelet count normalization was shorter with C+ (4 days vs 8, p < 0.05). C+ patients needed less TPE (5(4-8) sessions vs 11(6–16), p < 0.05) and experienced no case of refractory TTP. All patients requiring renal replacement therapy (RRT) belonged to the C− group (18% vs 0%, p = 0.056). For others, GFR was similar at discharge (C+ 78(59–94) mL/min/1.73 m2 vs C− 62(42–86) mL/min/1.73 m2, p = 0.11). Hospital mortality was higher in the C− group than in the C+ group (38% vs 3.5%, p < 0.05). After a follow up of 165 (24–630) days, 1/3 of patients requiring RRT during initial hospitalization were RRT-free. For others, GFR was similar (C+ 78(64–90) mL/min/1.73 m2 vs C− 62(42–80) mL/min/1.73 m2, p = 0.24).

Conclusion: Our results should be influenced by the fact that C− patients were managed during the earlier period of the study and received different SOC, including a lower frequency of rituximab use. In this study, Caplacizumab seemed to improve outcome in elderly TTP patients with no clear effect on renal dysfunction.

Compliance with ethics regulations: Yes in clinical research.

Flash communications

FC-001 Epidemiological profile of burns in children admitted to the casablanca national burns center

CHAKIR Anass1, MOKAKO Jacques2, HABLA Marouane2, ELHARTI Anas2, DIOURI Mounia2

1Département d'anesthésie et de réanimation, Centre hospitalier universitaire Ibn Rochd, Casablanca, Maroc; 2Centre national des brûlés et de chirurgie réparatrice, Centre Hospitalier Universitaire Ibn Rochd, Casablanca, Maroc
Correspondence: Youssef HAOUAS (h.youssef414@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-001

Rationale: This retrospective work of the last 3 years (January 2018–March 2021) analyzes the epidemiological characteristics of 1156 cases of burnt children aged 0–17 years admitted to the National Burn Center emergency room so that these data serve as a basis for the development of a program of prevention, adequate, fast and effective treatment of burnt children. The age group from 1 month to 2 years was the most affected with 587 cases or 50.77% of patients.

Patients and methods/Materials and methods: Male involvement is found in 54% of cases, i.e. 624 patients. Burns occur at home in 99.48% of cases, i.e. 1,150 patients, and accidentally in 99.39% of cases, i.e. 1,149 patients.

Results: Thermal burns accounted for 98.78% of cases or 1,142 patients, dominated by liquids in 77.94% of cases or 901 patients. The burnt skin surface was ≥ 10% in 44% of cases, i.e. 509 patients. The burn mainly concerns upper limbs 57% of cases or 659 patients. The mortality rate was 7.61% or 39 patients.

Conclusion: This work also includes a retrospective comparison of the COVID period (March 2020–March 2021) to the pre-COVID period (March 2019–February 2020) during which the number of emergencies had increased by 24 additional patients (370 versus 346) with hospitalization an increase of 3.14% (171 versus 149) and during which 1 child had tested positive for COVID 19. During this comparative period the mortality rate was down by 1.77% (5 versus 7).

Compliance with ethics regulations: Yes in clinical research.

FC-002 Changes in management practices for moderate to severe bronchiolitis in infants between 2010 and 2020: a retrospective study conducted in the pediatric intensive care unit

LESUEUR Simon1, SAVY Nadia1

1CHU Clermont Ferrand, Clermont Ferrand, France
Correspondence: Simon LESUEUR (simon.lesueur31@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-002

Rationale: Acute bronchiolitis represents 8 to 13% of respiratory distress hospitalised in Pediatric Intensive Care Units (PICUs). The main challenge of care is the early management of respiratory failure and digestive intolerance. In the PICU, our practice has been to use the High Flow Nasal Cannula (HFNC) almost exclusively, due to its ease of use and good tolerance, despite the fact that the latest trials do not demonstrate its non-inferiority compared to CPAP. With this study, we would like to highlight an improvement in the quality of care and well-being of our patients with moderate to severe bronchiolitis.

Patients and methods/Materials and methods: This is a retrospective descriptive study conducted over two periods P1 (2010–2013) and P2 (2017–2020) in the PICU on infants with moderate to severe acute bronchiolitis. The main objective of our study is to evaluate the improvement of the quality of care over time through a composite criterion: the use of antibiotic therapy and the time to complete enteral feeding, by comparing them over the two distinct periods. The secondary endpoints were comparisons of clinical and therapeutic data.

Results: Our analysis involved 106 patients, 45 in the first period P1 and 61 in the second period P2, matched for severity and age. Antibiotic use decreased over the decade (66.7% vs. 37.7%, p < 0.05) and completion of full enteral feeding tended to be shorter (3.1 (± 1.5) days vs. 2.6 (1.2) days respectively; p = 0.08). The use of HFNC as first-line treatment increased significantly over the decade (33.3% vs 96.7%; p < 0.05) at the expense of CPAP, which is no longer used on P2. More aggressive care tended to decrease with lower rates of intubation (1.6% vs 8.9%; p = 0.16) and less intravenous glucose solution infusion (60.7% vs 91.1%; p < 0.05). Complication rates were low and similar in both periods. However, the total duration of ventilation was shorter on P1 with 4.5 (± 3.0) days compared to 5.5 (± 2.7) days on P2; p = 0.07.

Conclusion: The quality of care in our unit has improved over the last decade with greater adherence to international guidelines regarding decreased antibiotic use and preference for enteral intake over infusion.

Compliance with ethics regulations: Yes in clinical research.

FC-003 Impact of the Nusinersen on the number of hospitalisations in pediatric intensive care units for respiratory decompensation in children with spinal muscular atrophy over the period 2015–2021

BAKAYOKO Awa1, VAUGIER Isabelle1, MBIELEU Blaise1, ESSID Aben1, ZINI Justine1, BELTAIEF Emna1, GUILLON Maud1, FAYSSOIL Abdallah1, GOMEZ GARCIA DE LA BANDA Marta1, QUIJANO ROY Susana1, BERGOUNIOUX Jean1

1 Hôpital Raymond-Poincaré, Garches, France
Correspondence: Awa BAKAYOKO (awa.bakayoko@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-003

Rationale: Spinal muscular atrophy is a neuromuscular disease of genetic origin. It is the leading genetic cause of infant mortality. Worldwide, the prevalence of this disease is estimated at 1 in 10,000 births. The genes involved are the SMN1 and SMN2 genes, located on chromosome 5, whose deletion leads to the destruction of motor neurons, which results in an impairment of respiratory function. Nusinersen is the first curative drug developed for the treatment of spinal muscular atrophy. It is an antisense oligonucleotide that binds to the pre-messenger RNA of the SMN2 gene, allowing the production of the SMN protein, and thus leading to improved motor control. The aim of this study was to evaluate the impact of Nusinersen on the admission to the pediatric intensive care unit in our hospital, for respiratory decompensation in children with spinal muscular atrophy.

Patients and methods/Materials and methods: Retrospective comparative study of the reasons for admission to a pediatric intensive care unit in children with spinal muscular atrophy, treated or not by Nusinersen, over the period 2015–2021.

Results: 69 patients with spinal muscular atrophy were hospitalised in our Intensive Care Unit between 2015–2021; 108 passages were related to respiratory decompensation, representing 41 patients. There has been a significant decrease in hospital admissions for respiratory decompensation in SMA over the last 4 years, which we were able to statistically correlate with the implementation of Nusinersen treatment (results under analysis).

Conclusion: We observed a significant decrease in hospitalisations for respiratory decompensation in the intensive care of unit of patients with AMSI and this correlated with the administration of Nusinersen.

Compliance with ethics regulations: N/A.

FC-004 Work of breathing during non invasive ventilation in severe acute bronchiolitis

VEDRENNE-CLOQUET Meryl1, KHIRANI Sonia1, GRIFFON Lucie1, COLLIGNON Charlotte1, RENOLLEAU Sylvain1, FAUROUX Brigitte1

1Necker-Enfants Malades, Paris, France
Correspondence: Meryl VEDRENNE-CLOQUET (meryl.vedrenne@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-004

Rationale: Continuous positive airway pressure (CPAP) has been shown to reduce the work of breathing (WOB) during severe acute bronchiolitis. Noninvasive Positive Pressure Ventilation (NIPPV) is also used in this condition but no study has compared NIPPV to CPAP. We aimed to compare WOB during CPAP and NIPPV in infants with acute bronchiolitis.

Patients and methods/Materials and methods: Infants < 6 months of age with bronchiolitis were included if they needed noninvasive respiratory support (NRS) within the first 24 h. Exclusion criteria included contra-indication for nasogastric tube, imminent intubation, neuromuscular disease, parental refusal. NRS was initiated by the attending physician according to local practice: CPAP + 7 cmH2O was the first-line setting, with NIPPV, set on clinical parameters and child’s comfort, being reserved for CPAP failure. Oesophageal (PES) and gastric pressures were measured using a nasogastric catheter (Gaeltec™). The study started with a first period with the baseline NRS (CPAP or NIPPV), followed by a 5-min washout (spontaneous breathing). Afterward, a second period was performed with the other NRS. Within each period, a first recording was performed with the clinical settings (Clin) and a second with a physiological setting (Phys) aiming at normalizing WOB. For CPAPPhys, the CPAP level was increased from 6 to 10 cmH2O. For NIPPVPhys, initial inspiratory pressure was set at + 4 cmH2O above CPAP, and progressively increased, with inspiratory and expiratory triggers set to optimize synchronization. The “optimal” NRS was the one associated with an optimal reduction in clinical symptoms, PTCCO2 (Sentec™), and estimated WOB (PTPES/min = AUC of PES during inspiration × Respiratory Rate) over 10 stable breaths.

Results: 20 children were included, with a median [IQR] age of 1.4[0.8; 2.9] months and a median weight of 4[3.5; 5.2] kilograms. Twelve infants had CPAP at baseline: CPAP remained the optimal mode in 7, whereas NIPPV was superior in 5. Eight infants had NIPPV at baseline: NIPPV remained the optimal mode in 2, whereas CPAP was superior in 6 (Figure).

Conclusion: CPAP was associated with a decrease in WOB in the majority of infants with acute bronchiolitis. NIPPV may be superior to CPAP in some infants. Predictive factors associated with a need for NIPPV were not identified in the present study.

Compliance with ethics regulations: Yes in clinical research.

figure ax

Study flow chart

FC-005 Continuous determination of optimal mean arterial pressures based on cerebral autoregulation after pediatric cardiac surgery

TABONE Laurence1, EL-TANNOURY Jihad1, LEVY Michaël3, SAUTHIER Michael1, JORAM Nicolas2, BOURGOUIN Pierre2, AL-OMAR Sally1, EMERIAUD Guillaume1, THIBAULT Céline1

1CHU Sainte Justine, Montréal, Canada; 2CHU de Nantes, Nantes, France; 3CHU Robert Debré, Paris, France
Correspondence: Laurence TABONE (lau.tabone@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-005

Rationale: Neuroprotection is a major concern in children with congenital heart diseases. Cerebrovascular autoregulation (CAR) is the capacity of cerebral vessels to ensure a constant blood flow in a given range of mean arterial pressures (MAP) and may be a modifiable perioperative factor influencing outcomes. CAR has been shown to be altered before and during cardiopulmonary bypass, but has not yet been described in the postoperative period. The cerebral oximetry index (COx) estimates CAR by correlating regional cerebral oxygenation and MAP. By plotting COx against MAP, the optimal MAP (opt-MAP) and the lower and upper limits of MAP corresponding to optimal CAR (LLA and ULA) can be determined. Our aim was to evaluate the feasibility of continuously determining the opt-MAP, LLA, and ULA in children within 48 h of cardiac surgery and to describe CAR parameters according to age and postoperative time frame.

Patients and methods/Materials and methods: Using a high-frequency database, we retrospectively included all children admitted in a single pediatric intensive care unit (PICU) after cardiac surgery between May 2020 and June 2021. An algorithm for the continuous calculation of the opt-MAP, ULA, and LLA was developed using a weighted combination of 40 time windows for the calculation of COx and opt-MAP. CAR results were described according to four predefined age groups and postoperative time frames. We calculated the percentage of time with MAP outside the range of LLA to ULA. Results are reported as median [interquartiles] and comparisons between age groups and postoperative time periods were performed using using Wilcoxon and Kruskal-Wallis tests.

Results: Fifty-one children were included with a median monitoring time of 42 [23–44] hours. Opt-MAP, LLA, and ULA were determined 92% [88–95] of the time, with first results available 74.0 [IQR 60.0–105.0] minutes after PICU admission. Lower opt-MAP were observed in neonates < 1 month old (Table). Children spent 25% [18–31] of their time with MAP outside the optimal CAR range, with no significant difference between age groups or periods.

Conclusion: The continuous calculation of Opt-MAP, LLA and ULA is feasible in children after cardiac surgery using signals routinely available in clinical practice. Children spent a significant proportion of time outside the optimal range of MAP based on CAR. Further research is warranted to explore the potential impacts of this deviation on neurological outcomes.

Compliance with ethics regulations: Yes in clinical research.

figure ay

Cerebral autoregulation parameters according to age groups

FC-006 Optical thermography infrastructure to assess thermal distribution in critically ill children

SHCHERBAKOVA Monisha1,2, NOUMEIR Rita2, LEVY Michael1, BRIDIER Armelle1, LESTRADE Victor1, JOUVET Philippe1

1CHU Sainte Justine, Montreal, Canada; 2Ecole de technologie supérieure, Montreal, Canada
Correspondence: Monisha SHCHERBAKOVA (monisha.shcherbakova.hsj@ssss.gouv.qc.ca)

Annals of Intensive Care 2022, 12(1):FC-006

Rationale: The body temperature distribution at the skin surface could be used to monitor changes in cardiac output [1]. The aim of this study was to explore infrared thermography (IRT) as a non-invasive and reliable method to analyze core body temperature of critically ill children and assess the clinical value of temperature evolution across different parts of the body.

Patients and methods/Materials and methods: Patients admitted to the pediatric intensive care unit (PICU) were included in this study after parental consent was obtained (approved by the CHU Ste-Justine Research Ethics Board). An infrared sensor (Lepton 3.0 & 3.5 Thermal Camera, Teledyne FLIR, Canada) was used to take infrared (IR) images in clinical conditions. The infrared core and limb temperatures (θc & θl) were extracted. A line was drawn on the IR images starting from the center (eyes/internal canthus or thorax) and running along the limbs to the extremities. The temperature along this line was extracted and plotted on a graph, to study how the temperature modulates across the body. The gradient was calculated by taking the difference between the core (θc) and limb (θl) temperatures extracted from the images. The correlation between values was assessed by Spearman's correlation coefficient.

Results: In total, 36 patients were included. Their median age was 8 months [1–64.5], 7.4 kg [4.5–24.6]. The median [interquartile range] for θc extracted from the images was 33.9 °C [32.7–34.2 °C] and the median θl was 30.2 °C [28.9–33.1 °C]. There was a good correlation between the θc and the clinical axillary temperature (rho = 0.39 and p-value = 0.016). The median thermal gradient was 3.2 °C [1.1-4.6] and the maximum gradient was 6.0 °C. The temperature gradient across the body was subject to many artefacts (Fig. 1). Due to the low number of patients with hemodynamic instability, we could not study the correlation between thermal gradient and clinical status. Surprisingly, we observed a child with a negative thermal gradient (− 1.14 °C) i.e. higher temperature on the extremities (fingers) compared to the thorax. This child had a cardiac surgery and was treated with a vasodilator (milrinone).

Conclusion: The study documented that the thermal gradient was easily manually calculated. The automatic thermal gradients calculation needs further work to have an adequate segmentation and to identify artefacts. Further work is also needed to document the added value of monitoring changes in the thermal gradient over time to assist in the management of critically ill children with hemodynamic instability.

Reference 1: [1] Ferraris A, Bouisse C, Mottard N, Thiollière F, Anselin S, Piriou V, et al. Mottling score and skin temperature in septic shock: Relation and impact on prognosis in ICU. PLoS One. 2018;13(8):e0202329.

Compliance with ethics regulations: Yes in clinical research.

figure az

IR image taken as part of the study, with a line joining the core (eyes) down to the extremities of the leg. The adjoining graph depicts the temperature as it changes along this line.

FC-007 Trend over three decades of the stated practice pattern on the hemoglobin (Hb) threshold that would guide red blood cell (RBC) transfusion practice in pediatric intensive care units, on behalf of the CCCTG, PCCS, JICRG and GFRUP

GALLAND Anne1, TUCCI Marisa1, LETEURTRE Stéphane2, SARFATTI Avishay3, RAY Samiran4, STANWORTH Simon5, FONTELA Patricia6, KAWAGUCHI Atsushi7, DEMARET Pierre8, DUCRUET Thierre9, LACROIX Jacques1, DU PONT-THIBODEAU Geneviève1

1Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, Canada; 2Réanimation et Surveillance Continue Pédiatriques, Hôpital Jeanne de Flandre, CHRU Lille, Lille, France; 3Department of Pediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Royaume-Uni; 4Department of Pediatrics, Great Ormond Street Hospital, London, Royaume-Uni; 5Transfusion Medicine, Department: Haematology, NHS Blood & Transplant/Oxford Radcliffe Hospitals, Oxford, Royaume-Uni; 6Pediatric Critical Care, Departments of Pediatrics and of Epidemiology, Biostatistics, and Occupational Health, The Montreal Children's Hospital, McGill University, Montreal, Canada; 7Pediatric Intensive Care Unit, Tokyo Women's Medical University, Department of Intensive Care Medicine, Tokyo, Japon; 8Pediatric intensive care unit, Department of Pediatrics, CHC Liège, Liège, Belgique; 9Unité de recherches cliniques appliquées, Research Centre, CHU Sainte-Justine, Montréal, Canada
Correspondence: Jacques LACROIX (jlacroix052@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-007

Rationale: To determine the trend over three decades of the stated practice pattern of pediatric intensivist on the Hb threshold that guides their RBC transfusion practice.

Patients and methods/Materials and methods: Three scenario-based self-administered questionnaires were filled by 163, 125 and 132 respondents in 19971, 20102 and 2021, respectively. Three scenarios were similar in these surveys: 1) previously healthy 4-year-old boy mechanically-ventilated after a severe multiple trauma; 2) idem with septic shock; 3) 5-month-old boy admitted to a Pediatric Intensive Care Unit (PICU) following corrective surgery for tetralogy of Fallot. Patients were hemodynamically stable in all scenarios. The question asked after each scenario was: what Hb concentration would prompt you to prescribe an RBC transfusion to this patient?

Results: Figure 1 reports the practice pattern stated in 1997, 2010 and 2021. For all scenarios, all respondents (100%) should have chosen to prescribe an RBC transfusion only if the Hb level was

Conclusion: The TRIPICU study, a non-inferiority randomized controlled trial (RCT) led by Lacroix et al. (N Engl J Med 2007;356:1609–19), enrolled 637 hemodynamically stable critically ill children who had Hb concentration ≤ 9.5 g/dL; it showed that a Hb threshold of 7 g/dL for RBC transfusion is not inferior to a threshold of 9.5 g/dL (absolute risk reduction with the restrictive strategy, 0.4%; 95% confidence interval, − 4.6 to 5.4) and that it can decrease transfusion requirements in PICU patients without increasing adverse outcomes. The main recommendation of TRIPICU was not giving an RBC transfusion to hemodynamically stable PICU patients if their Hb concentration is ≥ 7 g/dL. The RCT led by Cholette et al. (Ann Thorac Surg 2017;103:206–14) that enrolled 134 cardiac children weighing ≤ 10 kg undergoing biventricular repair cardiac surgery and the RCT led by Holst et al. (N Engl J Med 2014;371:1381–91) that enrolled 1005 adults in septic shock with an Hb concentration ≤ 9 g/dL recommended the same Hb threshold (7 g/dL). The gaps in 2021 between the expected proportion of respondents who should have chosen a Hb threshold of 7.0 g/dL (100%) and the proportion who chose a higher Hb threshold remained important in 2021.

Reference 1: Laverdière C, Gauvin F, Hébert PC, Infante-Rivard C, Hume H, Toledano BJ, et al. Survey of transfusion practices in pediatric intensive care units. Pediatr Crit Care Med 2002;3:335–40.

Reference 2: Du Pont-Thibodeau G, Tucci M, Ducruet T, Lacroix J. Survey on stated transfusion practices in PICU. Pediatr Crit Care Med 2014;15:409–16.

Compliance with ethics regulations: Yes in clinical research.

figure ba

Trajectory of the stated practice pattern of pediatric intensivists on the Hb concentration that would prompt them to prescribe an RBC transfusion in cases of pediatric trauma, septic shock and post Fallot repair, taking into account 3 RCTs (arrows).

FC-008 Visiting policies and parental presence in care: a survey in French Pediatric Intensive Care Units

MANON Bergerat1, DE SAINT BLANQUAT Laure1, BERANGER Agathe1

1Necker enfants malades, Paris, France
Correspondence: Agathe BERANGER (agathe.beranger@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-008

Rationale: The European charter of the hospitalized child recommends a 24-h presence of parents at the bedside. Despite major changes in the last decade, family presence in Pediatric Intensive Care Units (PICUs) still remain controversial within and across countries. The objective of this study was to describe the visiting policies and the parental presence during care in French PICUs.

Patients and methods/Materials and methods: A structured questionnaire was emailed to the 35 French PICUs. Data regarding visiting policies, involvement in care, evolution of policies and general characteristics were collected from April 2021 to May 2021. Descriptive analysis were conducted.

Results: Response rate was 80% with 28 PICUs included. A 24-h access for parents was available for all PICUs (n = 28) with many facilities. Other authorized visitors were principally grandparents (n = 20, 71%) and siblings (n = 18, 64%) with a professional support. Number of visitors at the same time was mainly restricted to two visitors in 82% (n = 23) PICUs. Family presence was always permitted during medical rounds for 19 (68%) PICUs and sometimes authorized during cardiopulmonary resuscitation for 8 (29%) PICUs. Most of the units never included parents during invasive procedures.

Conclusion: An unrestricted access at any time for both parents was found. Restriction regarding type and number of persons at bedside were still applied. Parental presence during care were heterogenous and still restricted. National guidelines and educational programs are needed to support family wishes and promote acceptance by healthcare providers.

Compliance with ethics regulations: N/A.

FC-009 Impact of hyperglycemia on critically ill COVID-19 patient outcomes

ALILA Ilef1, KHARRAT Sana1, HADDED Amina1, JERBI Salma1, BACCOUCH Najeh1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1hopital Habib Bourguiba Sfax, Sfax, Tunisie
Correspondence: Ilef ALILA (ilefalila1323@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-009

Rationale: Diabetes is a known risk factor for mortality in Coronavirus disease 19 (COVID-19) patient. Our objective was to identify prevalence of hyperglycemia in COVID-19 patients and its effect on patient outcomes.

Patients and methods/Materials and methods: We conducted a retrospective study including critically ill patients with confirmed SARS-COV2 infection in an intensive care unit in between September 2020 and December 2021.

Results: During the study period, 586 patients were included with a mean age of 59.5 ± 14.7 years and a sex ratio of 1.6. The median SAPSII and SOFA score were respectively of 29 ± 14.8 and 4 ± 2.6. Most patients had comorbidities, including hypertension (36%), obesity (32.1%) and diabetes mellitus (36.2%). The mean rate of serum glucose on admission was 12.5 ± 6.5 mmol/l. Hyperglycemia occurred in 225 (38.4%) patients; 66 of these hyperglycemic patients (29.3%) had no prior history of diabetes. The mean PH and the mean HCO3- at admission were significantly lower in patients with hyperglycemia (7.37 ± 0.1 vs. 7.41 ± 0.08; p < 0.001 and 22.7 ± 5.6 vs. 23.8 ± 4.7; p = 0.014 respectively). The use of invasive mechanical ventilation was significantly higher in patient with hyperglycemia (p = 0.002). The rate of bacterial infections and the length of stay were not significantly different between patients developing hyperglycemia or not. Mortality was significantly higher in patients developing hyperglycemia during hospitalization (58.2% versus 43% p < 0.001; OR = 1.8[1.3–2.5]).

Conclusion: Hyperglycemia without prior diabetes was common and was associated with an increased use of invasive mechanical ventilation and a higher risk of death.

Compliance with ethics regulations: Yes in clinical research.

FC-010 Cortisol serum level prediction of outcome in critically ill COVID-19 patients

HADDED Amina1, ALILA Ilef1, BEN KHALIFA Atraa1, KHARRAT Sana1, BACCOUCH Najeh1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1hopital Habib Bourguiba Sfax, Sfax, Tunisie
Correspondence: Ilef ALILA (ilefalila1323@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-010

Rationale: The COVID-19 epidemic has been a health threat worldwide causing multi-organ damage. However, the endocrine system and especially cortisol level has been less studied in this pathology. The aim of this study was to explore the role of cortisolaemia in the prediction of outcome in critically ill COVID-19 patients.

Patients and methods/Materials and methods: We conducted a retrospective study in a medical ICU over a period of 16 months [September 2020–December 2021] including patients with SARS-COV2 infection. Cortisolaemia were measured during the first 24 h of hospitalization.

Results: During study period, 132 patients were included with mean age of 62.5 ± 12.7 years, gender ratio of 1.9. The median SAPS II score was 34 ± 14.3 and the median SOFA score was 4 ± 2.4. Most patients had comorbidities, including hypertension (45.5%), obesity (34.8%) and diabetes (37%). Median cortisol level was 71.2 ng/ml with extremes between 5.2 and 643 ng/ml. Severe acute respiratory distress syndrome (ARDS) was diagnosed in 103 (95%) patients, invasive mechanical ventilation was required in 65 (49.2%) of cases and nosocomial infections were diagnosed in 58 (44%). Median ICU length of stay was 7 days ± 6.3 and overall mortality was of 49.2%. Hypocortisolemia was found in 78 (59%) patients. Fifty-seven patients (73%) with cortisol deficiency had severe ARDS versus only 46 (85%) in the group with a normal cortisolaemia (p = 0.325). Twenty-nine patients (37%) with cortisol deficiency required intubation vs 36 (67%) in the normal group; p = 0.001. The occurrence of infections during hospitalization was observed in 30 (38.5%) patients with cortisol deficiency versus 28 (52%) in the other group (p = 0.15). Mortality was observed in 32 patients with cortisol deficiency (41%) versus 33 (61%) in the other group.

Conclusion: Cortisol deficiency was frequently observed in our study but it was not associated with poor outcome in critically ill COVID-19 patients.

Compliance with ethics regulations: Yes in clinical research.

FC-011 Nutrition in critically ill patients: experience of a multidisciplinary improvement quality program

DE KEYSER Aude1,2, MICHEL Bruno1,2, GALERNEAU Louis-Marie1, LUMALE Sophie1, FERRAND Benoit1, CALVINO-GUNTHER Silvia1, GIROUD Benoit1, MAHI Lena1, IMBERT Wendnonga1, CHAPUIS Claire1, SCHWEBEL Carole1

1Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France; 2Cliniques Universitaires Saint-Luc, Bruxelles, Belgique
Correspondence: Aude DE KEYSER (aude.dekeyser@saintluc.uclouvain.be)

Annals of Intensive Care 2022, 12(1):FC-011

Rationale: Critically ill patients face significant catabolic situations. Nutrition is part of management beside various organ supply. The Intensive Care Unit (ICU) of our 2200-bed tertiary university hospital starts a quality and continuous improvement program for year 2021 targeting artificial nutrition. The objective of the work was to involve healthcare providers in evaluation and improvement of nutrition management in daily ICU practice.

Patients and methods/Materials and methods: A multidisciplinary board composed of physicians (3), clinical pharmacists (3), nurses (3), nursing auxiliaries (2), physiotherapists (2) and dietitian (1) was set up in January 2021. A baseline audit was conducted in April 2021 in the entire unit (18 beds) focusing on concordance with current recommendations between prescribed and administered nutritional intakes and traceability of written transmission. The board identified specific areas for quality improvement for each professional category. Impact of implemented measures was evaluated through a second identical audit in February 2022.

Results: The audit conducted over 10 days in April 2021 highlighted proper artificial nutrition practices. All included patients (n = 18; 60 ± 15 yo; 92 ± 23 kg; IGS2 48 ± 7) had enteral nutrition (EN) within 48 h of admission. Half of patients had a BMI over 30. Included population mean ICU duration was 11,3 days and nutrition support was lasting for 10,9 days at time of audit. No patients received parenteral nutrition (PN). At observation patients reached an average of 96% of recommended caloric targets with only 14/18 having nutritional objectives achieved at Day-7 of nutritional support. Other discrepancies included: adaptation to ideal body weight (0/9), protein target achievement (6/18), absence of complementary PN, lack of traceability of nutrition interruption (5/18), mismatch between either location or diameter of feeding tube (11/18), wrong or incomplete bedside EN identification (18/18). Major contributions resulted in weekly theorical and practical training sessions, digital tools for ICU providers, updated and standardized procedures for nutrition support initiation and follow up in various patient profile. Second audit is taking place during February 2022.

Conclusion: Nutrition brings ICU caregivers in a continuous improvement program. It favours interprofessional interactions for direct patients benefit and proved importance and performance of multidisciplinary approach for quality improvement. Preliminary data issued from second audit are encouraging but sustaining efforts are required for long lasting results. Other areas of ICU management may be eligible according to the same model.

Reference 1: D. Hurel, J. Y. Lefrant, N.J. Cano, C. Ichai, J. C. Preiser, F. Tamion. Nutrition artificielle en réanimation. Réanimation (2014) 23:332–350.

Reference 2: P. Singer, A.R. Blaser, M.M. Berger, W. Alhazzani, P.C. Calder, M. Casaer, M. Hiesmayr, K Mayer, J.C. Montejo, C. Pichard, J-C.Preiser, A.R.H. van Zanten, S. Oczkowski, W. Szczeklik, S.C. Bischoff. ESPEN guideline on clinical nutrition in the intensive ca.

Compliance with ethics regulations: N/A.

FC-012 Assessment of nutritional support in a medical ICU

PERRIN Clémence1, CIDERON Cédrick1, LABRO Guylaine1, DUREAU Anne Florence1, KUTEIFAN Khaldoun1

1GHRMSA, Mulhouse, France
Correspondence: Clémence PERRIN (clemenceperrin@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-012

Rationale: According to the recommendations, for all patients admitted to intensive care and likely to stay longer than 48 h nutrition must be quickly introduced. Lack of access to indirect calorimetry requires calculating the necessary nutritional intake according to the weight and the duration of hospitalization in ICU. Our objective is to assess caloric intake (nutritional and non-nutritional) in our medical intensive care unit.

Patients and methods/Materials and methods: This study is descriptive and retrospective. All patients admitted between July 1 and September 30, 2021 and hospitalized more than 3 days, were included. We collected daily nutritional and non-nutritional caloric intake during the whole hospitalization. The weight used for calculation was the one measured at the admission (BMI < 30 kg/m2) or the adjusted weight (BMI ≥ 30 kg/m2).

Results: 180 patients were admitted and 140 were included. The average age was 59.7 years (± 12), 61% were male. The average of SOFA score was 7.8 (± 4.3) and the average of SAPS II score was 45 (± 19.4). The average length of ICU stay was 8.1 days (± 5.9) and the mortality rate was 23.8%. At 48 h, 62 patients (44.3%) received nutrition. Among these patients, 49 received oral nutrition and 13 received enteral artificial nutrition. None of them received a parenteral artificial nutrition. From 140 patients, excluding 49 patients with an unquantifiable oral diet, the average caloric intake was 5.9 kcal/kg/day (± 2.8) for 91 patients. This caloric intake was distributed as follows: 49% from glucose solutions, 26.4% from lipids contained in propofol, 25.1% from artificial nutrition. At 7 days, 54 patients still hospitalized In ICU and 39 patients (72%) received an enteral nutrition. The caloric intake was 18.4 (± 7.4) kcal/kg/day.

Discussion: At 48 h, most of patients fed received a standard oral nutrition with an unknown number of calories ingested. During the first 3 days, if patients did not eat in the standard way, they had little or no nutritional support. Most of the calories ingested during the first 3 days of resuscitation are provided by therapies such as propofol and glucose. These therapies are administered either for sedation, or as a carrier or solvent, or for hydration, but not for nutritional purpose. The caloric intake targets were not reached according to the recommendations in force. However, the mortality rate is average according to the SAPS score.

Conclusion: In our department, patientscaloric intake was lower than recommended. Many of caloric intake was brought by non-nutritional caloric intake in acute phase.

Reference 1: Guidelines for Nutrition Support in Critically Ill Patient, Réanimation (2014) 23:332–350.

Reference 2: ESPEN guideline on clinical nutrition in the intensive care unit. Singer P, et al. Clin Nutr. 2019.

Compliance with ethics regulations: Yes in clinical research.

figure bb

Daily caloric intake

FC-013 Obese tool box evaluation

MAYENCO CARDENAL Nicolas1, SZTRYMF Benjamin1

1Hôpital Antoine Béclère, Clamart, France
Correspondence: Nicolas MAYENCO CARDENAL (nmayencocardenal@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-013

Rationale: Obese patients are more and more frequent in the Intensive Care Units (ICU). This group of patients has unique pathophysiologic features involving all organs. They raise special challenges about their management in ICUs. Aspects like mechanical ventilation, artificial nutrition, thromboprophylaxis or antibiotic dosing can be difficult. Guidelines and clinical data are available about obese patient care, but their application in every day’s practice is uncertain. In the ICU in Antoine Beclere’s hospital (Clamart), we have created a clinical decision support system that brings the existing guidelines about those four features to the physicians in a friendly-user interface. In this study we have assessed the impact of this support system on the physician’s prescriptions.

Patients and methods/Materials and methods: In this retrospective study we have collected data about prescriptions and outcomes of obese patients during two periods, before and after the support system was made available. The endpoint was the number of prescriptions following the existing guidelines. We have also assessed the physician’s satisfaction through a survey.

Results: Over a 3-year period, 39 patients have been included (23 before and 15 after the availability of the support system). They represent 500 days of ICU admission. Patients were comparable in the two groups. They had a mean age of 62.35 years, mean BMI of 39.13 kg/m2 and SOFA score of 4.71. For patients in the second group, prescribed tidal volume was lower (6.57 ml/kg of ideal body weight vs. 7.03 ml/kg; p < 0,001). Less overfeeding was observed (26.64 kcal/kg of adjusted body weight vs 28.32 kcal/kg; p = 0,03) without improving protein intake. Thromboprophylaxis prescriptions were more frequently in accordance with guidelines (74.8% vs 57,7%; p = 0,001). No difference was observed in antibiotic prescription or plasmatic concentration measurements. Surveyed physicians considered thromboprophylaxis and nutrition advice the most useful. They have used the support system several times when caring for an obese patient.

Conclusion: In our UCI, the availability of a computer clinical decision support system for prescription in obese patients brought physician’s prescriptions closer to existing guidelines. Physicians thought the system was useful and user-friendly, especially for nutrition and thromboprophylaxis aspects.

Compliance with ethics regulations: Yes in clinical research.

FC-014 Non thyroidal illness syndrome in critically ill patients with SARS-CoV-2 infection

TURKI Olfa1, SMAOUI Ayoub1, CHTARA Kamilia1, BRADAII Sabrine1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1CHU Habib Bourguiba Sfax, Sfax, Tunisie
Correspondence: Olfa TURKI (olfa.turki.rea@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-014

Rationale: “Non thyroidal illness syndrome” (NTIS) or “euthyroid sick syndrome” (ESS) is a possible biochemical finding in euthyroid patients with severe diseases. It is characterized by a reduction of serum T3 (fT3). The relationship between thyroid hormones levels and mortality is well known. The sudden spread of the 2019 novel coronavirus (SARS-CoV 2) infection (COVID-19) and its high mortality become a world healthcare problem. Our purpose was to investigate the incidence of this endocrinal perturbation in COVID-19 infected patients and the relationship between thyroid function and severity of this infection.

Patients and methods/Materials and methods: We prospectively considered patients admitted in SARS-CoV2 ICU Unit within 2 months. The SARS-Cov-2 infection was confirmed in all patients by PCR testing. Blood samples were collected within 48 h of admission and prior to any treatment that may affect thyroid hormone, on the third day and on the seventh day of ICU stay. NTIS was defined as serum FT3 levels < 2 pg/ml, FT4 and TSH levels within or below the normal reference ranges.

Results: We enrolled 57 patients. The average age was 64 ± 11.7 years with a sex ratio at 1.28. The average ICU stay was 7 days (2-31 days). Only 16 (28%) patients had normal thyroid hormone levels while 41 (72%) had developed NTIS. Thirty-one patients (54.4%) developed NTIS on admission. On the third day, 42% of ICU patients developed NTIS and they were 14 of 21 patients (66.6%) who developed this thyroid perturbation on the seventh day. Overall, troponin, cortisol-level, severe ARDS, ventilation and septic shock predicted disease severity and death. Patients with NTIS had worse symptomatology, worse profiles of inflammatory and tissue injury markers. But neither the NTIS, nor the Rt3 level predicted poor issue in our cohort.

Conclusion: NTIS pattern is common and relates to the severity of disease rather than SARS-CoV-2 infection. Thus, understanding the pathophysiology and evolution of NTIS is crucial even though it rarely require specific treatment. It is suggested that thyroid hormone monitoring in COVID-19 should not differ from other critically ill patients and it is important that endocrinologists recognize them to ensure appropriate management, particularly in the acute phase.

Compliance with ethics regulations: Yes in clinical research.

FC-015 Diabetic ketoacidosis in intensive care unit: epidemiological, clinical and evolutionary features

GUISSOUMA Jihene1,2, ALLOUCHE Hend1,2, BEN ALI Hana2, ABDOU Ghada1,2, TRABELSI Insaf1,2, GHADHOUNE Hatem1,2

1Faculté de médecine de Tunis, Bizerte, Tunisie; 2Université Tunis El Manar, Tunis, Tunisie
Correspondence: Jihene GUISSOUMA (guissouma.jihene@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-015

Rationale: Diabetic ketoacidosis (DKA) is a serious metabolic complication of diabetes. It is a potentially life-threatening condition and usually requires intensive care unit (ICU) hospitalization. We aimed to describe the epidemiological, clinical and evolutionary features of DKA managed in ICU.

Patients and methods/Materials and methods: A 7-year retrospective, descriptive and longitudinal single-center study including all patients admitted to a 6-bed ICU for DKA. Statistical analysis was performed using SPSS 23.

Results: Sixty-two patients were enrolled. The mean age was 36 ± 16 years with a female predominance (sex ratio 0.55). The most common type of diabetes was type 1 (60%), followed by type2 (21%) and inaugural diabetes (19%). The mean duration of diabetes was 9 ± 8 years. The most common comorbidities were hypertension (28%) and chronic renal failure (23%). The mean duration of symptoms before hospitalization was 20 ± 8 h. The most common were asthenia (92%) and nausea, vomiting with abdominal pain (69%). Confusion or less alertness and increase in polydipsia and polyuria were noted in 37% and 32% of cases respectively. On admission, 47% of patients had dehydration, 22% shock and 16% were comatose. Fifty percent had acute kidney injury. The mean capillary blood glucose measurement was 5.8 ± 1.6 g. The average levels of pH and bicarbonates were 7.12 ± 0.14 and 6 ± 4 respectively. DKA was severe, moderate and mild in 84%, 11% and 5% of cases respectively. The mean IGS II and APACHE II were 22 ± 18 and 13 ± 10 respectively. Infection was the predominant precipitating factor (50%) followed by non-compliance to treatment (30%). The symptoms regressed after restoration of fluid deficits, electrolyte replacement and continuous intravenous insulin therapy. Vasopressors and mechanical ventilation (MV) were imperative in 19% and 11% of cases respectively. Only 8% required hemodialysis. DKA resolved within 20 h (extremes 5 and 33 h). The mean length of stay in ICU was 5 ± 3 days and mortality rate was 13%. In univariate analysis: IGS II (p < 10−3), APACHE II (p < 10−3), GCS (p < 10−3), shock on admission (p = 0.01) and MV (p < 10−3) were all predictors of mortality. Besides APACHE II (p = 0.03) and MV (p = 0.009) were the two independent prognostic factors in multivariate analysis.

Conclusion: DKA occurs mainly in type1 diabetes. Although it was severe in most cases, it resolved within a few hours. However, mortality was relatively high in this study and was significantly associated to high APACHE II and need of mechanical ventilation. Adequate follow up and better diabetes education are necessary to avoid this serious metabolic complication.

Compliance with ethics regulations: Yes in clinical research.

FC-016 Early-onset acute kidney injury in COVID-19 critically ill patients, a monocentric retrospective analysis (SARCOV-AKI)

RUAULT Alice1, DUPUIS Claire1, EVRARD Bertrand1, CALVET Laure1, THOUY François1, GRAPIN Kévin1, GUIDO Olivia1, HERNANDEZ Gilles1, DOPEUX Loïc1, MASCLE Olivier1, BOUZGARROU Radhia1, ADDA Mireille1, BONNET Benjamin1, SAPIN Vincent1, PHILIPPONNET Carole1, SOUWEINE Bertrand1

1CHU Gabriel Montpied, CHU Clermont Ferrand, Clermont Ferrand, France
Correspondence: Claire DUPUIS (cdupuis1@chu-clermontferrand.fr)

Annals of Intensive Care 2022, 12(1):FC-016

Rationale: The aim of the study was to assess the epidemiology of early-onset Acute kidney injury (EO-AKI) in COVID-19 pneumonia patients admitted to ICU.

Patients and Methods/Materials and Methods: This study, approved by the ethical committee of the French Intensive Care Society (CE-SRLF20-20), was a prospective single center study, performed in the medical ICU of the university hospital of Clermont-Ferrand France. All consecutive adult patients aged ≥ 18 years, admitted between March 20th, 2020 and August 31th, 2021 for COVID-19 pneumonia were enrolled. Patients with chronic kidney disease, referred from another ICU, and ICU length of stay (LOS) ≤ 72 h were excluded. Baseline patients’ characteristics, variables recorded regarding ICU admission, organ support and main laboratory features during ICU stay and outcomes were collected. Biological testing on admission included mHLA-DR, plasma cytokines (IL-6, CXCL8, IFN-alpha, IL-10 and IL1Ra); and AKI urinary (L-FABP, PODXL, TIMP-2IGFP7) and serum biomarkers(s-Rage, SuPAR). AKI was defined according to the KDIGO classification and classified according to the timing of their recovery as transient, persistent and acute kidney disease (AKD) (ref 1). EO-AKI was defined as the first episode of AKI occurring within 7 days of ICU admission. MAKE (Major Adverse Kidney Events) including death or new RRT or no renal recovery during the first 90 days after ICU admission were recorded. Uni and multivariate analyses were performed to determine factors associated with the presence of AKI and predictors of MAKE.

Results: 264 patients were included in this study. Patients’ characteristics are described in Table 1. EO-AKI occurred in 87 patients (33%), including 43, 17 and 27 patients with EO-AKI stage 1, 2 and 3, respectively. EO-AKI was classified as transient, persistent and AKD in 31 (35.6%), 14 (16%) and 42 (48.2%) patients, respectively. The median ICU LOS was 8 days [5;13]. The ICU mortality was 30.4% (N = 80), and increased with EO-AKI occurrence and severity: 15.8%, 46.5%, 64.7% and 77.8% in patients without AKI, and with EO-AKI stage 1, 2 or 3, respectively (P < 0.001). ICU mortality in patients with transient, persistent AKI and AKD were 50%, 50% and 77.4%, respectively and was significantly lower in patients with EO-AKI not developing AKD than in patients developing (P < 0.01).

Conclusion: In this single center study, EO-AKI developed in 30% of COVID patients admitted to ICU. EO-AKI stage 3 or AKD was associated with a fatal outcome in ≥ 77% of cases. Preventing EO-AKI occurrence and achieving EO-AKI recovery is of paramount importance in COVID-19 patients.

Reference 1: Darmon, ICM, 2018.

Compliance with ethics regulations: Yes in clinical research.

figure bc

Characteristics and comparisons of COVID-19 ICU patients with and without Early Onset AKI

FC-017 Acute kidney injury in critically ill COVID 19 patients: clinical features

BEN MILED Cherifa1, SOUILHI Jawhar1, DRIDI Amira1, NAIMI Skander1, FITOUHI Nizar1, OUERGHI Sonia1, MESTIRI Tahar1

1Hôpital Abderrahman Mami- Ariana, Tunis, Tunisie
Correspondence: Cherifa BEN MILED (cherifa.bm@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-017

Rationale: Acute kidney injury is a frequent complication in critically ill COVID 19 patients and is associated with severe outcomes. This study aims to describe the clinical characteristics of this Acute kidney injury and to assess its incidence.

Patients and methods/Materials and methods: A retrospective and descriptive study was conducted including all covid-19 patients admitted in our ICU who presented an acute kidney injury defined by the KDIGO criteria, during a 6-month period. We collected demographic and anthropometric parameters, underlying comorbidities, nephrotoxic medicine prescription, clinical features of the acute renal failure with the KDIGO grade, mechanical ventilation characteristics, requirement of kidney replacement therapy and outcomes. Data analysis was performed using SPSS 28.0 software.

Results: During our study period, 147 patients were admitted in our ICU. AKI incidence was 52,2% (71 patients out of 147). According to KDIGO criteria, 16.9% were staged KDIGO 1, 35.2% KDIGO 2 and 47.8% KDIGO 3. The mean age was 61 years, ranged from 27 to 93 years. 38% were considered as elderly (> 65 years old). The main comorbidities were arterial hypertension (66%), diabetes mellitus (54.9%), atrial fibrillation (28.1%) and obesity (22.5%). Acute kidney injury occurred mainly around the 6th day of ICU and resolved after 7 days. For 18.3% of the patients, the AKI was transient, defined as a return to the baseline serum creatinine levels or its decrease of 50% or more within the 72 h after the onset of the AKI. Most of the patients were intubated (87%) and 96% were ventilated with a high PEEP (> 12 cmH2O). AKI occurred after the intubation in 73.2% of the cases, 2 days after on average. In 25.4% of the cases, AKI was associated with septic shock. Prescription of nephrotoxic drugs was identified in 77.4% of cases. 12 patients (16.9%) required a replacement kidney therapy, but only 2 of them had a dialysis session, due to the lack of dialysis facilities in our ICU. The 28-day mortality rate was 84,5%.

Conclusion: The incidence of Acute kidney injury in our ICU was 52.2% and occurred mainly in elderly patients with underlying comorbidities. Most patients required a mechanical ventilation with high levels of PEEP. The 28-day mortality was 84,5%.

Compliance with ethics regulations: Yes in clinical research.

FC-018 Clinical features and outcomes of Acute Kidney Injury in severe to critical COVID-19 patients

BOUGUEZZI Nabil1, BEN SAIDA Imen1,2, TOUMI Radhouane1,2, MAATOUK Iyed1, ZGHIDI Maroua1, ZOUARI Hajer1, MEDDEB Khaoula1,2, BOUSSARSAR Mohamed1,2

1Farhat Hached University Hospital, Sousse, Tunisie; 2Research Laboratory N° LR12SP09. Heart Failure. Farhat Hached University Hospital, Sousse, Tunisie
Correspondence: Nabil BOUGUEZZI (dr_nabil@live.fr)

Annals of Intensive Care 2022, 12(1):FC-018

Rationale: Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by an emerged virus SARS-CoV-2. An alarming number of patients with SARS-CoV-2 infection especially severe cases have been reported to develop Acute Kidney Injury (AKI). Our study is aimed to investigate features, outcomes and risk factors for Acute Kidney Injury in Critically Ill COVID-19 patients.

Patients and methods/Materials and methods: It is a retrospective observational study conducted from March 2020 to October 2021, in a Medical ICU. Information regarding demographic, clinical characteristics and outcomes of Critically Ill COVID-19 patients was obtained from medical records. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice Guideline. Multivariate analysis was performed to evaluate risk factors for AKI.

Results: 442 critically ill COVID-19 patients were admitted to ICU during the study period. Median age, 64 [54–71] years; 279(63.1) were males. Hypertension, 197(44.6); diabetes mellitus, 187(42.3) and chronic kidney disease 36(8,1). Median SAPS II, 28 [22–35]. All patients had acute hypoxic respiratory failure and needed either noninvasive or invasive mechanical ventilatory support. 215(48.6) patients required invasive mechanical ventilation (IMV) and 195(44) received a vasoactive drug. 209(47,2) developed AKI during hospitalization. Among the 209 patients with AKI, 31(14.8), 22(10.5) and 156(74.6) had stage 1, 2, and 3, respectively. AKI occurred within a median of 5[1–24] days of hospitalization. 37(21,0) patients received renal replacement therapy, with a total of 117 sessions. The causes of acute kidney injury can be divided into two categories, hypoxic acute tubular necrosis in 177(84) and type 1 cardiorenal syndrome in 31(14.8) patients. The mortality was significantly higher in AKI group compared to those without (54% vs 43%, p 0.01). The mortality rate was 6.6% (n = 14), 3.8% (n = 8), and 42% (n = 89) among those with AKI stages 1, 2, and 3, respectively. On univariate analysis, the factors predicting AKI were mechanical ventilation(p = 0.05), cardiogenic shock (p = 0.001), positive fluid balance (p = 0.000), vasopressors use (p = 0,019); Multivariate regression model identified the following factors as independently associated to AKI, cardiogenic shock, (OR, 2.59; 95% CI, [1.5–4.3]; p = 0.000); positive fluid balance, (OR, 1.76; 95% CI, [1.3–2.2]; p = 0.000).

Conclusion: AKI among patients with severe to critical COVID-19 was common. Several factors were shown to contribute to its occurrence. This complication was highly associated with mortality.

Compliance with ethics regulations: Yes in clinical research.

FC-019 Incidence and risk factors of acute kidney injury in critical forms of COVID-19

GUISSOUMA Jihene1,2, BEN ALI Hana2, TRABELSI Insaf1,2, ALLOUCHE Hend1,2, SAMET Mohamed2, BRAHMI Habib2, GHADHOUNE Hatem1,2

1Faculté de médecine de Tunis, Bizerte, Tunisie; 2Université Tunis El Manar, Tunis, Tunisie
Correspondence: Jihene GUISSOUMA (guissouma.jihene@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-019

Rationale: Acute kidney injury (AKI) is a common metabolic complication in the COVID-19 particularly among critical forms. Besides the viral tropism the pathogenesis of AKI is likely multifactorial. We aimed to describe the epidemiological, clinical and biological features of patients admitted to intensive care unit (ICU) for critical forms of COVID-19 in order to deduce the risk factors of AKI.

Patients and methods/Materials and methods: A 16-month prospective analytic study (September 2020–December 2021) including all patients (without a chronic kidney failure history) admitted to ICU for critical forms of COVID-19. The patients were divided into two groups: -Group 1: patients who developed AKI during ICU stay. -Group 2: patients who have maintained normal kidney function. The KDIGO classification was adopted to stratify the AKI. The statistical analysis was performed using SPSS 23.

Results: Overall 140 patients were included. Twenty-three per cent developed AKI (33 cases in group 1 and 107 in group 2). The mean age was 58 ± 13 with male predominance (sex ratio 1.2). The most common comorbidities were hypertension (64%) and diabetes (62%). The mean IGS II and APACHE II were 40 ± 13 and 13 ± 6 respectively. The mean base creatinine level was 79 ± 22 mmol/l. The mean creatinine level at the onset of AKI was 295 ± 201 mmol/l. According to the KDIGO criteria the group 1 patients were staged class I (4 cases), class II (11 cases) or class III (18 cases). The mean period for developing AKI was 8 days. Sepsis and hypotension were the two predominant precipitating factors of the AKI (45% and 33% of cases of group 1). Hemodialysis was indicated in 40% of cases. The AKI was irreversible in 72% of the cases. In univariate analysis, there were no significant differences between the two groups in gender, comorbidities, IGS II and ICU length of stay. However, age (p = 0.007), Apache II (p = 0.01) and septic shock (p < 10-3) were the main risk factors of AKI. Only septic shock (p < 10-3) was an independent factor in multivariate analysis. Besides group 1 patients required more invasive ventilation (p = 0.001) and developed much more healthcare-associated infections (p < 10-3). Overall mortality rate was 69%. It was higher in group 1 (87%) compared to group 2 (63%) with a significant difference (p = 0.029).

Conclusion: The occurrence of AKI in critical forms of COVID-19 was frequent in our study and was associated to a higher mortality. Septic shock was the main risk factor of AKI. These results need to be confirmed by further larger studies.

Compliance with ethics regulations: Yes in clinical research.

FC-020 Impact of dexamethasone and inhaled nitric oxide on severe acute kidney injury in critically ill patients with COVID-19

BOBOT Mickaël1,2,7, TONON David3, PERES Noémie2, GUERVILLY Christophe2, LEFÈVRE Flora1, MAX Howard4, BOMMEL Youri4, VOLFF Maxime4, LEONE Marc5, LOPEZ Alexandre5, SIMEONE Pierre4, CARVELLI Julien6, HRAIECH Sami2, PAPAZIAN Laurent2, VELLY Lionel4, BOURRENNE Jérémy6, FOREL Jean-Marie2

1Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Aix-Marseille Université, Marseille, France; 2Service de Médecine Intensive Réanimation, Hôpital Nord, AP-HM, Aix-Marseille Université, Marseille, France; 3Département d'Anesthésie Réanimation, Hôpital de la Conception, AP-HM, Aix-Marseille Université, Marseille, France; 4Département d'Anesthésie Réanimation, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France; 5Service d'Anesthésie Réanimation, Hôpital Nord, AP-HM, Aix-Marseille Université, Marseille, France; 6Service de Réanimation et Surveillance Continue, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France; 7C2VN, INSERM 1263, INRAE 1260, Aix-Marseille Université, Marseille, France
Correspondence: Mickaël BOBOT (mickael.bobot@ap-hm.fr)

Annals of Intensive Care 2022, 12(1):FC-020

Rationale: Kidney failure is the second most frequent condition after acute respiratory distress syndrome (ARDS) in critically ill patients with severe COVID-19 and is strongly associated with mortality. The aim of this multicentric study was to assess the impact of the specific treatments of COVID-19 and ARDS on the risk of severe acute kidney injury (AKI) in critically ill COVID-19 patients.

Patients and methods/Materials and methods: In our cohort study, we retrospectively analysed a database of consecutive patients hospitalized in 6 ICUs for COVID-19. The incidence and severity of AKI were monitored during the entire ICU stay. Patients older than 18 years admitted to the ICU for COVID-19-related ARDS requiring mechanical ventilation were included.

Results: 164 patients were included in the final analysis, 97 (59.1%) displayed AKI, of which 39 (23.8%) severe stage 3 AKI and 21 (12.8%) requiring renal replacement therapy (RRT). In univariate analysis, severe AKI was associated with Angiotensin Converting Enzyme inhibitors (ACEI) exposure (p = 0.016), arterial hypertension (p = 0.029), APACHE-II score (p = 0.004) and mortality at D28 (p = 0.008), D60 (p < 0.001) and D90 (p < 0.001). In multivariate analysis, the factors associated with the onset of stage 3 AKI were: exposure to ACEI (OR: 4.238 (1.307–13.736), p = 0.016), APACHE II score (without age) (OR: 1.138 (1.044–1.241), p = 0.003) and iNO (OR: 5.694 (1.953–16.606), p = 0.001). Protective factors were prone positioning (OR: 0.234 (0.057–0.967), p = 0.045) and dexamethasone (OR: 0.194 (0.053–0.713), p = 0.014).

Discussion: Our study confirms the negative impact of AKI on mortality in COVID-19 in critically ill patients, and then the need to be careful about risk factors of AKI and to implement strategies to limit nephrotoxicity in the ICU. We report for the first time an independent association of iNO with both severe AKI and the need for RRT in severe COVID-19 patients. In our study, iNO did not improve mortality rates or the duration of MV and was associated with AKI and RRT. Thus, we suggest against its using in COVID-19-related ARDS, when other therapeutic strategies are available. Dexamethasone could decrease glomerular and interstitial inflammation observed in kidneys, decreasing the risk of AKI during severe COVID-19, which may have contributed to a decrease in the AKI rate between the first and the second wave of COVID pandemics.

Conclusion: Dexamethasone was associated with a prevention of the risk of severe AKI and RRT, and iNO was associated with severe AKI and RRT in critically ill patients with COVID-19; iNO should be used with caution in COVID-19 related ARDS.

Reference 1: Orieux A et al. Impact of dexamethasone use to prevent from severe COVID-19-induced acute kidney injury. Crit Care Lond Engl. 2021 Jul 16;25(1):249.

Reference 2: Ruan SY et al. Inhaled nitric oxide therapy and risk of renal dysfunction: a systematic review and meta-analysis of randomized trials. Crit Care. 2015 Dec;19(1):137.

Compliance with ethics regulations: Yes in clinical research.

figure bd

Figure 1: Flow chart of the study AKI: Acute Kidney Injury, ESRD: End-stage renal disease, ICU: Intensive Care Unit, RRT: Renal replacement therapy

FC-021 Is hyponatremia associated with poor outcome in critically ill COVID-19 patients?

SDIRI Ines1, JARRAYA Fatma1, RACHDI Emna1, JAMOUSSI Amira1, AYED Samia1, BEN KHELIL Jalila1

1Hôpital Abderrahmane Mami, Ariana, Tunisie
Correspondence: Fatma JARRAYA (fatma.jarraya8@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-021

Rationale: Patients with COVID-19 have multiple clinical conditions that may cause electrolyte imbalances. Hyponatremia is a prevalent metabolic disorder that could be involved with adverse outcomes in critically ill COVID-19 patients. The aim of this study was to describe the impact of hyponatremia on outcomes of COVID-19 patients, including mortality.

Patients and methods/Materials and methods: This was retrospective observational cohort study included all consecutive COVID19 patients admitted to the intensive care unit from March 2020 to September 2021. All COVID-19 patients in whom serum sodium was measured at admission were included. Patients were divided into two groups: GI patients without hyponatremia; G II patients with hyponatremia (serum sodium < 135 mmol/L). Outcomes such as mortality, need for invasive mechanical ventilation (IMV), sepsis, and acute kidney injury (AKI) were assessed.

Results: During the study period, 520 patients were collected and divided into two groups (G I n = 394; G II n = 126). The median age was 61 years [52-69] with a gender ratio (H/F) of 1.65. The mean of the SAPS II score was 27.9 ± 10. The most common comorbidities were hypertension (38.2%) and diabetes (36.5%). The mean body mass index was 30.79. The incidence of hyponatremia at admission was 23.4% and it was generally mild (n = 100; 79%). Demographic characteristics were similar between the two groups. Transit disorders particularly emesis prior to admission were more common in the hyponatremia group (21% vs 13.3%; p = 0.055). Pulmonary bacterial co-infection occurred more in GII (14.3% vs 7.8%; p = 0.030). Hyponatremic patients had higher ferritin levels (1500 μg/l [205–1500] vs 401 μg/l [250–1030]; p = 0.05). Hyponatremia was not associated with increased risk of AKI (48.3% vs 41.8%; p = 0.403) or sepsis (35.8% vs 26.1%; p = 0.140). IMV and death were not significantly more frequent in hyponatremic patients compared with normonatremic patients (61.1% vs 55.3%; p = 0.257; 59.5% vs 52.3%; p = 0.156, respectively).

Conclusion: Mild hyponatremia at admission is common but is not associated with poor outcomes in patients with critical COVID-19.

Compliance with ethics regulations: Yes in clinical research.

FC-022 Hypokalemia in critically ill COVID-19 patients

HADDED Amina1, ALILA Ilef1, KHARRAT Sana1, BRADAI Sabrine1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1hopital Habib Bourguiba Sfax, Sfax, Tunisie
Correspondence: Ilef ALILA (ilefalila1323@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-022

Rationale: Patients with COVID-19 have multiple clinical conditions that can cause electrolyte imbalances, including hypokalemia. This study aimed to estimate the prevalence and outcomes of hypokalemia in patients withCOVID-19 admitted to intensive care units (ICU).

Patients and methods/Materials and methods: We conducted a retrospective study in an ICU over a period of 16 months [September 2020–December 2021] including patients with SARS-COV2 infection.

Results: During the study period, 586 patients were included with a mean age of 59.5 ± 14.7 years and a sex ratio of 1.6. The median SAPSII and SOFA score were respectively of 29 ± 14.8 and 4 ± 2.6. Most patients had comorbidities, including hypertension (36%), obesity (32.1%) and diabetes mellitus (36.2%). A total of 52 patients (9%) had hypokalemia. Severe ARDS was observed in 63% of the first group versus 72% of the second group (p = 0.109). No significant difference was found in terms of use of NIV (59.6% versus 65%; p = 0.4) and invasive mechanical ventilation (75% versus 72.8%; p = 0.73). The mean duration of mechanical ventilation was longer in the hypokalemia group: 7.7 days versus 4.4 days in the second group (p < 0.001). Similarly, the average length of stay in the intensive care unit was higher in the first group than in the second group: 9.3 days versus 7.3 days (p = 0.021). Mortality was higher in patients with hypokalemia but the difference was not significant 59.6% versus 47.9% (p = 0.108). The use of diuretics and corticosteroids was comparable between two groups.

Conclusion: Hypokalemia in patients with covid-19 admitted to the ICU is associated with prolonged duration of mechanical ventilation and ICU stay but does not influence mortality.

Compliance with ethics regulations: Yes in clinical research.

FC-023 Hyponatremia in critically ill COVID-19 patients

HADDED Amina1, KHARRAT Sana1, ALILA Ilef1, AMMAR Rania1, BEN KHALIFA Atraa1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1hopital Habib Bourguiba Sfax, Sfax, Tunisie

Correspondence: Ilef ALILA (ilefalila1323@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-023

Rationale: Dysnatremia is common in patients hospitalized in the intensive care units, often worsening the prognosis of lung disease and severe illness. The main objective of this study is to assess the prevalence of hyponatremia in patients with COVID-19 admitted to the IC U and to evaluate the impact of hyponatremia on severity and outcomes in COVID-19 patients.

Patients and Methods/Materials and methods: We conducted a retrospective study including all COVID-19 patients hospitalized in an intensive care unit during a period of 16 months. We compared two groups of patients: the first (G1) group of patients with hyponatremia and the second (G2) group of patients with normal natremia.

Results: A total of 126 patients (21.5%) developed hyponatremia in our study. There were more male patients in hyponatremia group 91 (72.2%) versus 269(58.5%) (p = 0.005). The average age was comparable between the two groups (59.1 year in G1 versus 60.9 year in G2; p = 0.24). Pulmonary lesions on chest CT performed during hospitalization were significantly more extensive in the first group (p = 0.023). The prevalence of renal failure was higher in the hyponatremia group with a significant difference (49.2% versus 38.5%; p = 0.03). Regarding the use of invasive ventilation, the two groups were comparable (p = 0.96) and there was no significant difference in terms of duration of mechanical ventilation (p = 0.6). Hyponatremia was a risk factor for prolonged stay in intensive care units 8.9 days i versus 7.1 days (p = 0.03). Mortality was higher in the hyponatremia group but the difference was not significant 52.4% versus 48% (p = 0.38).

Conclusion: Hyponatremia had poor outcome in our study. It was associated with more extensive parenchymal damage, an increased prevalence of renal failure and a longer stay in ICU.

Compliance with ethics regulations: Yes in clinical research.

FC-024 Incidence, characteristics, and long-term outcomes of new-onset atrial fibrillation in a medical intensive care unit

DOYEN Denis1, LABBAOUI Mohamed1, SQUARA Fabien1, HYVERNAT Hervé1, BERNARDIN Gilles1, JOZWIAK Mathieu1, DELLAMONICA Jean1

1Centre Hospitalier Universitaire de Nice, Nice, France
Correspondence: Denis DOYEN (doyen.d@chu-nice.fr)

Annals of Intensive Care 2022, 12(1):FC-024

Rationale: Atrial fibrillation is the most common acquired arrhythmia in the intensive care unit (ICU) and is associated with increased morbidity and mortality. However, patient characteristics, particularly echocardiographic features of new-onset atrial fibrillation (New-AF), are scarce. In addition, little is known about the long-term outcomes of patients with New-AF.

Patients and methods/Materials and methods: We conducted a single-center prospective observational study in a medical intensive care unit. All consecutive patients admitted were included. Continuous electrocardiogram monitoring was checked daily for New-AF. Patients were divided into the following groups: New-AF patients, patients with a history of AF, and No-AF patients when no AF was previously diagnosed or documented during hospitalization. Transthoracic echocardiography, electrocardiogram, and blood analysis were performed at admission and in case of New-AF. The following outcomes were collected 6 months after ICU discharge: re-hospitalizations, strokes or other thromboembolism, and mortality.

Results: Over a 5-month period, 110 patients were included: 21% (23) New-AF patients, 13% (14) with a history of AF, and 66% (73) No-AF patients. New-AF patients were predominantly male (61%), were significantly older (70 versus 58 years, p < 0.01), and had more comorbidities than patients without AF. Patients with New-AF had higher levels of high-sensitivity troponin I, B-type natriuretic peptide and protein C reactive than No-AF patients (respectively 73 vs 18 ng/L, 408 vs 55 pg/L, and 114 vs 32 mg/L; p < 0.01). At the time of AF onset in the New-AF group, kalemia was lower than at admission (3.5 vs 4.4 mmol/L, p < 0.01). In New-AF patients, TTE showed more left ventricular systolic and diastolic dysfunction, right ventricular systolic dysfunction, pulmonary hypertension and more enlarged left atrial and left ventricular index volumes than in No-AF patients. New-AF patients had more acute pulmonary edema and cardiogenic shock than No-AF patients (respectively 48% versus 6% and 26% versus 4%; p < 0.01). New-AF was significantly associated with greater use of inotropic or vasopressor drugs, mechanical ventilation, and renal replacement, and had higher in-hospital mortality (44% vs 12%, p < 0.01) than No-AF patients. During follow-up, there was no difference in re-hospitalizations, thromboembolism, or mortality between all groups (42% versus 36%, 8% versus 2%, and 15% versus 10%, respectively, between patients with AF and No-AF patients; p > 0.05).

Conclusion: In a medical intensive care unit, the incidence of New-AF was 21%. New-AF patients had more echocardiographic abnormalities, organ failure, and higher in-hospital mortality than No-AF patients. No difference in outcomes was observed 6 months after ICU discharge between all groups.

Compliance with ethics regulations: Yes in clinical research.

FC-025 Lactate/Pyruvate ratio as a marker of tissue hypoxia in cardiac surgery

KOLSI Hichem1, JAWADI Wael1, KAMMOUN Anas1, SELLAMI Bouthaina1, FOURATI Mahdi1, KETATA Salma1, CHEIKHROUHOU Hichem1, TRIKI Zied1, ZOUARI Dhouha1, JALLOULI Dana1, NAIFAR Manel1, AYADI Fatma1

1Centre hospitalo-universitaire Habib Bourguiba, Sfax, Sfax, Tunisie
Correspondence: Hichem KOLSI (hichem.kolsi17@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-025

Rationale: Cardiac surgery with cardiopulmonary bypass (CPB) has a high risk to induce tissue hypoperfusion and oxygenation impairment. This can lead to complications and organ failure. Blood lactate elevation is a classic marker of anaerobic metabolism and hypoperfusion. But lactate increasing can result from aerobic glycolysis acceleration or impaired clearance. Lactate/Pyruvate ratio (L/P) was studied in septic shock and seems to have a better specificity of anaerobic metabolism. The aim of this study is to assess whether the L/P is associated with adverse outcome after cardiac surgery.

Patients and methods/Materials and methods: This is a prospective, observational, monocentric clinical study being performed. We included 26 patients over 18 years undergoing cardiac surgery with CPB, from October 2021. We have an objective of 80 patients. We did not include patients with severe hepatocellular impairment, preoperative hemodynamic instability, or severe renal failure. We have excluded patients who have died during surgery, patients who can only leave the operating room with a circulatory assistance technique. Arterial blood lactate and pyruvate were collected, lactate in sodium fluoride tube, pyruvate in perchloric acid tube. The samples were transported at 4 °C, and then analyzed by enzymatic colorimetric reaction for lactate and spectrophotometry for pyruvate. We have analyzed receiving operating curve (ROC) of L/P for complications occurring. We tested then the correlation of the variables with prognosis interest to L/P by Spearman test.

Results: Complications rate was 46.2%. Mortality rate was 26.9%. Mean age was 61.96 ± 9.34. Median Euroscore II was 1.5 (1.09; 2.13). 23 patients have lactate level > 2 mmol/l. Only 18 (78.26%) of these patients have L/P > 16 (a cutoff used previously in septic shock). L/P was predictive of complications with area under ROC 0.857, higher than area under ROC of lactate which was 0.777. Best threshold was 20.34. LP median was significantly higher in group with complications and in non survivor group. We found that L/P is correlated to Euroscore II, duration of CPB and SAPSII at one and two days postoperative.

Conclusion: We conclude that L/P is associated with poor outcome after cardiac surgery. L/P is more efficient than lactate to predict postoperative complications. L/P could be used as an additional tool to identify patients with high risk of adverse outcome after cardiac surgery. Nevertheless, these results should be confirmed in larger multicentric studies. A randomized trial comparing a standard therapy strategy with a strategy based on L/P is needed to allow clinicians to make a therapy decision using LP.

Compliance with ethics regulations: Yes in clinical research.

FC-026 Phenotypic heterogeneity of covid-19-related myocarditis in adults

BARHOUM Petra1, PINETON DE CHAMBRUN Marc1, DORGHAM Karim1, KERNEIS Mathieu1, BURREL Sonia1, QUENTRIC Paul1, PARIZOT Christophe1, CHOMMELOUX Juliette1, BRECHOT Nicolas1, LEBRETON Guillaume1, BOUSSOUAR Samia1, SCHMIDT Matthieu1, YSSEL Hans1, LEFEVRE Lucie1, MIYARA Makoto1, CHARUEL Jean-Luc1, MAROT Stephane1, LUYT Charles-Edouard1, LEPRINCE Pascal1, AMOURA Zahir1, MONTALESCOT Gilles1, REDHEUIL Alban1, COMBES Alain1, GOROCHOV Guy1, HEKIMIAN Guillaume1

1GROUPE HOSPITALIER PITIE SALPETRIERE, Paris, France
Correspondence: Petra BARHOUM (pbarhoum@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-026

Rationale: Adults who have been infected with SARS-CoV-2 can develop a multisystem inflammatory syndrome (MIS-A), including myocarditis. Yet, several patients fail to meet MIS-A criteria, suggesting the existence of distinct phenotypes of COVID-19 related myocarditis. The objective of this study was to compare the characteristics and clinical outcome between patients with COVID-19-related myocarditis fulfilling MIS-A criteria (MIS-A+) or not (MIS-A−).

Patients and methods/Materials and methods: We retrospectively reviewed the prospectively constituted database of our 26-bed ICU between March 2020 and June 2021, and included all patients admitted for suspected myocarditis with proven SARS-CoV-2 infection, without vaccination against COVID-19. The primary endpoint was in-hospital mortality. The secondary outcomes included left ventricle ejection fraction (LVEF) evolution, and long-term survival.

Results: Between March 2020 and June 2021, 38 patients required ICU admission (male: 66%; mean age: 32 ± 15 years) for suspected COVID-19-related myocarditis. All had positive SARS-CoV-2 RT-PCR (37%) or serology (68%). In-ICU treatment for organ failures included dobutamine (79%), norepinephrine (60%), mechanical ventilation (50%), VA-ECMO (42%) and renal replacement therapy (29%). In-hospital mortality was 13%. Twenty-five (66%) patients met the MIS-A criteria. MIS-A− compared to MIS-A+ patients were characterized by a shorter time lapse between the first COVID-19 symptoms and myocarditis (3 vs. 8 days, p = 0.04), a lower left ventricle ejection fraction (LVEF 10 vs. 30%, p = 0.01; LVOT-VTI 5 vs.13 cm, p < 0.0001), as well as higher in-ICU organ failure, need for mechanical circulatory support with VA-ECMO (92% vs.16%, p < 0.0001), and in-hospital mortality (31% vs. 4%, p = 0.04). The main differences between the phenotypes of MIS-A+ and MIS-A− patients are summarized in the Central Illustration Median LVEF at ICU and hospital discharge was 42% [30–54] and 60% [50–64] respectively. At the last follow-up (median [IQR] 235 [155–359] days), 32 patients were alive, all but one with normal LVEF, and one was lost of follow-up. The main differences between the phenotypes of MIS-A+ and MIS-A− patients are summarized in the Central Illustration.

Conclusion: MIS-A+ and MIS-A− COVID-19-related myocarditis patients have two distinct phenotypes in term of clinical presentation, timing, prognosis, and immunological profile. This study differentiated for the first time these two phenotypes, and it seems relevant for patients’ management and further understanding of their pathophysiology.

Compliance with ethics regulations: Yes in clinical research.

figure be

Main phenotypic differences between (MIS-A+) and (MIS-A−) COVID-19-related myocarditis.

FC-027 Impaired microvascular endothelial reactivity in critically ill COVID-19 patients

RAIA Lisa1, URBINA Tomas1, GABARRE Paul1, BONNY Vincent1, HARIRI Geoffroy1, ERHMINGER Sébastien1, BIGÉ Naïke1, BAUDEL Jean-Luc1, GUIDET Bertrand1, MAURY Eric1, JOFFRE Jérémie1, AIT-OUFELLA Hafid1

1Hôpital Saint Antoine, Paris, France
Correspondence: Lisa RAIA (lr.lisa.raia@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-027

Rationale: The COVID-19 outbreak, caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV2), has affected unprecedently all regions of the world. Critically ill COVID-19 patients exhibit inflammatory syndrome and frequent arterial and venous thrombosis affecting large vessels and microcirculation. Plus, clinical and histological studies have reported that SARS-CoV2 infection may damage the endothelium. However, the impact of this virus on endothelial function in vivo remains poorly characterized. This prospective observational study aimed to compare skin microvascular endothelial reactivity in critically-ill COVID-19 to patients admitted in the ICU for non-COVID-19 bacterial pneumonia (NCBP).

Patients and methods/Materials and methods: We conducted a prospective observational study in an 18-bed ICU. We included consecutive COVID-19 adult patients and patients with non-COVID-19 bacterial pneumonia admitted to our ICU for acute respiratory failure. Microvascular endothelial reactivity was assessed in the forearm skin area within the first 24 h of admission using acetylcholine iontophoresis coupled with Laser doppler. This non-invasive technique allows transdermal diffusion of acetylcholine across the skin to subcutaneous capillaries which results in endothelium-dependent vasodilatation and increased blood flow. The endothelial reactivity was quantified by the area under the curve (AUC) of the blood flow curve within a standardized 10-min recording. Hemodynamic and tissue perfusion parameters were also recorded.

Results: During 3 consecutive months, 32 COVID-19 patients and 11 control NCBP patients with acute respiratory failure were included. The median age was 59 [50–68] and 69 [57–75] years in COVID-19 and NCBP groups, respectively (P = 0.11). No significant difference in comorbidities or medications was observed between the two groups, except for body mass index, which was higher in COVID-19 patients. NCBP patients had higher SAPS II score compared to COVID-19 patients (46 [32–51] vs. 23 [18-30], P < 0.0001) but SOFA score was not different between groups (4 [3–4] vs 4 [2–5.3], P = 0.51). Global hemodynamic and peripheral tissue perfusion parameters were not different between groups. COVID-19 patients had significant lower skin basal blood flow compared to NCBP patients (7.9 [5.5–9.9] vs. 10.4 [9.4–12.1] UI, P = 0.02). In addition, endothelium-dependent microvascular reactivity was threefold lower in COVID-19 patients compared to NCBP patients (AUC 3911 [1725–6318] vs. 14280 [5038–19743], P = 0.008) (Fig. 1)

Conclusion: In critically ill COVID-19 patients, we evidenced a drastically impaired skin microvascular endothelium-dependent vasoreactivity at the early phase of the disease compared to non-COVID-19 bacterial pneumonia patients. This result supports the hypothesis of a singular and clinically relevant SARS-CoV 2-associated endotheliopathy.

Compliance with ethics regulations: Yes in clinical research.

figure bf

Figure 1. A. Skin microvascular blood flow in response to three stimulation of acetylcholine (arrows) in NCBP patients (grey) and in COVID-19 patients (red), represented as mean+/ SEM every seconds for 10 min after the first electric stimulation. B.

FC-028 Venous Thromboembolism events in critically ill COVID-19 patients

ALILA Ilef1, HADDED Amina1, KHARRAT Sana1, CHTARA Kamilia1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1hopital Habib Bourguiba Sfax, Sfax, Tunisie
Correspondence: Ilef ALILA (ilefalila1323@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-028

Rationale: There is some evidence that Covid 19 pneumonia is associated with prothrombotic status and increased risk of venous thromboembolic events (1). The aim of this study was to determine the incidence of PE in patients with COVID-19, risk factors and its prediction of outcome in critically ill COVID19 patients.

Patients and methods/Materials and methods: We conducted a retrospective study in a medical ICU over a period of 16 months [September 2020–December 2021] including patients with SARS-COV2 infection.

Results: During the study period, 586 patients were included with a mean age of 59.5 ± 14.7 and a gender ratio of 1.6. The median SAPSII and SOFA score were respectively of 29 ± 14.8 and 4 ± 2.6. Most patients had comorbidities, including hypertension (36%), obesity (32.1%) and diabetes (36.2%). 509 (87%) patients received therapeutic anticoagulation on admission versus only 77 (13%) received prophylactic anticoagulation. Twenty-eight (4.7%) patients had venous thromboembolic events: PE was diagnosed through CT pulmonary angiography in 22 (3.8%) of 586 hospitalized patients with COVID-19 and deep venous thrombosis was diagnosed in 10 (1.7%) patients through doppler ultrasound of lower limb. Four patients had both complications. The comparison between 2 groups with or without thromboembolic (TE) complications showed that the risk factors usually associated the development of thromboembolic complications were not significantly different (high blood pressure in 7 (25%) vs 204 (36.6%) p = 0.2, diabetes in 9 (32.1%) vs 203 (36.4%) p = 0.8, obesity in 13 (46.4%) vs 175 (31.3%) p = 0.09, smoking in 6 (21.4%) vs 125 (22.4) p = 0.9). Invasive mechanical ventilation was required in 264 (45.1%) patients, 20 (71.4%) in the group with TE complications and 244 (43.7%) in the other group, p = 0.004. Mortality was similar between the 2 groups (15 (53.5%) vs 272 (48.7%); P = 0.6).

Conclusion: TE complications were rare in our cohort. These complications are associated with higher use of mechanical ventilation but not with higher mortality.

Reference 1: (1) Pompilio Faggiano, Andrea Bonelli, Sara Paris, Giuseppe Milesi, Stefano Bisegna, Nicola Bernardi, Antonio Curnis, Eustachio Agricola, Roberto Maroldi: Acute pulmonary embolism in COVID-19 disease: Preliminary report on seven patients.

Compliance with ethics regulations: Yes in clinical research.

FC-029 Anti-RNA-polymerase III autoantibodies-associated fulminant myocarditis

PINETON DE CHAMBRUN Marc1, CHARUEL Jean-Luc1, DORGHAM Karim1, QUENTRIC Paul1, KERNEIS Mathieu1, LEBRETON Guillaume1, MIYARA Makoto1, SCHMIDT Matthieu1, LUYT Charles-Edouard1, LIFERMANN Francois2, MELKI Isabelle3, AMOURA Zahir1, GOROCHOV Guy1, HEKIMIAN Guillaume1, COMBES Alain1

1Hôpital La Pitié-Salpêtrière, Paris, France; 2CH DAX, Dax, France; 3Hôpital Robert Debré, Paris, France
Correspondence: Marc PINETON DE CHAMBRUN (marc.dechambrun@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-029

Rationale: Anti-RNA-polymerase III autoantibodies (RNApol3)-associated fulminant myocarditis is a recently discovered entity associating recurrent viral (mostly influenzae)-induced fulminant myocarditis and/or severe pericarditis in patients with RNApol3 but no overt systemic sclerosis. It is a serious condition owing the severity of myocarditis episodes and the risk of relapse. The pathophysiology of the disease is unknown. We conducted this study to better delineate the clinical characteristics and the outcome of these patients.

Patients and methods/Materials and methods: Retrospective, monocenter study between January 2013 and January 2022 including every patients admitted to a 26-bed intensive care unit for myocarditis and/or severe pericarditis in the presence of RNApol3.

Results: Twenty-five patients (women 80%, mean age at first episode 35 ± 11.4 years) were included in the study. Seven (28%) patients died after a median follow-up 39 [6–50] months: during a first myocarditis episode (n = 2), a relapse (n = 4) or from other cause (n = 1). The mean number of episodes per patients was 1.6 ± 0.9 and 40% patients had at least one relapse. Every patient was admitted at least once in critical care for a median duration of 9 [5–14] days. The lowest left ventricle ejection fraction value was 5 [5–10] % and the highest troponin value 82 [19–370] fold over ULN. Pericardial effusion was reported in 94% cases, requiring drainage in 40% cases. Inflammatory parameters were mildly elevated: C-reactive protein 7 [5–14] mg/L, procalcitonin 0.1 [0.06–0.4] ng/mL and fibrinogen 3 [2.4–3.4] g/L. Conduction and rhythm disorders were infrequent: 3 and 7% respectively. In-ICU organ-failure treatment frequencies were: dobutamine 83%, VA-ECMO 77%, vasopressors 70%, mechanical ventilation 67% and renal replacement therapy 30%. Two patients received cardiac transplantation because of unrecovering cardiac failure while all survivors could be weaned from ECMO and recovered normal cardiac function at distant follow-up. The etiology of myocarditis were: influenza 52%, COVID-19 44%, unknown viral infection 12% and other virus 4%. Four patients had a myocarditis episode on the occasion of both influenzae virus infection and COVID-19. RNApol3 were confirmed on distant follow-up in every patient (n = 17) after a mean duration of 8 [2.5–16.5] months. Two patients only had systemic sclerosis classification score ≥ 9 without visceral involvement.

Conclusion: RNApol3-associated fulminant myocarditis is a new severe entity. Our study shows that both influenza and COVID-19 are responsible for myocarditis in these patients. A significant number of patients have been diagnosed on the occasion of COVID-19 pandemic. The pathophysiology of this disease needs further investigation.

Compliance with ethics regulations: Yes in clinical research.

FC-030 Safety, diagnostic yield and therapeutical consequences of myocardial biopsy in unexplained acute heart failure requiring extracorporeal life support

PINETON DE CHAMBRUN Marc1, YANN Marquet1, ROUVIER Philippe1, KERNEIS Mathieu1, BRECHOT Nicolas1, SCHMIDT Matthieu1, CHOMMELOUX Juliette1, MOYON Quentin1, BARHOUM Petra1, LEFEVRE Lucie1, SAURA Ouriel1, LEVY David1, ASSOULINE Benjamin1, LUYT Charles-Edouard1, COMBES Alain1, HEKIMIAN Guillaume1

1Hôpital La Pitié-Salpêtrière, Paris, France
Correspondence: Marc PINETON DE CHAMBRUN (marc.dechambrun@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-030

Rationale: Myocardial biopsy is strongly recommended in patients with unexplained acute heart failure, especially in case of cardiogenic shock, despite a very low level of evidence. The safety, the diagnostic yield and the therapeutical consequences of myocardial biopsy in patients requiring extracorporeal life support (ECLS) is poorly investigated.

Patients and methods/Materials and methods: Retrospective, monocenter study between January 2002 and January 2018 including every patients admitted to a 26-bed intensive care unit undergoing a myocardial biopsy (surgical or endomyocardial) for unexplained acute heart failure while being under ECLS. All patients had a myocardial biopsy altogether with a comprehensive noninvasive diagnosis work-up. The primary endpoint was the rate of therapeutical modifications as a direct consequence of myocardial biopsy results.

Results: Forty-seven patients (women 53%, mean age at admission 39 ± 11 years) were included in the study. Forty-two (89%) received veno-arterial extracorporeal membrane oxygenation (VA-ECMO), requiring centralization in 26 (62%) and 15 (32%) were given ventricle assist device. Twenty-six (55%) patients died in hospital, 16 (34%) could be weaned from ECLS and 7 (15%) required cardiac transplantation. According the Bonaca myocarditis classification, 75% had definite and 25% probable myocarditis. Biopsy was endomyocardial in 17 (36%) patients and surgical in other cases. Organ failure treatments on biopsy-day were: ECLS 100%, inotropes/vasopressors 96%, mechanical ventilation 75% and renal replacement therapy 30%. Endomyocardial and surgical biopsy was followed by tamponade in 29% and 10% cases respectively. One patient undergoing endomyocardial biopsy died as a direct consequence of the procedure. The biopsy-based and the noninvasive heart failure mechanism diagnosis work-up resulted in the following diagnosis respectively: myocarditis 51 and 13%; none 45 and 57% and alternated diagnosis 4 and 30%. The biopsy-based and the noninvasive etiology diagnosis work-up led to a diagnosis in 25 and 47% cases respectively. The biopsy-based and the noninvasive diagnosis work-up results in a therapeutical modification in 13 and 19% patients respectively (Fig. 1). Among the 6 patients whose biopsy led to a treatment change, 2 survived to hospital discharge, including one whose etiological diagnosis was also given by the noninvasive work-up.

Conclusion: Myocardial biopsy in patients with acute heart failure of unknown etiology requiring ECLS has low diagnostic yield and therapeutical consequences and is associated with significant adverse events. The benefit/risk ratio of this procedure should be carefully weighted in these patients.

Compliance with ethics regulations: Yes in clinical research.

figure bg

Figure 1. Diagnosis and therapeutic consequences according biopsy-based or noninvasive diagnosis work-up

FC-031 Stent thrombosis in cardiac arrest patients: prevalence, risk factors and long-term outcome

BOIS Antoine1

1Hôpital Henri Mondor, Villejuif, France
Correspondence: Antoine BOIS (antoinebois01@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-031

Rationale: Ischemic heart disease is the leading cause of cardiac arrest (CA) and stent thrombosis (ST) is ten times more frequent when acute coronary syndrome is initially associated with CA. Data are missing about impact and risk factors of this complication.

Patients and Methods/Materials and Methods: We conducted a monocenter and retrospective study from January 2010 to September 2019 including all patients hospitalized after a CA who were treated by stent andhad a second coronary angiography in the 3 following months. Demographics and characteristics of patient care were compared according to ST. Long-term follow-up was provided using the French National Healthcare Insurance database.

Results: 22 patients met the inclusion criteria during the study period. The incidence of ST was 50%. Stent length was associated with ST occurrence (26.8 mm vs 17.0 mm, p = 0.023), whereas there was no significant difference on age, gender, coronary lesion features, type of stent or drugs used. Long-term follow-up of 7 patients, including 6 cases of ST, revealed no major adverse cardiac event.

Conclusion: Stent thrombosis is a frequent complication after CA and appears to be associated to stent’s length. Larger prospective studies, are needed to define the prognosis and risk factors of ST.

Compliance with ethics regulations: Yes in clinical research.

figure bh

Kaplan–Meier plot of probability of MACE occurrence according to the presence of ST

FC-032 SSEP N20 and P25 amplitudes predict poor and good neurologic outcomes after cardiac arrest

BENGHANEM Sarah1,2, NGUYEN Lee Son1, GAVARET Martine2, MIRA Jean Paul1, PENE Frederic1, CHARPENTIER Julien1, MARCHI Angela2, CARIOU Alain1

1Hôpital Cochin APHP, Paris, France; 2Unité INSERM 1266 Institut de Psychiatrie et Neurosciences Paris IPNP, Hopital Sainte Anne, Paris, France
Correspondence: Sarah BENGHANEM (sarah.benghanem@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-032

Rationale: Background: To assess in comatose patients after cardiac arrest (CA) if amplitudes of two somatosensory evoked potentials (SSEP) responses, namely N20-baseline (N20-b) and N20-P25, are predictive of neurological outcome.

Patients and methods/Materials and Methods: Methods: Monocenterand prospective study in a tertiary cardiac center between November 2019 and July 2021. All patients comatose at 72 h after CA with at least one SSEP recorded were included. The N20-b and N20-P25 amplitudes were automatically measured in microvolts (µV), along with other recommended prognostic markers (status myoclonus, neuron-specific enolase levels at 2 and 3 days, and EEG pattern). We assessed the predictive value of SSEP for neurologic outcome using the best Cerebral Performance Categories (CPC 1 or 2 as good outcome) at 3 months (main endpoint) and 6 months (secondary endpoint). Specificity and sensitivity of different thresholds of SSEP amplitudes, alone or in combination with other prognostic markers, were calculated.

Results: Results: Among 82 patients, a poor outcome (CPC 3-5) was observed in 78% of patients at 3 months. The median time to SSEP recording was 3(2–4) days after CA, with a pattern “bilaterally absent” in 19 patients, “unilaterally present” in 4, and “bilaterally present” in 59 patients. The median N20-b amplitudes were different between patients with poor and good outcomes, i.e., 0.93 [0–2.05] µV vs 1.56 [1.24–2.75] µV respectively (p < 0.0001), as the median N20-P25 amplitudes (0.57 [0–1.43] µV in poor outcome vs 2.64 [1.39–3.80] µV in good outcome patients p < 0.0001). A N20-b > 2 µV predicted good outcome with a specificity of 73% and a moderate sensitivity of 39%, although a N20-P25 > 3.2 µV was 93% specific and only 30% sensitive. A low voltage N20-b < 0.88 µV and N20-P25 < 1 µV predicted poor outcome with a high specificity (specificity of 94% and 93% respectively) and a moderate sensitivity (sensitivity of 50% and 66% respectively). Association of “bilaterally absent or low voltage SSEP” patterns increased the sensitivity significantly as compared to “bilaterally absent” SSEP alone (58 vs 30%, p = 0.002) for prediction of poor outcome.

Conclusion: Conclusion: In comatose patient after CA, both N20-b and N20-P25 amplitudes could predict both good and poor outcomes with high specificity but low sensitivity. Our results suggest that SSEP amplitudes are inversely related to the severity of neurological injury, although this indicator should be combined with other indicators in a multimodal approach for prognostication.

Reference 1: Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021;47:369–421.

Reference 2: Scarpino M, Lolli F, Lanzo G, Carrai R, Spalletti M, Valzania F, et al. SSEP amplitude accurately predicts both good and poor neurological outcome early after cardiac arrest; a post-hoc analysis of the ProNeCA multicentre study. Resuscitation 2021;163:162

Compliance with ethics regulations: Yes in clinical research.

figure bi

In a normal SSEP (panel 1), the channels show the cortical responses N20 and P25, the spinal component (N13) and the peripheral component (N9). In the panel 2, N20 and P25 were presented but amplitudes were reduced. In the panel 3, N20 and P25 were absent

FC-033 Head-up position reduces intra-cranial pressure during extracorporeal resuscitation following refractory cardiac arrest in swine

LEVY Yael1, HUTIN Alice2, POLGE Nicolas3, LIDOUREN Fanny3, FERNANDEZ Rocio3, KOHLHAUER Matthias3, LEGER Pierre-Louis1, DEBATY Guillaume4, LURIE Keith5, LAMHAUT Lionel2, GHALEH Bijan3, TISSIER Renaud3

1CHU Armand Trousseau, Paris, France; 2CHU Necker, Paris, France; 3Ecole Nationale Vétérinaire d’Alfort, Maison-Alfort, France; 4CHU de Grenoble, Grenoble, France; 5Hennepin Healthcare Research Institute, Minneapolis, Etats-Unis
Correspondence: Yael LEVY (yael.levy@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-033

Rationale: Head-up position was shown to mitigate cerebral alterations and improve cerebral perfusion pressure during conventional cardiopulmonary resuscitation. Since extracorporeal cardiopulmonary resuscitation (E-CPR) is more and more used for the management of refractory cardiac arrest, we aimed at determining whether head-up position could also modify cerebral hemodynamics during E-CPR. Accordingly, we compared this hemodynamics in swine submitted to E-CPR in flat position as compared to head position (head-up position at 30 °C). Hypothesis: Our goal was to determine whether a standardized head-up could improve intracranial pressure (ICP) and cerebral autoregulation during E-CPR in a swine model of cardiac arrest.

Patients and methods/Materials and methods: Pigs were anesthetized and instrumented for the continuous evaluation of carotid blood flow, intracranial pressure (ICP), cerebral perfusion pressure, pressure reactivity index (PRx) and systemic hemodynamics. They were submitted to 15 min of untreated ventricular fibrillation followed by 30 min of E-CPR. Defibrillations were then delivered until resumption of spontaneous circulation (ROSC). Extracorporeal circulation was initially set to an average flow of 40 ml/kg/min. Epinephrine was delivered to achieve a mean arterial pressure ≥ 65 mmHg. An automated head-up position device (over two minutes, 30°) was used in head-up group. Animals were followed during 120-min after ROSC.

Results: Six animals were included in both groups. Cerebral hemodynamic parameters are illustrated in Figure. During E-CPR and ROSC, ICP decreased in head-up vs flat position and cerebral perfusion pressure tended to be improved at the end of the follow-up (NS). Cerebral oxygen saturation, carotid blood flow and PRx, which is the correlation coefficient between arterial blood pressure and ICP, were not different among groups.

Conclusion: During E-CPR, head-up is associated with lower ICP with a trend toward higher cerebral perfusion pressure. This study supports the need for further investigations to confirm that the early decrease in ICP could be associated with an improvement in neurological outcome after E-CPR.

Compliance with ethics regulations: Yes in animal testing.

figure bj

Cerebral hemodynamic parameters after cardiac arrest

FC-034 Targeted temperature management after in-hospital cardiac arrest: an ancillary analysis of hyperion trial data

BLANC Alexiane1, COLIN Gwenhaël2, CARIOU Alain3,4, MERDJI Hamid5,6, GRILLET Guillaume7, GIRARDIE Patrick8, COUPEZ Elisabeth9, DEQUIN Pierre-François10,11, BOULAIN Thierry12, FRAT Jean-Pierre13,14,15, ASFAR Pierre16, PICHON Nicolas17,18, LANDAIS Mickael19, PLANTEFEVE Gaëtan20, QUENOT Jean-Pierre21, CHAKARIAN Jean-Charles22, SIRODOT Michel23, LEGRIEL Stéphane24, MASSART Nicolas25, THEVENIN Didier26, DESACHY Arnaud27, DELAHAYE Arnaud28, BOTOC Vlad29, VIMEUX Sylvie30, MARTINO Frederic31, REIGNIER Jean1, TACCONE Fabio Silvio32, LASCARROU Jean-Baptiste1,3

1Centre Hospitalier Universitaire de Nantes, Médecine intensive réanimation, Nantes, France; 2Centre Hospitalier Départemental de La Roche-sur-Yon, La Roche-Sur-Yon, France; 3Centre de recherche cardiovasculaire INSERM U970, Paris, France; 4Centre Hospitalier Universitaire de Cochin, Médecine intensive réanimation, Paris, France; 5Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Médecine intensive réanimation, Strasbourg, France; 6Fédération de Médecine Translationnelle de Strasbourg UMR 1260, Strasbourg, France; 7Centre hospitalier de Bretagne sud Lorient, Médecine intensive réanimation, Lorient, France; 8Centre Hospitalier Universitaire de Lille, Médecine intensive réanimation, Lille, France; 9Centre Hospitalier Universitaire de Clermont-Ferrand, Médecine intensive réanimation, Clermont-Ferrand, France; 10Centre Hospitalier Universitaire de Tours, Médecine intensive réanimation, Tours, France; 11Centre d’Étude des Pathologies Respiratoires, Université de Tours, Tours, France; 12Centre Hospitalier Régional d'Orléans, Médecine intensive réanimation, Orléans, France; 13Centre Hospitalier Universitaire de Poitiers, Médecine intensive réanimation, Poitiers, France; 14INSERM, CIC-1402, Poitiers, France; 15Faculté de Médecine et de Pharmacie de l'Université de Poitiers, Poitiers, France; 16Centre Hospitalier Universitaire d'Angers, Médecine intensive réanimation, Angers, France; 17Centre Hospitalier Universitaire de Limoges, Service de Réanimation Polyvalente, Limoges, France; 18Centre Hospitalier Universitaire de Limoges, CIC 1435, Limoges, France; 19Centre Hospitalier du Mans, Service de réanimation, Le Mans, France; 20Centre Hospitalier d'Argenteuil, Service de réanimation, Argenteuil, France; 21Centre Hospitalier Universitaire de Dijon, Médecine intensive réanimation, Dijon, France; 22Centre Hospitalier de Roanne, Service de réanimation, Roanne, France; 23Centre Hospitalier d'Annecy, Service de réanimation, Annecy, France; 24Centre Hospitalier de Versailles, Service de réanimation, Versailles, France; 25Centre Hospitalier de Saint Brieuc, Service de réanimation, Saint Brieuc, France; 26Centre Hospitalier de Lens, Service de réanimation, Lens, France; 27Centre Hospitalier d'Angoulême, Service de réanimation, Angoulême, France; 28Centre Hospitalier de Rodez, Service de réanimation, Rodez, France; 29Centre Hospitalier de Saint Malo, Service de réanimation, Saint Malo, France; 30Centre Hospitalier de Montauban, Service de réanimation, Montauban, France; 31Centre Hospitalier Universitaire de Pointe-à-Pitre, Médecine intensive réanimation, Pointe-À-Pitre, France; 32Centre Hospitalier Universitaire Erasmus, Université de Bruxelles, Bruxelles, Belgique
Correspondence: Alexiane BLANC (alexiane.blanc@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-034

Rationale: Targeted temperature management (TTM) is currently the only treatment with demonstrated efficacy in attenuating the harmful effects on the brain of ischemia-reperfusion injury after cardiac arrest. However, whether TTM is beneficial in the subset of patients with in-hospital cardiac arrest remains unclear. Is hypothermia at 33 °C associated with better neurological outcomes after in-hospital cardiac arrest in a non-shockable rhythm, compared to targeted normothermia at 37 °C?

Patients and methods/Materials and methods: We performed a post hoc analysis of data from the published Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm (HYPERION) randomized controlled trial in 584 patients. We included the 159 patients with in-hospital cardiac arrest; 73 were randomized to 33 °C and 86 to 37 °C. The primary outcome was survival with a good neurological outcome (Cerebral Performance Category [CPC] score 1 or 2) at day 90. Mixed multivariable adjusted logistic regression analysis was performed to determine whether survival with CPC 1 or 2 on day 90 was associated with type of temperature management after adjustment on baseline characteristics not balanced by randomization.

Results: Compared to targeted normothermia for 48 h, hypothermia at 33 °C for 24 h was associated with a higher percentage of patients who were alive with good neurological outcomes at day 90 (16.4% vs. 5.8%; P = 0.03). Day-90 mortality was not significantly different between the two groups (68.5% vs. 76.7%; P = 0.24). By mixed multivariable analysis adjusted on the CAHP score and circulatory shock, hypothermia was significantly associated with good day-90 neurological outcomes (2.40 [1.17;13.03]; P = 0.03).

Conclusion: Hypothermia at 33 °C was associated with better day-90 neurological outcomes after in-hospital cardiac arrest in a non-shockable rhythm, compared to targeted normothermia. However, our limited sample size resulted in wide confidence intervals. Further studies of patients after cardiac arrest from any cause, including in-hospital cardiac arrest, are needed.

Compliance with ethics regulations: Yes in clinical research.

FC-035 Impact of Methylene Blue for post resuscitation syndrome in a pig model of refractory cardiac arrest resuscitated with veno-arterial ECMO

PEQUIGNOT Benjamin1, LESCROART Mickael 1, ALBUISSON Eliane1, ORLOWSKI Sophie1, PINA Héloise1, TRAN Nguyen 1, GRANDMOUGIN Daniel1, LEVY Bruno1

1CHRU de Nancy, Vandœuvre-Lès-Nancy, France
Correspondence: Benjamin PEQUIGNOT (b.pequignot@chru-nancy.fr)

Annals of Intensive Care 2022, 12(1):FC-035

Rationale: Selected patients with a refractory cardiac arrest could benefit from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as rescue with good prognosis. Circulatory flow recovery with ECMO is associated with vasoplegia and vasopressor need. The aim of the present work is to assess the interest of Methylene Blue perfusion in a pig model of ischemic refractory cardiac arrest implanted by VA-ECMO.

Patients and methods/Materials and methods: Ischemic refractory cardiac arrest was performed in 20 pigs. After a low flow period of 30 min, VA-ECMO was initiated and pigs were randomly assigned to standard care group (norepinephrine + crystalloids) or methylene blue group (IV methylene blue + standard care). Macrocirculatory and metabolic parameters were assessed by lactate clearance. Microcirculatory parameters were assessed by sublingual microcirculation with Sidestream Dark Field (SDF). Pulmonary oedema was evaluated by measuring lung wet/dry weight ratio. Severity of ischemic digestive lesions were assessed by Chiu/Park scale.

Results: 18 pigs were included in statistical analyses. There was no significant difference between the groups with regard to lactate clearance levels (29.16 [12.5–39.32], 46.10 [22.61–64.54] % for control and methylene blue group). There was no significant difference between the groups regarding sublingual capillary microvascular parameters assessed by SDF. Total crystalloid load was significantly reduced with Methylene Blue infusion (5000 [6000–8000] mL vs. 17000 [10000–19000] mL p = 0.007, Methylene Blue versus control group). Methylene blue infusion significantly reduced catecholamine requirements (0.31 [0.14–0.44] μg.kg1.min−1 vs. 2.32 [1.17–5.55] μg.kg1.min−1, methylene blue versus control group p = 0.004). The was not difference in Chiu/Park scale and Lung wet/dry weight ratio between groups.

Discussion: The main result of this study is that in an experimental pig model of refractory cardiac arrest resuscitated with veno-arterial ECMO, the use of methylene blue infusion was not associated with a faster lactate clearance. Importantly, the adjunction of methylene blue was associated with sharp reduction of crystalloid fluid load and catecholamine perfusion. There were also some limitations: no return of spontaneous circulation was achieved for any animal of the experiment. The study time over a 6-h period represents a major limitation as it could be mis-scaled to assess benefits and drawbacks of catecholamine or fluid restriction.

Conclusion: Methylene blue infusion was efficient for catecholamine and fluid restriction respectively but failed to improve lactate clearance in a pig model of post resuscitation syndrome after refractory cardiac arrest treated with VA-ECMO.

Compliance with ethics regulations: Yes in animal testing.

figure bk

Lactate clairance, Volume and cathecolamine dose between groups

FC-036 Right ventricular changes before and after veno-venous ECMO implantation in refractory COVID-19 ARDS

LÉVY David1, DESNOS Cyrielle1,3, THÉRY Guillaume1,2, SCHMIDT Matthieu1, BRECHOT Nicolas1, PINETON DE CHAMBRUN Marc1, CHOMMELOUX Juliette1, COMBES Alain1, HEKIMIAN Guillaume1

1Pitié-Salpêtrière, Paris, France; 2CHU de Reims, Reims, France; 3Hôpital Tenon, Paris, France
Correspondence: David LEVY (dlevy88@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-036

Rationale: Right ventricular (RV) failure is a common complication during acute respiratory distress syndrome (ARDS). Veno-venous ECMO (VV-ECMO) is considered in refractory ARDS and might be responsible for RV function changes. Our objective was to describe RV function before and after VV-ECMO course in refractory ARDS COVID-19 patients.

Patients and methods/Materials and methods: This retrospective observational single-center study was performed between April 2020 and April 2021. Patients included were refractory ARDS secondary to SARS-CoV-2 infection and required VV-ECMO according to EOLIA criteria. Patients underwent serial echocardiographic examinations (Philips, CX-50) before and after VV-ECMO implantation.

Results: 15 patients were included. Median age was 54 years (46–62), 9/15 (60%) were male. Before ECMO cannulation, median PaO2/FiO2 was 60 (56–72) mmHg, delay between ventilation and cannulation was 6 (4–11) days. SAPS-II at cannulation was 46 (30–55). Inhaled nitric oxide and norepinephrine were used in 8/15 patients (53.3%) before ECMO. Fractional area change of RV (FAC-RV) was greater after ECMO implantation, (36 [20–44] % before ECMO, 42 [35–45] % at day 1 and 42 [40–46] % at day 3, p = 0.008). Estimated systolic pulmonary pressure (sPAP) decreased over time (47 [40–55] mmHg before, 40 [36.3–40.1] mmHg at day 1 and 37 [34–45] mmHg at day 3, p = 0.048). PCO2 was higher before ECMO implantation (56 [49–63] mmHg versus 44 [39–47] mmHg at day 1 and 41 [39–44] mmHg at day 3, p = 0.001). FAC-RV/sPAP increased after ECMO cannulation (0.68 [0.31–0.97] before vs. 1 [0.74–1.2] at day 1 and 1.1 [0.96–1.3] at day 3, p = 0.027). Tricuspid valve systolic velocity (S’ wave) and TAPSE were similar before and after ECMO implantation (S’wave, 17 [13–20] vs. 15 [12–20] cm/sec at day 1 and 14 [11–26] cm/sec at day 3, p = 0.28; TAPSE, 21 [19–27] mm before ECMO, 21 [17–26.5] mm at day 1 and 23 [19–25] mm at day 3, p = 0.44). Arterial blood lactate level decreased after cannulation (2 [1.6–2] mmol/L before vs. 1.7 [1.5–2.3] mmol/L at day 1 and 1.6 [1.6 1–1.7] mmol/L at day 3, p = 0.006). Also, inotropic score tended to be lower (40.7 [24.5–75.8] before ECMO vs. 4.9 [0–20.8] at day 1 and 0 at day 3, p = 0.05). Median time of VV-ECMO course was 20 (15–41) days and 7/15 (46.6%) were alive at ICU discharge.

Conclusion: Based on this small-sample study in refractory ARDS, VV-ECMO could be responsible for RV systolic function improvements while decreasing sPAP, and could provide hemodynamic stability through right ventricular-pulmonary artery coupling.

Compliance with ethics regulations: Yes in clinical research.

figure bl

Right ventricular metrics and hemodynamic changes before and after VV-ECMO implantation

FC-037 Interest of albumin infusion for post resuscitation syndrome in a porcine model of refractory cardiac arrest resuscitated with veno-arterial ECMO

LESCROART Mickael1,2, PEQUIGNOT Benjamin1,2, GRANDMOUGIN Daniel1,2, TRAN N’Guyen2, ALBUISSON Eliane1, LEVY Bruno1,2

1CHRU Nancy, Vandoeuvre, France; 2Université de Lorraine, Nancy, France
Correspondence: Mickael LESCROART (dr.lescroart@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-037

Rationale: Hemodynamic instability is common in post resuscitation syndrome and could worsen survival and neurological outcomes. The myocardial and vascular dysfunction may be exacerbated by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implanted as a rescue therapy for refractory cardiac arrest. Standard care of haemodynamic management after VA-ECMO initiation are based on norepinephrine and crystalloids. The aim of the present work is to assess the interest on haemodynamics of albumin perfusion in a swine model of ischemic refractory cardiac arrest implanted by VA-ECMO.

Patients and methods/Materials and methods: Ischemic refractory cardiac arrest was performed in 20 pigs. After a low flow period of 30 min, VA-ECMO was initiated and pigs were randomly assigned to standard care group (norepinephrine + crystalloids) or albumin group (10 ml/kg of 20% albumin + standard care). Hemodynamical assessment was performed over the 6 h of the experiment

Results: 18 pigs were included in statistical analyses. There was no significant difference between groups with regard to lactate clearance (29.16% [12.5–39.32] and 10.09% [6.78–29.36] for control and albumin group respectively). Blood albumin concentration rapidly decreased after ECMO priming in the sham group while it remained stable in the albumin group. Total crystalloid load was significantly reduced with albumin infusion (1000 [1000–2278] mL vs. 17000 [10000–19000] mL, albumin versus control group respectively, p < 0.001).

Conclusion: This is the first study assessing albumin for fluid resuscitation in post resuscitation syndrome rescued by VA-ECMO. Albumin infusion did not improve lactate clearance but was highly efficient to reduce fluid loading in a porcine model of post resuscitation syndrome after refractory cardiac arrest treated with VA-ECMO.

Compliance with ethics regulations: Yes in animal testing.

figure bm

Panel A: experimental protocol. Panel B: albumin concentration over time (in hours). Panel C: Lactate clearance 6 h after initial resuscitation. Panel D: fluid loading over a 6 h resuscitation. ALB: albumin group. CTL: control group.

FC-038 Clinical characteristic, injuries pattern and management of pediatric polytraumatized patients: an experience of an emergency departement

MALLEK Mariam1, KARRAY Rim1, BEN ALI Hana1, ZOUARI Alaeddine1, BEN SALEM Imen1, KSENTINI Hana1, NASRI Abdennour1, CHAKROUN Olfa1, REKIK Noureddine1

1Service des Urgences et SAMU 04 CHU Habib Bourguiba Sfax Tunisie, Sfax, Tunisie
Correspondence: Rim KARRAY (karray_rim@medecinesfax.org)

Annals of Intensive Care 2022, 12(1):FC-038

Rationale: Caring for pediatric trauma patient requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared with adult. As a result, the degree of awarning towards polytraumatized children must be higher. The aim of our study is to identify clinical and therapeutic aspects of pediatric polytraumatized patients.

Patients and methods/Materials and methods: A 5-month prospective study including polytraumatized children admitted to ICU of Emergency Department. Demographic clinical and radiological data are described. Management and outcomes of patients are also reported.

Results: We enrolled 20 pediatric polytraumatized patients. Fifty percent of them were boys. Road traffic was the main cause of pediatric trauma in 75% of cases. Half of the polytraumatized patients were conscious and 20% of children had a severe traumatic brain injury with a Glasgow coma scale under 8. In the majority of cases, pupils were normodilated. Convulsion and agitation were reported in 15% of patients. The most frequent brain injury was brain contusion in 55% of cases. Extradural, subdural hematoma and subarachnoid hemorrhage were present in 25% of cases. Chest trauma was present in 40% of cases and the main chest injury was thoracic contusion in 35% of cases. One in four children had an abdominal trauma with abdominal hemorrhage in 15% of cases, hepatic contusion in 10% and splenic contusion in 5% of cases. Pelvic fracture was present in 15% of cases. Airway management was performed in 35% of cases for neurological distress. Fluid administration was performed only in 15% of cases and transfusion in 30% of cases. A brain surgery was necessary in 20% of patients. No children died and only 10% referred to home after a stay in the emergency department. Overall, 85% of patients were transferred: 30% to the intensive care unit, 40% to neurosurgery service and 10% to a surgical pediatric unit.

Conclusion: Trauma is the cause of more than 45% of deaths in children aged 1 to 14 years. Since multiple injuries are common in children, the emergency physician must assess all organs of a child with high-energy injuries, regardless of the mechanism of the trauma.

Compliance with ethics regulations: Yes in clinical research.

FC-039 Impact of pre-hospital intubation on the outcome of polytraumatic patients

MALLEK Mariam1, KARRAY Rim1, BEN ALI Hana1, MZOUGHI Faten1, BEN SALEM Imen1, CHAARI Leila1, CHAKROUN Olfa1, CHAARI Adel1, REKIK Noureddine1

1service des Urgences et SAMU 04 CHU Habib Bourguiba Sfax Tunisie, Sfax, Tunisie
Correspondence: Rim KARRAY (karray_rim@medecinesfax.org)

Annals of Intensive Care 2022, 12(1):FC-039

Rationale: Polytrauma is a leading cause of mortality and disability all over the world. Respiratory, hemodynamic and neurological distress are very frequent and correlated with high mortality. Therefore, an early energetic therapy controlling these distresses, by pharmacological methods and airway management can improve the outcome of polytraumatized patients. The aim of our study is to evaluate the impact of an early airway management on patient prognosis of patient in terms of length of stay in emergency department, mortality and neurological outcomes.

Patients and methods/Materials and methods: In this prospective study, only intubated patients were enrolled. The enrolled patients were randomly assigned into two groups: group A: intubated in prehospital phase and group B: intubated in hospital phase. Basic characteristics of injury, length of stay in emergency department, mortality and neurological outcomes according to the GOS score at one month (GOS1: death, GOS2: vegetative state, GOS3: severe state, GOS4: moderate state, GOS5: good recovery) lwere compared.

Results: During the study period, we enrolled 116 polytraumatized patients and 54 patients were intubated. The main indication of airway management was coma with a Glasgow coma scale < 8 in almost half of the population and cardiac arrest in 12% of cases. Seven percent and 3% of patients were intubated for hemodynamic and respiratory distress respectively. The two groups did not differ regarding to injury severity assessed by the ‘Injury severity score’ (p < 0.001). The mean length of stay in the emergency department was 23 ± 2 h in group B vs 20 ± 2 h in group A. There was no difference iin terms of transfer to an intensive care between the two groups (94% in each group). Two patients (10%) in group A and six patients (17%) in group B died. There was no difference in terms of neurological outcome: in Group A, 55% of patients had a GOS 5, 20% a GOS 3 and10% a GOS 2. In Group B, 40% of patients had a GOS 5,18% a GOS 3 and 12% a GOS 2 (p > 0.05 for each one).

Conclusion: Prehospital intubation reduces the length of stay in emergency department and mortality but has no influence on the orientation of patient or on their neurological evolution. However, ambulance practitioner should be familiar with airway management and should be trained in such a challenging treatment that could worsen the prognosis of polytraumatized patients if not performed correctly.

Compliance with ethics regulations: Yes in clinical research.

FC-040 Chest trauma in children: a monocenter study

CHAARI Zied1, BEN AYED Aymen1, KAMMOUN Jaweher1, ABID Walid1, BEN AYED Ahmed1, HENTATI Abdessalem1, FRIKHA Imed1

1Université de Sfax - CHU Habib Bourguiba, Sfax, Tunisie
Correspondence: Zied CHAARI (chaari.zied1@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-040

Rationale: Children are vulnerable to injuries most often occurring following a road accident. As part of polytrauma, pediatric thoracic trauma often requires special care.

Patients and methods/Materials and methods: This is a retrospective and analytical study including all children aged under 17 years of age, victims of thoracic trauma (whether open or closed), and hospitalized in our department (after or without admission in intensive care or pediatric resuscitation unit) between January 2015 and December 2021.

Results: During the study period, 25 children were admitted to our department following severe chest trauma with an average age of 9.7 ± 5.3 years (2–16 years) and a male predominance (88%). Road accidents (48%), domestic accidents (28%), and assaults (16%) were the most frequently reported circumstances. Seven children (28%) presented a penetrating thoracic trauma including 2 (28%) of ballistic origin. The most common lesions were pneumothorax (44%), cerebral contusions (43%), pulmonary contusions (40%), intra-abdominal lesions (36%), rib fractures (32%), pneumothorax (20%) and pneumomediastinum (12%). Cranial, peripheral, or pelvic fractures were associated in 28%, 16%, and 4% of patients respectively. The median length of stay in our service was 2 days (1-38 days). Urgent surgery was necessary for 6 children (24%) divided into 2 abdominal, 2 pulmonary, one pleural, and one cardiac surgery. The follow-up was favorable for the majority of patients (60%). Complications were mainly observed in patients who underwent surgery or were intubated for more than 4 days. No deaths were noted in our series.

Conclusion: The management of thoracic trauma in children must be multidisciplinary involving clinicians, emergency physicians, intensivists, as well as surgeons. Associated peripheral and cranial lesions influence the prognosis.

Compliance with ethics regulations: N/A.

FC-041 Value of early thoracic computed tomography in severe blunt chest trauma

BOUGDAL Dalila1, SADAT Souhila1, ZEGHDOUD Dalila1

1Etablissement SalimZemirli, Alger, Algerie
Correspondence: Dalila BOUGDAL (bougdalila@yahoo.fr)

Annals of Intensive Care 2022, 12(1):FC-041

Rationale: Blunt chest trauma is common. Severe chest trauma can be life-threatening immediately or secondarily after a period of apparent calm. The objective of this study is to determine the contribution of early injury assessment to the morbidity and mortality of patients with severe blunt chest trauma.

Patients and methods/Materials and methods: prospective, observational study including 90 patients with severe blunt chest trauma, hospitalized in the ICU during the period March 2015–March 2017. We studied the lesion mechanism, the severity scores, we collected the pleuro-pulmonary lesions, their treatment and the future of the patients. We noted the hourly delays between the accident and the realization of the thoracic computed tomography (CT), as well as the delay between the admission to the hospital and the realization of the thoracic CT. We investigated the impact of thoracic CT on morbidity and mortality. The data were entered with the EPIINFO 7 software and analyzed using the SPSS statistics 23 software. The statistical tests are significant from p ≤ 0.05

Results: The mean age of the patients was 33.6 ± 17.9 years with a male predominance (sex-ratio = 4M/1F). 98.8% were polytraumatized. The mean ISS score was 34.5 ± 8.9; 68% of patients arrived with at least one vital distress. The delay between the thoracic radiological assessment and the time of the accident was less than 6 h in 73% of the patients. Furthermore, early assessment of injuries improved mortality (p = 0.02).

Conclusion: Early thoracic CT in severe blunt chest trauma allows an exhaustive diagnosis of thoracic lesions and improves mortality.

Keywords: Severe blunt chest trauma, Early chest CT.

Compliance with ethics regulations: N/A.

FC-042 Flail chest: what are the associated morbidity and mortality risk factors?

CHAARI Zied1, BEN AYED Aymen1, KAMMOUN Jaweher1, BEN AYED Ahmed1, ABID Walid1, HENTATI Abdessalem1, FRIKHA Imed1

1Université de Sfax - CHU Habib Bourguiba, Sfax, Tunisie
Correspondence: Zied CHAARI (chaari.zied1@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-042

Rationale: Rib fractures are frequently observed in patients with chest or multiple trauma. Flail chest represents a particular entity in terms of prognosis and management. Rare are the studies that have focused on the search for morbidity and mortality associated factors for patients with traumatic flail chest.

Patients and methods/Materials and methods: This was a retrospective and analytical study including all patients hospitalized in our department for a flail chest (with or without going through an intensive care or resuscitation unit) between January 1987 and December 2021.

Results: During the study period, 2342 patients were admitted to our department for chest trauma including 159 patients with confirmed flail chest (7%). The mean age was 53 ± 16 years (11–90 years) and a male predominance was noted (sex ratio = 6.22). The mean number of rib fractures was 12.9 ± 4.9 fractures (6–22 fractures). An intensive care unit hospitalization was necessary for 66% of patients. Conservative treatment (thoracic drainage, analgesia, nebulization and respiratory physiotherapy) was performed in the majority of cases (95%), and surgical treatment was necessary for only 8 patients (5%). During hospital stay we have reported complications for 56 patients (35%) and 7 patients died (hospital mortality of 4%). The mean injury severity score (ISS) was 20 (13–50). The factors associated with high morbidity rates were: ISS score > 25, hospitalization in intensive care unit, the need for intubation, and length of hospitalization > 7 days. For all possible mortality-studied factors, only an ISS score > 25 was associated with an increase in mortality rates.

Conclusion: Flail chest are associated with several factors influencing vital prognosis, as well as post-traumatic consequences during hospital or intensive care unit stays. A good knowledge of these factors would make it possible to better manage patients and improve subsequent follow-up.

Compliance with ethics regulations: N/A.

FC-043 Antivenoms to treat Bothrops genus snakebite envenoming in the French Territories in the Americas: comparative experimental studies

FLORENTIN Jonathan, RESIERE Dabor1, KALLEL Hatem2, FLORENTIN Jonathan1, GUTIÉRREZ José Maria3, MEHDAOUI Hossein1, NEVIERE Remi4, MEGARBANE Bruno5

1Critical Care Unit, University Hospital of Martinique (French West Indies), Fort-De-France, Martinique; 2Intensive Care Unit, Cayenne General Hospital, Cayenne, Guyana; 3Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica; 4Department of cardiovascular surgery, University Hospital of Martinique, Fort-De-France, Martinique; 5Department of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris University, INSERM UMRS1144, Paris, France
Correspondence: Dabor RESIERE (dabor.resiere@chu-martinique.fr)

Annals of Intensive Care 2022, 12(1):FC-043

Rationale: In the French Territories in the Americas, Bothrops snakebite envenoming represent a public health issue. In Martinique, Bothrops lanceolatus is the only snake responsible for envenoming with thrombotic complications. In French Guiana, Bothrops atrox is responsible for most envenomings. The first antivenom specific to Bothrops lanceolatus, Bothrofav®1, produced in 1991, reduced complications. However, in 2004, an upsurge in cases of ischemic stroke despite early antivenom infusion, suggested a decline in its effectiveness. A new antivenom, Bothrofav®2 was produced in 2011 and manufactured in France. However, its marketing should be stopped in 2022. Polival-ICP® (manufactured in Costa Rica) and Antivipmyn Tri® (manufactured in Mexico) are successfully used to treat Bothrops atrox envenoming in French Guiana. We compared the effectiveness of all three antivenoms on Bothrops lanceolatus and B. atrox venoms using an experimental bench protocol.

Patients and methods/Materials and methods: We conducted third-generation antivenomics quantitative analyses, in vivo mouse and in vitro assays comparing Bothrofav®2, Polival-ICP® and Antivipmyn Tri® on Bothrops lanceolatus and B. atrox venoms.

Results: Bothrofav®2 immunocaptured all major Bothrops lanceolatus venom protein components, underscoring its high neutralizing efficacy (Table 1). Our in vivo and in vitro assays demonstrated its effectiveness in the neutralization of lethal, local and systemic haemorrhagic, oedema forming, myotoxic, thrombocytopenic, proteinase and phospholipase A2 activities, showing a higher preclinical efficacy as compared to previous batch used in the past. Regarding the neutralization of B. atrox venom, Polival-ICP® has higher neutralizing activity than Antivipmyn Tri® against lethal, haemorrhagic and in vitro coagulant activities. Antivipmyn Tri® and Polival-ICP® antivenoms similarly neutralized the venom-induced myotoxic effects of B. atrox venom, while Antivipmyn Tri® did not neutralize the lethal activity at the highest antivenom level tested.

Conclusion: Based on preclinical investigations, Bothrofav2® was highly effective in the neutralization of the venom of B. lanceolatus, whereas Polival-ICP® and Antivipmyn Tri® neutralized the venom of B. atrox, albeit with different efficacies.

Compliance with ethics regulations: Yes in animal testing.

FC-044 Association between healthcare trajectories before critical illness and 1-year survival among elderly patients hospitalized in ICU for acute respiratory infection—To predict the future, you need to know the past

TCHATAT WANGUEU Lionel1, GABORIT Christophe1, LAURENT Emeline1, GRAMMATICO-GUILLON Leslie1, GUILLON Antoine1

1CHRU Tours, Tours, France
Correspondence: Lionel TCHATAT WANGUEU (tchatatlegrand@outlook.fr).

Annals of Intensive Care 2022, 12(1):FC-044

Rationale: Intensive care unit (ICU) hospitalizations of elderly patients with acute respiratory infection (ARI) have increased; however, we observed an important mortality during the ICU stay and in the first year of hospital discharge. Yet many physicians have doubts as to whether elderly patients benefit from ICU admission. Our hypothesis is that healthcare trajectories before critical illness might be used as surrogate of frailty that can be useful for the decision-making. The aim of this study was to assess whether the healthcare trajectories in the 3 months preceding ICU admission were associated with 1-year survival in elderly patients with ARI.

Patients and methods/Materials and methods: A national population-based cohort study was performed from hospital discharge databases (2013–2017) and included ICU patients ≥ 80 years old with an ARI. Patient characteristics were collected as well as ICU procedures and their healthcare trajectories before and after discharge from ICU. Healthcare trajectories before critical illness were evaluated by the number of emergency room visits and the number of cumulative days of hospitalization 3 months before admission in ICU. Mortality refers to mortality at hospital or 1 year after discharge, during the follow-up period. The vital status of patients was assessed during at least 3-year follow-up. Logistic regression was used to find prehospital factors associated with mortality. Odd ratios (OR) and 95% confidence intervals (95% CI) were calculated. Results are in median (IQR).

Results: 40 327 patients aged 80 years or older were hospitalized in ICU for ARI during the studied period. Among them, 35 666 (88%) had a known vital status at 1 year of which 19 379 (54%) died during ICU stay or the first year of discharge. Patient characteristics were: age 84 [82–87] years old, male 19 708 (55.2%), SAPS II 30 [20; 44], invasive mechanical ventilation 9241 (26%). During the 3-month period preceding the ICU-admission, ≥ 1 day of hospitalization or ≥ 1 visit to the emergency room were independently associated with increased 1-year mortality: OR 1.27 [1.19–1.35] and 1.13 [1.06–1.20], respectively. Other independent factors associated with a worse outcome were: age (OR 1.05 [1.04–1.06]), male sex (OR 1.40 [1.34–1.46]), ≥ 3 comorbidities (OR 1.10 [1.03–1.18]) and frailty score ≥ 5 (OR 1.17 [1.11–1.25]).

Conclusion: Healthcare consumption 3 months prior to ICU was associated with 1-year mortality among elderly patients hospitalized for ARI. Healthcare consumption is an objective and easy-to-obtain information that may be used to implement a clinical score designed to help the decision-making for ICU admission of elderly with ARI.

Compliance with ethics regulations: Yes in clinical research.

FC-045 Evaluation of preoperative frailty in cardiac surgery patients using the Edmonton Frail Scale. “Frail heart” study, a preliminary analysis

NTWALI Francis1, MOMENI Mona1, JACQUET Luc1, VANCAENEGEM Olivier1, LATERRE Pierre-François1, DECHAMPS Melanie1

1UCLouvain, Bruxelles, Belgique
Correspondence: Francis NTWALI (francisntwali@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-045

Rationale: Frailty is a state of increased vulnerability to a stressor event, resulting in a poor resolution of homeostasis which increases the risk of adverse outcome. Recent studies have shown association between pre-operative frailty in older patients and mortality after cardiac surgery. The Edmonton Frail Scale (EFS) is a valid, quick to use tool which allows bedside assessment of preoperative frailty without the need of any special training. Frailty is usually assessed for patients aged 65 years and older, but prevalence in younger patients admitted to hospital is significant and is associated with adverse outcome. The primary objective of this study is to assess the association between frailty and intensive care unit (ICU) length-of-stay, hospital discharge after 30 days and one-year mortality in patients undergoing cardiac surgery, independently of age.

Patients and methods/Materials and methods: This is a prospective, monocenter and observational study in a tertiary care academic hospital. The study has been approved by the ethics comity of the hospital and all patients signed an informed consent. Overall, 233 consecutive patients who met the inclusion criteria (18 years old and older undergoing any cardiac surgery under cardiopulmonary bypass) and agreed with the study protocol were included between 25th April 2019 and 24th February 2020 and were evaluated preoperatively by EFS. Exclusion criteria were salvage surgery and patients with cirrhosis CHILD B or C.

Results: 191 (82%) patients were not frail, 42 (18%) were vulnerable or frail. The mean age of the entire cohort was 66.88 ± 12.01 years old. 80 patients were under 65 years old and 10 (12.5%) of them were vulnerable or frail. 153 were 65 years old or more and 32 (20.9%) of them were vulnerable or frail. Functional independence was the frailty domain with the strongest correlation with the overall EFS score. Prealbumin was the biological value with the strongest correlation with frailty (r = − 0.40, p < 0.05). In the non-frail group, 184 patients (96.3%) were discharged at day 30 compared to 34 (80.9%) in the frail group. The mean ICU length of stay was 3.38 ± 2.17 days in the non-frail group and 8.26 ± 14.95 days in the frail group. One year after surgery, 4 (2.3%) patients died in the non-frail group and 7 (21.9%) died in the frail group (p < 0.05).

Conclusion: Frailty significantly affects patients undergoing cardiac surgery, even under the age of 65, and is associated with significantly longer ICU length-of-stay, lower discharge at 30 days and higher one-year mortality.

Compliance with ethics regulations: Yes in clinical research.

figure bn

Results

FC-046 Community peritonitis in the elderly

JARIR Ibtissam1, KHALLEQ Khalid1, BAZA Sanaa1, HARRAR Rachid1, BOUHOURI Mohamed Amine1, HATTABI Khalid1

1CHU IBN ROCHD, Casablanca, Maroc
Correspondence: Ibtissam JARIR (ibtissamjarir30@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-046

Rationale: Community peritonitis in the elderly is a medical-surgical emergency, acquired by the patient in an extra hospital environment. The diagnosis is usually late due to the heterogeneity of clinical signs, this leads to a delay in management. The objective of our study is to evaluate the prognostic factors of an epidemiological, clinical, paraclinical, etiological, therapeutic and evolutionary order of the community peritonitis in the elderly in our context.

Patients and methods/Materials and methods: We conducted an analytical descriptive retrospective study of 50 cases of community peritonitis hospitalized in the surgical emergency resuscitation department over a period from January 2018 to June 2020. All patients over 65 years of age who were admitted for community peritonitis and who received medical and surgical care were included in this study. The parameters studied are demographic data, clinical and paraclinical signs, management and patient evolution. The Statistical analysis was performed using SPSS software, the evaluation of prognostic factors using a univariate and multivariate analysis.

Results: The study showed that the mean age was 70.08 ± 6.07 years, with a sex ratio of 2.12. The medical history was dominated by smoking (38%), the extra-abdominal signs (hemodynamic failure (70%), renal failure (68%), hematological disorders (48%), respiratory disorders (34%) andneurological disorders (32%)). Therapeutic management was based on perioperative resuscitation, treatment of organ failure, probabilistic antibiotic therapy and median laparotomy surgery. The main etiologies of community peritonitis were: peptic ulcer perforation (44%), intestinal perforation (22%), intestinal necrosis (12%), cholecystitis (4%). The bacteriological samples carried out in per operative allowed to have the following bacteriological profile: predominance of Gram-negative bacteria (61%) dominated by E. coli (39%), the average length of hospitalization was 6.32 ± 5.25 days. The mortality rate was 68%. The main prognostic factors identified in our univariate analysis study were: high blood pressure, organ failure, increased gravity scores, site of intervention, duration of intervention, use of catecholamines, development of septic shock, as well as duration of mechanical ventilation and duration of stay in intensive care unit. Multivariate analysis showed a statistically significant association between high blood pressure and the development of hemodynamic failure, creatinine > 13 mg/L, C-reactive protein > 150 mg/L, Occlusion, norepinephrine + epinephrine, duration of ventilation > 2.5 days and mortality.

Conclusion: Community peritonitis in the elderly is a serious condition, fraught with high mortality. The improvement of its prognosis is based on a screening of risk factors, and an updating of medical—surgical protocols.

Compliance with ethics regulations: Yes in clinical research.

FC-047 COVID-19 and elderly population

CHOUCHÈNE Salma1, FATHALLAH Ines1, FAZZENI Hayfa1, MAHMOUD Jihene2, KOURAICHI Nadia1

1Hôpital régional de Ben Arous, Ben Arous, Tunisie; 2hopital Sahloul, Sousse, Tunisie
Correspondence: Salma CHOUCHÈNE (Zamitisalma92@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-047

Rationale: To describe the clinical and prognostic particularities of COVID-19 infection in elderly patients hospitalized for a SARSCOV 2 infection.

Patients and methods/Materials and methods: Descriptive and comparative retrospective study conducted from September 2020 to September 2021. We included all patients admitted to intensive care with a serious SARSCOV2 infection. The infection was confirmed by RT-PCR, a rapid test or a typical chest CT scan. Elderly patients were defined as whom aged over 65 years old.

Results: We included 217 patients, 93 (42%) of whom were elderly subjects. The gender ratio was 1.11. The average IGSII score was 38 ± 14. For the past history, hypertension (56%) was at the top of the list followed by diabetes (43%). Twenty-eight patients were treated at home, 9 of whom required oxygen therapy. The first clinical examination showed anxiety and agitation in 17 (18%) and 18 (19%) patients respectively. Mechanical ventilation (MV) was used in 55 patients (59%) with prone positioning in 41 of cases (44%). Acute renal failure was noted in 46 (51%) patients and six (7%) patients required dialysis. Forty-one patients presented septic shock, 10 trophic disorders and five resuscitation delirium. The median durations of MV and intensive care unit (ICU) stay were respectively 7 [2;14] and 10 [6;16] days. The overall mortality was 53%. In the young population, more agitation (p = 0.033) and anxiety (p = 0.04) were noted with a longer duration of ventilation (11 vs 7 days (p = 0.004)). Elderly subjects were more severe on admission [IGSII score 37 vs 29 (p < 0.001)] and they developed more acute renal failure (51 vs 28%. (p < 0.001)). There was no significant difference between the two groups (old and young subjects) in terms of intubation time and mortality.

Conclusion: The elderly population was more severe on admission and the ICU stay was complicated by more acute renal failure. There was no difference in terms of mortality between young and old subjects.

Compliance with ethics regulations: Yes in clinical research.

FC-048 Utilization of automated oxygen titration in patients managed at the emergency department for suspected or confirmed COVID-19

DALLAIRE Léa1, GUIROY Antoine1, BOUCHARD Pierre-Alexandre 1, LELLOUCHE Francois1

1Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Canada
Correspondence: Francois LELLOUCHE (francois.lellouche@criucpq.ulaval.ca)

Annals of Intensive Care 2022, 12(1):FC-048

Rationale: During the COVID-19 pandemic, automated oxygen titration has been implemented at the emergency department (ED) to maintain the patients within the oxygenation targets and to reduce the interventions from healthcare workers. We report here our experience to manage patients with suspected or confirmed COVID-19 at the ED.

Patients and methods/Materials and methods: We retrospectively collected data from the automated oxygen titration device (O2 flow, SpO2, SpO2 target, respiratory rate and heart rate) in patients managed at the ED between April 2021 and February 2022. We analyzed the time within the SpO2 target (set SpO2 ± 2%), with hypoxemia (SpO2 < target − 5%), with hyperoxemia (SpO2 > target + 5%). We analyzed the whole population and the subgroup of patients with confirmed COVID-19. We evaluated the number of patients with oxygen weaning during the management. We evaluated separately the impact of the SpO2 target on oxygen flow when the target was modified by the clinicians by 2% or more. In this subgroup of patients, we evaluated the mean oxygen flowrate 15 min before and after the modification of the SpO2 target.

Results: We included 98 patients (mean age 72 ± 16 years, 57% were men) admitted to the ED with acute respiratory distress and suspected (n = 77) or confirmed (n = 21) COVID-19 requiring oxygen therapy. The mean duration of utilization of automated oxygen titration device was 14.3 ± 4.7 h. A SpO2 signal was present 91.9% of the time. Main SpO2 targets set by the clinicians were 90% (43%), 88% (27%), 92% (20%), 94% (4%). Oxygen weaning was possible in 35/98 patients (36%). For the whole population/COVID-19 patients, the time in the SpO2 target was 78/81%, time with hypoxemia was 3/3%, time with hyperoxemia was 2/0.6%. In a subgroup of 11 patients, the effect of modifying the SpO2 target was evaluated. The mean initial SpO2 target was 91.9% and the mean final target was 89.5%. The mean initial and final oxygen flow were 3.3 ± 0.6 and 1.9 ± 0.6 L/min respectively, P = 0.0076.

Conclusion: In patients with acute respiratory failure, the utilization of automated oxygen therapy was feasible to manage patients with suspected or confirmed COVID-19 with potential benefits. Similarly to other studies with automated oxygen therapy, the time in the oxygenation target was high, and oxygen weaning was potential in 1/3 of the patients. SpO2 target has a significant impact on oxygen flow rates and is a useful tool with this new device.

Compliance with ethics regulations: Yes in clinical research.

figure bo

impact of the SpO 2 target on oxygen flowrate in a subgroup of 11 patients with modified target. With high SpO 2 target (mean 91.9%) reduced to low SpO 2 target (mean 89.5%), oxygen flow was significantly reduced from 3.3 to 1.9 L/min.

FC-049 Acute heart failure in the emergency department: prognosis value of PaO2/FiO2 ratio

GHABARA Racha1, BAHRI Badra1, SEDGHIANI Ines1, KHIARI Saoussen1, DOGHRI Hamdi1, TOUJ Hager1, ZAGHDOUDI Imen1, FALFOUL Nebiha1

1Hopital Habib Thameur, Tunis, Tunisie
Correspondence: Racha GHABARA (Rsha993@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-049

Rationale: Heart failure is a common presentation in the emergency department. Searching for risk factors is a challenging step in the emergency physicians. The purpose of our study was to search for prognosis values of ratio PaO2/FiO2 in patients admitted to the emergency department for acute heart failure.

Patients and methods/Materials and methods: Prospective monocenter observational study, conducted between November 2021 and January 2022. We included patients over the age of 18, we established diagnosis of heart failure on clinical grounds. We performed blood gases at admission. The primary endpoint was in-hospital mortality.

Results: We included 100 patients. Average age: 73 ± 11 years and sex ratio M/F = 51/49. The most common comorbidities were hypertension: 81(82%), diabetes 46 (47%), coronary artery disease 47(47%) patients; 68% had a left ventricular ejection fraction (LVEF) more than 40%, with an average pro-BNP of 9,440 pg/mL; 37% of patients had permanent atrial fibrillation. 24% returned in < 30 days with an average of readmissions/year of 1.75(± 0.96). Seventy-two patients (76%) required ventilatory support, 5% required the use of invasive mechanical ventilation. The mortality rate was 12%. There was no significant difference in terms of comorbidity between the group of deceased and surviving patients. However, deceased patients had a higher SOFA score (4 vs 2; p = 0.001), a lower LVEF (43% vs 25%; p = 0.18). D-dimers and CRP were higher in the deaceased patients, with a median value of 3636 vs 1385 µg/L (p = 0.001) and 98 vs 56 mg/L (p = 0.08) respectively. The PaO2/FiO2 ratio in admission was 195 in the deceased patients vs 298 in the surviving patients (p = 0.01). The PaO2/FiO2 ratio was as an independent mortality factor (OR = 0.99, CI [0.98; 1.00], p = 0.05). Using the ROC curve, the best cut-off for the PaO2/FiO2 ratio was 160. A PaO2/FiO2 ratio ≤ 160 was predictive of mortality with an area under curve of 0.74, a sensitivity of 86% and a specificity of 76%.

Conclusion: A PaO2/FiO2 ratio ≤ 160 is an independent factor of death in patients admitted to the emergency department with acute heart failure.

Compliance with ethics regulations: Yes in clinical research.

FC-050 Care prognosis and outcomes in elderly patients admitted to the intensive care unit

JERBI Mouna1, GHORBEL Rezk1, REKIK Achraf1, BEN JEDDOU Kais1, GHARBI Emna1, BEN AMAR Boutheina1, CHAKROUN Olfa1, REKIK Noureddine1

1Centre Hospitalo-universitaire Habib Bourguiba sfax, Sfax, Tunisie
Correspondence: Rezk GHORBEL (rezkghorbel3@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-050

Rationale: To describe the medical histories, demographic characteristics and analyze the standardized geriatric assessment in elderly patients admitted to emergency department intensive care unit (EDUCI). To determine the pathologies found in these patients as well as the therapeutic and outcomes.

Patients and methods/Materials and methods: This is a prospective descriptive study carried out at the EDUCI of the Habib Bourguiba University Hospital, during a period of four months. We included all people aged 65 and older admitted to our intensive care unit. We observed their therapeutic management as well as their demographic and evolutionary characteristics. We also calculated the ADL score for all patients and followed their evolution at discharge from the emergency room.

Results: Our study involved 262 patients during the enrollment period. The average age was 77 ± 8 years with a sex ratio of 1.1. From pathological medical history was noted in most patients (82%) dominated by hypertension and diabetes mellitus. The majority of patients (74%) are polymedicated. The history of hospitalization was found in 42% of cases. Data anamnestics have shown the presence of cognitive disorders and Alzheimer’s disease in 21% and 7% of cases, respectively. The ADL score showed a loss of autonomy for 39% of the population. The reasons of hospitalizations were mainly medical and, to a lesser extent, traumatic and visceral reasons while the deterioration of the general state was involved in 5% cases. Overall, 11% of patients required mechanical ventilation and 9% of patients required a blood transfusion. The average length of hospital stay was 3 ± 4 days. The evolution was favorable in the majority of cases (75%). Among home leavers (41%), a quarter sustained moderate or severe sequelae. These sequelae were essentially neurological deficit, resuscitation neuromyopathy and/or pressure sores. The evolution has been fatal in 17% of cases, in the EDICU. The main causes of death were cerebral suffering (8%), septic shock and hypoxemia.

Conclusion: The admission of geriatric patients to the ICU is increasing. Frailty assessment may play an important role in the clinical evaluation of such individuals for triage, but should not be considered a priori as an exclusion criterion for admission. Physicians are aware of the difficulties faced with such patients and the need to promote short admission pathways.

Compliance with ethics regulations: Yes in clinical research.

FC-051 French translation and validation of the Healthy Aging Brain Care-Monitor, Hybrid Version (HABC-M-HV): a new tool for remote post-intensive care syndrome screening

BOUGARD Laurine1, BEAUDART Charlotte1, COLSON Camille1, HORLAIT Geoffrey2, BORNHEIM Stephen3, BRUYERE Olivier1,3, MISSET Benoit1, ROUSSEAU Anne-Françoise1

1CHU Liège, Liège, Belgique; 2CHU UCL Namur, Namur, Belgique; 3University of Liège, Liège, Belgique
Correspondence: Laurine BOUGARD (laurine_bougard@hotmail.com)

Annals of Intensive Care 2022, 12(1):FC-051

Rationale: Patients surviving a stay in an intensive care unit (ICU) may experience new or worsening disorders that have been labeled as “post-intensive care Syndrome” (PICS). PICS includes physical weakness, mental disorders and neurocognitive impairments that can affect the patient’s quality of life. Authors of the Healthy Aging Brain Care Monitor have developed a hybrid version (HABC-M-HV) suited to the daily needs of their post-ICU follow-up clinic. This is a 30-item questionnaire with 4 subscales for cognitive, functional, psychological and quality of life assessment. The hybrid version of the HABC-M questionnaire (HABC-M-HV) has not yet been validated in its English version. Using rigorous methodologies, the objectives of this cross-sectional observational study were to translate the HABC-M-HV questionnaire into French (HABC-M-HV-F, Fig. 1) and to evaluate the main measurement properties of this new version.

Patients and methods/Materials and methods: The questionnaire was translated following a five-stage validated method for the translation and cross-cultural adaptation of questionnaires. A convenience sample of ICU survivors was recruited in our follow-up clinic to validate the questionnaire. The HABC-M-HV-F was administered by phone. The measurement performances of the questionnaire were tested using internal consistency, test–retest reliability, standard error of measurement (SEM) and smallest detectable change (SDC) calculation, floor and ceiling effect measurement and construct validity.

Results: A total of 51 patients with 14/51 (27.5%) women were recruited between February and September 2021. Their median age was 63 [55–71] years. The internal consistency was very good (Cronbach’s alpha coefficient 0.79). The intra- and inter-examinator reliabilities were excellent (Intraclass Coefficient Correlation = 0.99 and 0.97, respectively). Total scores of the HABC-M-HV-F were very similar between test and retest with the same examinator, respectively 9 [4–15] and 8 [4–16], as well as with two examinators, respectively 12 [6–24] and 12 [4–23]. The SEM was 0.62 and the SDC was 1.72. No floor nor ceiling effects were observed. The convergent validity was almost entirely confirmed with 71.4% of our hypothesis confirmed.

Conclusion: The HABC-M-HV-F has been shown to be a valid and reliable tool for standardized PICS screening and follow-up among French-speaking ICU survivors. A remote administration by phone is feasible, making it an advantageous alternative in the growing context of telemedicine.

Compliance with ethics regulations: Yes in clinical research.

figure bp

Healthy Aging Brain Care Monitor Hybrid Version in French

FC-052 Ceftolozane/Tazobactam use for the treatment of bacterial infections in France: focus on patients with abnormal renal functions

RUIMY Raymond1, AKRICH Brune2, BOURGE Xavier2, BOUTOILLE David3, BRASSAC Isabelle2, CASTAN Bernard4, LORIEAU-THIBAULT Raphaèle2, MACKOSSO Carole2, MONTEIRO TAVARES Linsay5, MOOTIEN Joy6, RUIZ Fabrice5, TIMSIT Jean-François7

1CHU Nice, Nice, France; 2MSD France, Puteaux, France; 3CHU Nantes, Nantes, France; 4CH Périgueux, Périgueux, France; 5ClinSearch, Malakoff, France; 6CHU Mulhouse, Mulhouse, France; 7AP-HP Bichat, Paris, France
Correspondence: Gabriella PASSONI (gabriella.passoni@clinsearch.net)

Annals of Intensive Care 2022, 12(1):FC-052

Rationale: The Conduct study was initiated following a request from the French Health Authorities, to describe the use of Ceftolozane/Tazobactam (C/T) in current clinical practice.

Patients and methods/Materials and methods: This was an observational, prospective, multicenter, French study. Any patient having received at least one dose of C/T was eligible to participate and followed-up upon inclusion until stop of C/T. This analysis aims to examine C/T outcomes relative to renal functions, in patients with pneumonia, or treated for complicated intra-abdominal (cIAI) or urinary tract infections (cUTI) and pyelonephritis (other indications). Current recommended daily C/T doses are 6 g/3 g for pneumonia treatment (indication approved in August 2019), and 3 g/1.5 g for the other indications, with decreased daily doses recommended in patients with renal impairment. Normal renal functions were defined as creatinine clearance (CLCR) between 50–150 mL/min, augmented renal clearance (ARC) was defined as CLCR > 150 mL/min, and renal impairment (RI) as CLCR < 50 mL/min.

Results: Between October 2018 and December 2019, 260 patients were enrolled and data on renal functions were available for 240. Of these, 133 (55.4%) presented with pneumonia (of whom, 30.8% [N = 41/133] included after the approved indication), and 50 (20.8%) received C/T for the three other approved indications (the remaining 57 received C/T for another indication—data not shown). Baseline demographic and clinical characteristics are presented in Table 1. Among patients treated for pneumonia and included after the indication was approved, all RI patients received a dose adaptation (less than 6 g/3 g). On the other hand, 3/5 (60%) of ARC patients and 10/29 (34.5%) of patients with normal renal functions received doses lower than 6 g/3 g. For the other indications, the majority of ARC and normal renal function patients received the standard dose (57.1% [N = 4/7] and 71% [22/31], respectively); 42.8% of ARC patients and 22.6% with normal renal function received higher doses (between 4 g/2 g and 6 g/3 g). Among RI patients, dose adaptation was not strictly followed (8/12 received 3 g/1.5 g, and one patient received 4.5 g/2.25 g). In both groups, the most commonly reported reasons for treatment termination were complete or partial cure (100%, 93.1%, 85.7%, for ARC, normal renal functions, and RI pneumonia patients respectively, and 57.1%, 71%, 66.6%, for the same subgroups in patients with other indications).

Conclusion: These results suggest that C/T dose adaptation is followed by most clinicians, and provides important cure rates among all renal function groups.

Compliance with ethics regulations: Yes in clinical research.

figure bq

Table 1

FC-053 Does the cefepime plasma concentration at steady-state in critical ill patients frequently exceed the maximum target assumed to be neurotoxic?

JEAN-MICHEL Vanessa1, HOMEY Corentin1, CAULIER Thomas1, DELANNOY Pierre-Yves1, BOUSSEKEY Nicolas1, GEORGES Hugues1

1CH TOURCOING, Tourcoing, France
Correspondence: Vanessa JEAN-MICHEL (vanessa.jeanmichel@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-053

Rationale: Cefepime (CEF) is one of antimicrobials commonly prescribed for nosocomial infections in intensive care unit (ICU). Neurotoxicity of cefepime can occur for plasma concentration > 35 mg/L, when administered by continuous infusion [1,2]. We aimed to assess the risk factors of plasma CEF concentration at steady state above 35 mg/L. We also determined the relationship between neurotoxicity, CEF concentration and general co-morbidities.

Patients and methods/Materials and methods: We performed a retrospective study of adult ICU patients treated with CEF for at least 48 h between January 2019 and September 2021.

Results: Fifty-seven patients were included. Twenty-one patients had a renal clearance < 60 mL/min/1.73 m2 before CEF initiation. The mean starting daily dose of CEF was 5.4 (1.3) g. The mean time to first CEF monitoring was 2.9 (1.7) days and the incidence of CEF concentration above 35 mg/L was 46/57 (80.7%) patients. Factors independently associated with CEF concentration above 35 mg/L were age upper to 65 years old [OR = 4.1 (95% CI 1.1–62.1), p = 0.04] and initial daily delivery of 6 g of CEF [OR = 2.7 (95% CI 1.2–68.9); p = 0.03]. Presumed CEF neurotoxicity was 12/57 (21.1%) patients. Mean CEF concentration was higher for patients who developed neurotoxicity: 85 (31.2) mg/L vs 50.9 (23.4) mg/L; p = 0.001. No patient with neurotoxicity had a CEF concentration of 35 mg/L or less. The mean treatment duration was 5.4 (2.6) days. The mean time to develop neurotoxicity related to CEF was 4.8 (1.8) days. Seventeen patients were not neurologically assessable due to deep sedation. The mean time from CEF change to neurological improvement was 2.8 (1.6) days. CEF concentration above 40 mg/L (p = 0.01) was more frequently associated with neurotoxicity in univariate analysis but did not appear to be an independent factor. The only independent factor for presumed CEF neurotoxicity was estimated glomerular filtration rate below 60 mL/min/1.73 m2 at initiation of treatment [OR = 8.6 (95% CI 1.4–51.9); p = 0.02].

Conclusion: CEF concentration above 35 mg/L is frequent and therefore should be systematically investigated to prevent neurotoxicity.

Reference 1: Guilhaumou R, Benaboud S, Bennis Y, Dahyot-Fizelier C, Dailly E, Gandia P, et al. Optimization of the treatment with beta-lactam antibiotics in critically ill patients. Crit Care Lond Engl. 2019;23:104.

Reference 2: Huwyler T, Lenggenhager L, Abbas M, Ing Lorenzini K, Hughes S, Huttner B, et al. Cefepime plasma concentrations and clinical toxicity: a retrospective cohort study. Clin Microbiol Infect. 2017 Jul;23(7):454–9.

Compliance with ethics regulations: Yes in clinical research.

FC-054 Population pharmacokinetics of fluconazole and dosing simulations in critically ill patients

VASSAL Olivia1, MATUSIK Elodie2,3, FERRY Tristan4,5, MILLET Aurelien6, BOHE Julien1, GUITTON Jerome6, FRIGGERI Arnaud1,5, GOUTELLE Sylvain2,3

1Service Anesthésie Reanimation Medecine Intensive, Groupement Hospitalier Sud, Hospices Civils de Lyon, Pierre Benite, France; 2Service Pharmacie/Pharmacologie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France; 3CNRS UMR 5558 LBBE, Université Lyon 1, Lyon, France; 4Service des maladies infectieuses et tropicales, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France; 5Inserm U111, CNRS UMR 5308, Centre International de Recherche en Infectiologie, Lyon, France; 6Laboratoire de Pharmacologie toxicologie, Groupement Hospitalier Sud, Hospices Civils de Lyon, Lyon, France.
Correspondence: Olivia VASSAL (Oliviavassal@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-054

Rationale: Fluconazole pharmacokinetics (PK) may be altered in critically ill patients, but changes and implications for drug dosing remain unclear. We aimed to describe the PK and dosage requirements of fluconazole in intensive care unit (ICU) patients.

Patients and methods/Materials and methods: This was a PK study performed in an ICU over 1 year. All patients who were prescribed fluconazole with at least two measured concentrations were included. A second dataset from a medical unit was also analyzed for comparison. Population PK modelling was performed by with Monolix software. Classical criteria were used for model evaluation including goodness-of-fit and simulation-based diagnostics. Patient covariates were investigated. Dosing simulations were performed with the final model with Simulx software. Various loading (LD) and maintenance doses (MD) were evaluated, and probability of target attainment (PTA) was computed in simulated patients (n = 1000). PK targets were set as a trough concentration (Cmin) of 15 mg/L and a daily AUC of 400 mg.h/L.

Results: A total of 202 plasma concentrations were available. They were 33 men and 19 women, with mean age of 61 ± 16 years and mean initial weight of 72 ± 21 kg. 59% of patients had proven invasive candidiasis (C. albicans 35%, C. tropicalis 8%) and 4% has cryptococcosis. In ICU patients, a LD of 800 mg was administered in 83% of patients. Data were best described with by a one-compartment model with first-order elimination. The mean (CV%) of body clearance (CL) and volume of distribution (Vd) parameters were as follows: 0.46 L/h (56%) and 40.72 L (10%). ICU hospitalization was associated with a 80% increase in CL. The optimal dosage regimen was based on a LD of 800 mg q12h over the first 24 h followed by a MD of 600 mg/24 h. This dosage was associated with median [percentiles 5th–95th] Cmin of 29.5 mg/L [19.2–37.3] at 24 h and 30.9 mg/L [8,6–62,8] at 120 h and a median AUC of 583.7 mg.h/L [461.4–706.5] at 24 h and 895.0 mg.h/L [356.8–1597.0] at 120 h. PTA at 24 h and 120 h were as follows 98.7% and 99.9% for Cmin; 99.2% and 93.4% for AUC, respectively. Only 6% of patients had a concentration over 80 mg/L after 5 days.

Discussion: We identified increased fluconazole clearance in ICU patients. LD and MD higher than currently recommended are necessary to achieve PK/PD targets in most patients.

Conclusion: This study confirms interindividual variability of fluconazole PK and the need for higher dosage in ICU patients. Early therapeutic drug monitoring may be useful for dosage individualization.

Compliance with ethics regulations: Yes in clinical research.

FC-055 Factors associated with failure to achieve meropenem plasma concentration target in critically ill patients

TOURNAYRE Sarah1, MATHIEU Olivier1, VILLIET Maxime1, KLOUCHE Kada1, LARCHER Romaric2

1CHU MONTPELLIER, Montpellier, France; 2CHU NIMES, Nimes, France
Correspondence: Sarah TOURNAYRE (tournayresarah@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-055

Rationale: Optimal management of septic shock requires prompt and adequate administration of broad-spectrum antibiotic therapy, ensuring that effective therapeutic levels are achieved. We aimed to determine factors associated with failure to achieve meropenem plasma concentration target in critically ill patients.

Patients and methods/Materials and methods: Between January 2019 and March 2020, charts of all patients admitted in medical intensive care unit (ICU) for septic shock and treated with meropenem and who had at least one meropenem plasma concentration measurement were reviewed. Adequate target meropenem plasma concentration was ranged from 10 to 50 mg/L. Factors associated with meropenem plasma concentration target non-attainment were assessed by multivariable logistic regression (R software version 4.1.2).

Results: 117 meropenem plasma concentrations were measured 3 days after initiation of meropenem or change on its dosage regimen, in 70 ICU patients. Meropenem was administered by prolonged intermittent infusion in 34 patients and by continuous infusion in 36. Factors independently associated with failure to achieve 10 mg/L of meropenem plasma concentration were female sex, age < 65 years old, prolonged intermittent rather than continuous infusion and low daily doses of meropenem (Fig. 1). Factors associated with plasma concentrations above 50 mg/L were low body weight, renal clearance < 25 ml/min and higher daily doses of meropenem. Of note, only 3 patients had neurotoxicity.

Conclusion: In ICU patients, age < 65 years old, female sex, prolonged intermittent infusion and low dose of meropenem were significantly associated with failure to achieve meropenem plasma concentration target. Some patients experienced a high meropenem plasma concentration but few of them had clinical signs of toxicity. Our results suggest to prefer continuous infusion of meropenem over 24 h rather than prolonged intermittent infusion, particularly in patients with normal or increased renal clearance.

Reference 1: Abdul-Aziz, M.H., Alffenaar, JW.C., Bassetti, M. et al. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper#. Intensive Care Med 46, 1127–1153 (2020).

Reference 2: Li C, Du X, Kuti JL, Nicolau DP..Clinical pharmacodynamics of meropenem in patients with lower respiratory tract infections. Antimicrob Agents Chemother 51:1725–1730 (2007).

Compliance with ethics regulations: Yes in clinical research.

figure br

Meropenem concentration after different daily dose among patients with different renal clearance. Group 1 = CrCl < 25 ml/min, Group 2 = CrCl 25–50 ml/min or CRRT, Group 3 = CrCl 50–90 ml/min, Group 4 = CrCl 90–130 ml/min, Group 5 = CrCl > 130 ml/min.

FC-056 Optimisation of piperacillin-tazobactam dosing regimen for critically-ill patient with sepsis: the OPT-TAZ population pharmacokinetics study

SARFATI Sacha1, WILS Julien1, CARPENTIER Dorothée1, NILES Christopher2, GOUIN Philippe1, BRAULT Clément3, IMBERT Laurent1, GAËTAN Béduneau1, NSEIR Saad2, DAHYOT Sandrine1, MISSET Benoit4, LAMOUREUX Fabien1

1CHU de Rouen, Rouen, France; 2CHRU de Lille, Lille, France; 3CHU d'Amiens, Amiens, France; 4CHU de Liège, Liège, Belgique
Correspondence: Sacha SARFATI (sacha.sarfati@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-056

Rationale: In critically-ill patient with sepsis, the piperacillin-tazobactam (pip-taz) combination is one of the most used antibiotics. Although pharmacokinetics of pip-taz exhibits very high inter-individual variability mainly based on volume of distribution, renal clearance, patient’s weight and serum albumin level, a standard dosing protocol is generally used (1). Moreover, these covariates are highly variable in sepsis and predictive algorithms based on clinical and biological parameters may help to optimize dosing and improve outcomes. The aim of the study is to use a population pharmacokinetics study to build a Bayesian model predicting the optimal dosing regimen of pip-taz in sepsis patients.

Patients and methods/Materials and methods: The OPT-TAZ (optimisation of pip-taz) study is a prospective multicenter open-label non-comparative cohort study designed with a 60-patient learning cohort and a 30-patient validation cohort. Patients will be included prospectively in 4 ICUs in France. The protocol plan to analyze pharmacokinetics of 60 patients then development of a predictive model validated on 30 patients. We present here the analysis of the 60 first patients. Standard dosing of pip-taz 4 g/0,5 g each 6 h (group 1) or 8 h (group 2) in 3 h infusion has been chosen according to clinician choice. Serum concentration of piperacillin and tazobactam has been measured at H0, 1.5, 3, 4, 5 (G1) or 6 (G2), 6 (G1) or 8 (G1), 12 (G1) or 16 (G2), 24, 48 and 120 with a liquid chromatography coupled with tandem mass spectrometry (LC–MS/MS).

Results: In our cohort, we showed that pharmacokinetics of pip-taz present a very high inter-individual variability. Residual concentration was lower than recommended target concentration in more than 50% of cases. Dosing of 4 g/0.5 g every 8 h and augmented renal clearance were risk factor for failure of PK/PD target attainment. PK of piperacillin and tazobactam show a strong association and tazobactam concentration was of the order of 10% of piperacillin concentration.

Conclusion: In conclusion, pip-taz dosing regimen must be adapted to patient characteristics. Creatinine clearance is one of the most important covariates to take into consideration for dose adaptation. The dose of 4 g/0.5 g each 8 h must be considered of high risk of failure of PK/PD attainment in patient with no impaired renal function. Therapeutic drug monitoring is an essential tool to assess the match of dosing regimen with PK/PD target.

Reference 1: (1) Huttner A, Harbarth S, Hope WW, Lipman J, Roberts JA. Therapeutic drug monitoring of the ?-lactam antibiotics: what is the evidence and which patients should we be using it for? J Antimicrob Chemother2015;70(12):3178–83.

Compliance with ethics regulations: Yes in clinical research.

figure bs

Residual concentration of piperacillin over time in group 1 (4 g each 6 h) and group 2 (4 each 8 h) compared to different level of PK/PD target.

FC-057 Should we really ban 3rd generation cephalosporin (C3G) use for the treatment of Enterobacter cloacae infection in ICU patients?

BERNIER Juliette1, TANKOVIC Jacques1, VILLA Antoine1, URBINA Tomas1, BONNY Vincent1, GABARRE Paul1, AIT OUFELLA Hafid1, MAURY Eric1

1CHU Saint Antoine, Paris, France
Correspondence: Juliette BERNIER (j.bernier1505@laposte.net)

Annals of Intensive Care 2022, 12(1):FC-057

Rationale: Limiting the ecological impact of antibiotics through accurate prescription is one of the major goals of antibiotic stewardship policy. However, an antibiotic-sparing strategy must not have a potential deleterious impact on patient’s prognosis. Group 3 Enterobacteriaceae possess the AmpC gene encoding a cephalosporinase. Antibiotic therapy with a 3rd generation cephalosporin (C3Gs) might lead to treatment failure when cephalosporinase hyperproducing mutants (Hcase) emergence occurs making them resistant to all penicillins and C3Gs. Thus, expert recommendations advise against the use of C3Gs as monotherapy in this case (1). This risk would be increased for Enterobacter cloacae species. This statement, based on old studies, is now being debated (2). This study aimed at evaluating mutants Hcase emergence when treating Enterobacter cloacae complex wild-type infections in ICU patients with C3Gs.

Patients and methods/Materials and methods: Methods: We performed a multicenter retrospective study including microbiological files of patients more than 18, admitted to intensive care unit, between January 2015 and August 2021, and who were treated for wild-type Enterobacter cloacae infection and assessed mutants emergence defined by a subsequent sample finding mutants Hcase emergence whatever clinical evolution.

Results: Among the 5275 Enterobacter cloacae species found from the microbiology files during the study period, 373 were associated to infections occurring in ICU patients and finally 165 ICU patients infected with C3Gs susceptible E cloacae were included in the analysis. C3Gs resistance emergence was observed in 19 cases (11.5%), 13 being related to Hcase mechanism and 6 to extended spectrum beta-lactamase (ESBL) production. C3G were used in 56 cases (35%) before identification (n = 12), after identification (n = 18) or exclusively (n = 26). Cefepime was used in 67 cases (41%) before identification (n = 11), after identification (n = 28), exclusively (n = 21), or combined with a fluoroquinolone (n = 3), an aminoglycoside (n = 3) or sulfamethoxazole (n = 1). Mutants Hcase emergence occurred most often after an exclusive treatment by cefotaxime (n = 5), cefepime (n = 2), tazocillin (n = 3). Three were observed following tazocillin/aminoglycoside association (n = 1), tazocillin followed by sulfamethoxazole (n = 1) or cefepime/fluoroquinolone association (n = 1). None was observed after carbapenem use. Considering patients receiving monotherapy following identification, mutants Hcase emergence was more frequent in the C3G group than in the cefepime group (11,4 vs 4% respectively, (p = 0.3).

Conclusion: Enterobacter cloacae mutants Hcase emergence could be more frequent following C3G use than cefepime. The data reported here are not significantly different but are obtained on a limited population. A prospective study would be necessary to answer this question.

Reference 1: 1. 2021. CASFM / EUCAST AVRIL 2021 V1.0. Société Française de Microbiologie. https://www.sfm-microbiologie.org/2021/04/23/casfm-avril-2021-v1-0/. Retrieved 23 January 2022.

Reference 2: 2. Mizrahi A, Delerue T, Morel H, Le Monnier A, Carbonnelle E, Pilmis B, Zahar JR. 2020. Infections caused by naturally AmpC-producing Enterobacteriaceae: Can we use third-generation cephalosporins? A narrative review. International Journal of Antimicrob.

Compliance with ethics regulations: Yes in clinical research.

FC-058 Anticoagulation, thromboembolic and bleeding events in COVID-19 VV-ECMO patients in the French Territories in the Americas

DAOUD Laura1, VALLY Shazima1, KALLEL Hatem2, CHAPLAIN Agathe1, FLORENTIN Jonathan1, MEGARBANE Bruno3, MEHDAOUI Hossein1, VALENTINO Ruddy1, RESIERE Dabor1

1Centre Hospitalier Universitaire, Fort-De-France, Martinique; 2Cayenne General Hospital, French Guiana, Cayenne, Guyane Francaise; 3Lariboisière Hospital, Paris University; Paris, France
Correspondence: Dabor RESIERE (dabor.resiere@chu-martinique.fr)

Annals of Intensive Care 2022, 12(1):FC-058

Rationale: Since December 2019, COVID-19 has affected more than 400 million people and caused more than 5 million deaths, causing a truly global pandemic. While most people with COVID-19 will have a minor or moderate form of the disease, some people will develop severe acute respiratory distress syndrome (ARDS), requiring admission to intensive care and the use of mechanical ventilation (VM) and sometimes venovenous extracorporeal membrane oxygenation (VV-ECMO). However, COVID-19 has been associated with an increased risk of thromboembolic and bleeding events, and heparin resistance during VV-ECMO treatment in critically ill patients admitted to the intensive care unit (ICU). The therapeutic target for anticoagulation under VV-ECMO is not really known. The anticoagulant treatment of choice according to the ELSO recommendations is unfractionated heparin with anti-Xa targets between 0.2 and 0.4. The objective of this cohort study was to evaluate the association between severe COVID-19 infection and the occurrence of thromboembolic and bleeding complications following VV-ECMO.

Patients and methods/Materials and methods: We conducted a monocenter retrospective observational study in the ICU department of the University Hospital of Martinique from January 2020 to December 2021. Our center has an on-call ECMO mobile unit (UMAC) which includes a cardiothoracic surgeon and a perfusionist nurse. Requests for VV-ECMO French West Indies (Guadeloupe, Martinique, and French Guyana) are regulated by the intensivist on duty at the Martinique University Hospital.

Results: We included the records of 40 patients with 25 COVID-19 patients and 15 non-COVID-19 patients over the period January 2020 to December 2021. Six non-COVID-19 patients were excluded: 3 for deaths within 24 h, one patient with acute myeloid leukemia type 3, and 2 patients with a contraindication to heparin therapy. The median age was 46 years old for COVID-19 patients et 49 year old for non-COVID-19 patients. COVID-19 patients experienced thromboembolic complications in 55% of cases (11) and non-COVID-19 patients in 24% of cases (2), p = 0.1

Conclusion: Our study confirms that the management of anticoagulation in VV-ECMO represents a particular challenge in COVID-19 patients who appear to be at increased risk of thromboembolic risk complications without sparing the bleeding consequences of the assistance. On the other hand, the difference in thromboembolic and hemorrhagic complications in our two groups was not significant.

Compliance with ethics regulations: Yes in clinical research.

FC-059 Bilateral acral ischemia in COVID-19 patients: a peculiar symptom and treatment options

SGHAIER Ameni1, RHAIEM Sirine1, JAMOUSSI Amira1, AYED Samia1, RACHDI Emna1, JARRAYA Fatma1, BESBES Mohamed1, BEN KHELIL Jalila1

1Hopital Abderrahman Mami, Ariana, Tunisie
Correspondence: Ameni SGHAIER (sghaier.ameni@caramail.com)

Annals of Intensive Care 2022, 12(1):FC-059

Rationale: Although primarily a respiratory virus, SARS-CoV-2 has shown clear impact on hemostasis, often resulting in hypercoagulability state. Deep vein thrombosis, pulmonary embolism and arterial occlusion have all been increasingly reported and investigated during the COVID-19 pandemic. Few studies have however focused on the occurrence of bilateral acral ischemia (BAI). The aim of our study was to examine the characteristics of COVID-19 patients who developed BAI, as well as the various therapy options that might be offered to them.

Patients and methods/Materials and methods: We conducted a retrospective study including patients admitted to our intensive-care unit for acute respiratory distress (ARDS) due to COVID-19 between January and August 2021. Clinical characteristics, laboratory findings and vasopressive treatment doses were recorded and used to compare between patients who developed BAI and those who did not. Fischer bilateral exact test and Mann–Whitney-u test were used for comparison between groups.

Results: During the study period, 398 patients were admitted; 238 male and 160 female. Of these patients, 8 developed BAI (7 men). Mean age was 67 years old. Medical history of diabetes was present in 7 patients, and hypertension in all 8 patients. All patients who developed BAI had severe ARDS. Only one patient remained on non-invasive ventilation support at the time of BAI occurrence and until discharge. The main affected sites of BAI were fingers and toes although ear lobules were also involved in 3 patients. The mean time to development of BAI starting from the day of admission was 4.9 days. Among patients who were intubated, the mean time of BAI occurrence after intubation was 1.2 days. 4 patients were not under any vasopressive treatment at the time of BAI development. The mean norepinephrine dose among the other 4 patients was 0.65 mg/h. When compared to the other group of patients, there was no statistically significant difference in gender (p = 0.12), median age (56 vs 67 years old; p = 0.054), baseline prothrombin time levels (p = 0.08), d-Dimer levels (p = 0.13), platelet count (p = 0.22) and blood fibrinogen levels (p = 0.061) when available. Survival rates between the two groups were not statistically significant (196 vs 1 patient; p = 0.068). Anticoagulant treatment using heparin was given to 4 patients, with only one patient improved over the course of 10 days. One patient received thrombolysis for subsequent pulmonary embolism with improvement in less than 2 days.

Conclusion: BAI has been increasingly reported in critically-ill COVID-19 patients with no apparent other risk factors to predict its occurrence and limited options for treatment and prevention.

Compliance with ethics regulations: N/A.

FC-060 Comparative profiles of routine and specialized biomarkers of coagulopathy and endotheliopathy in moderate and severe COVID-19 disease: a prospective observational study

BOUSQUET Giovanni1, LACROIX Romaric3, PAHUS Laurie1, VALERA Sabine1, HEZARD Nathalie2, ARNAUD Laurent3, ABDILI Evelyne3, BAUMSTARCK Karine4, CHANEZ Pascal1, DIGNAT-GEORGE Françoise3, PAPAZIAN Laurent1, FOREL Jean-Marie1, HRAIECH Sami1, MORANGE Pierre2, GUERVILLY Christophe1

1Centre Hospitalier Universitaire de Marseille - Nord, Marseille, France; 2Centre Hospitalier Universitaire de Marseille - La Timone, Marseille, France; 3Centre Hospitalier Universitaire de Marseille - La Conception, Marseille, France; 4Faculté de Médecine de Marseille - La Timone, Marseille, France
Correspondence: Giovanni BOUSQUET (giovanni.bousquet@icloud.com)

Annals of Intensive Care 2022, 12(1):FC-060

Rationale: Endothelial injury and coagulation activation are prominent axis in coronavirus disease 19 (COVID-19) pathogenesis. However, few studies have compared comprehensive profiles of biomarkers of coagulopathy/endotheliopathy with regard to the initial severity of COVID-19 and the time course of the disease.

Patients and methods/Materials and methods: In a prospective longitudinal study, we explored coagulation and endothelial function biomarkers in two cohorts of severe and moderate COVID-19 patients and according to their respective outcomes.

Results: We found that Tissue factor pathway inhibition (TFPI), Extracellular vesicles—tissue factor (EV-TF), von Willebrand factor antigen (VWF:Ag) and soluble thrombomodulin (sTM) at admission were associated with disease severity. With regard to outcome, d-dimers, TFPI, EV-TF, VWF:Ag/ADAMTS13 ratio and sTM at admission, at day 3 and at day 7 were associated with death and mechanical ventilation. TFPI with a cut-off value of 37.5 ng/mL had 87% sensitivity and 94% specificity and EV-TF with a cut-off value of 13 fM had 87% sensitivity and 83% specificity. ROC curves analysis for severe outcome was significant with AUC = 0.90 for TFPI and AUC = 0.88 for EV-TF (p < 0.001 for both).

Conclusion: We found a specific profile of specialized biomarkers of coagulopathy/endotheliopathy associated with the severe forms of COVID-19 and its clinical outcome. We identified TFPI and EV-TF to be of potential interest in stratifying patients’ risk or to design specific treatment targeting coagulation pathways. Additional studies are warranted to confirm our results.

Compliance with ethics regulations: Yes in clinical research.

figure bt

ROC curves of specialized biomarkers at admission for severe outcome (death or mechanical ventilation) Definition of abbreviations: AUC, area under the curve; TFPI, tissue factor pathway inhibitor; EV-TF, extracellular vesicles—tissue factor; VWF, vo.

FC-061 Bedside ACT anticoagulation monitoring in patients infected with SARS-CoV-2 comparing to anti-Xa activity

MOUNIR Anass1, FALAHI Salma1, SAADAOUI Soufiane1, CHERKAB Rachid1, EL KETTANI Chafik1, BARROU Houcine1

1Réanimation chirurgicale P17, CHU IBN ROCHD, Casablanca, Maroc.
Correspondence: Salma FALAHI (salmafalahi73@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-061

Rationale: Patients with coronavirus disease 2019 appear to be at high risk for thrombotic disease in both venous and arterial circulations due to excessive inflammation, platelet activation, endothelial dysfunction, and immobility. Anti-Xa and aPTT are prone to monitor therapeutic range of unfractionated heparin of patients with COVID-19 and severe illness. These biological parameters are certainly effective but are not momentary. Hence the idea of proposing ACT (Activated Clotting Time), as an element for monitoring anticoagulation in patients infected with SARS-CoV-2, given its multiple advantages: simple, fast, inexpensive, and which can be done at the bedside.

Patients and methods/Materials and methods: We performed a study comparing the results of anticoagulation monitoring by ACT with anti-Xa and TCA activity in 20 patients infected with COVID-19 and treated with curative anticoagulation (LMWH 0.8UIx2/day) over a one month-period. We excluded from the study patients with potentials that could interfere with TCA results: Hypofibrinogenaemia, clotting factor deficiencies, haemodilution, Aprotinin, thrombocytopaenia, qualitative platelet abnormalities, oral anticoagulants.

Results: Our results are shown in Table 1. The mean age of the population was 54 ± 10. 50% of the patients were diabetic, 25% were hypertensive, one patient was asthmatic, and one patient had dyslipidemia. 50% of patients had parenchymal involvement ≥ 75%. 35% of patients presented a high risk of thromboembolism. No agreement was found between ACT results and anti-Xa activity in our sample. In contrast, in 95% of cases, there was a linear trend between ACT and TCA results.

Discussion: The ACT is routinely used to monitor anticoagulation during cardiopulmonary bypass surgery and endovascular procedures. ACT is determined predominantly by the anti-IIa activity of the anticoagulant. Thus, ACT is higher with heparin or bivalirudin than with LMWH for the same intensity of anticoagulation. However, ACT can be used to monitor LMWH anticoagulation with appropriate adjustments. Several studies have attempted to compare the concordance between ACT results with anti-Xa and TCA activity in patients on low-grade UFH anticoagulation. They have shown that In Intensive care unit patients, no relationship between ACT and either UFH dose, aPTT and anti-Xa was observed. All the studies that were found were in IV anticoagulation with UFH. The literature remains very limited about monitoring by ACT for anticoagulation by LMWH.

Conclusion: COVID-19 infection presents a problem with the management of anticoagulation. The biological monitoring parameters are effective but are not momentary. However, bedside ACT anticoagulation monitoring cannot be recommended in patients infected with SARS-CoV-2.

Compliance with ethics regulations: Yes in clinical research.

figure bu

Table 1: Clinico-biological and radiological parameters of our patients.

FC-062 Is there a place to sulodexide in COVID-19 critically ill patients?

DHIA Boudour1,4, BEN ISMAIL Khaoula1,4, ESSAFI Fatma1,4, TALIK Imen1,4, BAYOUDH Aida3,4, FESSI Ilhem3,4, CHKIRBENE Mariem2, JERBI Tahany2, MERHBENE Takoua1,4

1Service de réanimation Médicale, Hôpital Régional de Zaghouan, Zaghouan, Tunisie; 2Département pharmacie, Hôpital Régional de Zaghouan, Zaghouan, Tunisie; 3Service de pneumologie, Hôpital Régional de Zaghouan, Zaghouan, Tunisie; 4Faculté de médecine de Tunis, Université Tunis El Manar, Tunis, Tunisie
Correspondence: Boudour DHIA (bidourabdbg2014@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-062

Rationale: Several studies have demonstrated that endothelitis is prominent in COVID-19. Sulodexide (glycosaminoglycan with endothelial protective, vascular anti-inflammatory and antithrombotic activities) was identified to be helpful in hypoxemic patients. The aim of this study was to assess the contribution of sulodexide addition in severe SARS-CoV-2 pneumonia and to determine its impact on prognosis.

Patients and methods/Materials and methods: Double-arm interventional clinical trial conducted at the medical intensive care unit (ICU) of the regional hospital of Zaghouan (Tunisia) from April 2021 to December 2021, after approval of the ethics committee. Consenting COVID-19 patients over 18 years were included. Two groups were identified: Group 1 (G1) interventional group and Group 2 (G2) control. Sulodexide (500 LSU) was administered from the first day of ICU hospitalization to discharge for a total of 21 days. Epidemiological and prognostic data were analyzed. The study was conducted anonymously. No conflict of interest to be declared.

Results: During the study period, 149 patients were admitted with severe SARS-CoV-2 pneumonia. Seventy-two patients agreed to participate in the clinical trial (G1). The rest defined the control group. On admission, the two groups were comparable in terms of demographic characteristics, clinical presentation and initial severity. Comparison of outcome parameters showed that patients in group 1 had developed less thromboembolic complications (23.1% vs 39.6%, p = 0.016), need for invasive mechanical ventilation (16.8% vs 21.3%, p = 0.031), with lower mortality in G1 (19% vs 36%, p = 0.047). More intra-hospital cardiovascular complications were noted in G2 (37% vs 12% p = 0.03). There were no significant differences in terms of bleeding complications’ occurrence, hemodynamic instability, incidence of healthcare-associated infections, barotrauma complications and length of ICU stay. Multivariate analysis showed that sulodexide use was an independent protective factor against thromboembolic events (OR = 0.57; 95% CI [0.6–0.8]; p = 0.04).Follow-up of patients after three months of discharge showed no difference in terms of cardiovascular complications or post-COVID effects.

Conclusion: In this preliminary study, it appears that sulodexide may reduce the risk of thromboembolic and cardiovascular complications in severe COVID-19 patients without affecting the final outcome. Further prospective, multicentre studies with endothelial function studies are needed to confirm this contribution.

Compliance with ethics regulations: Yes in clinical research.

FC-063 Impact of corticosteroids on coagulation profile of critically ill COVID-19 patients—a before-after study

GABARRE Paul1, URBINA Tomas1, CUNAT Sibylle2, MERDJI Hamid 2,3, BONNY Vincent1, LAVILLEGRAND Jean-Rémi1,4, RAIA Lisa1, BIGE Naike1, BAUDEL Jean-Luc1, MAURY Eric1, GUIDET Bertrand1, HELMS Julie2,3, AIT-OUFELLA Hafid1,4

1Hôpital Saint Antoine, Paris, France; 2Hôpital civil, Strasbourg, France; 3INSERM, UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France; 4INSERM U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France.
Correspondence: Paul GABARRE (paulgabarre@hotmail.com)

Annals of Intensive Care 2022, 12(1):FC-063

Rationale: Several studies have reported an increased risk of thrombotic events in COVID-19 patients, but the pathophysiology of this procoagulant phenotype remains poorly understood. In addition to direct virus-induced endothelial injury, systemic release of pro-inflammatory cytokines may be involved. We hypothesized that corticosteroids may attenuate this procoagulant state through their anti-inflammatory effects.

Patients and methods/Materials and METHODS: We conducted a before/after bi-centric cohort study among ICU patients hospitalized for severe COVID-19 and receiving therapeutic anticoagulation by unfractionated heparin (UFH). Before and after the standardized use of dexamethasone (DXM), we compared inflammatory and coagulation profiles, as well as the kinetics of heparin requirement, adjusted for weight and anti-Xa activity.

Results: Eighty-six patients were included, 35 in the no-DXM group, and 51 in the DXM group. At admission, CRP and fibrinogen levels were not different between groups, neither were UFH infusion rates. At day 3 after ICU admission, CRP (178 ± 94 mg/L vs 99 ± 68 mg/L, p < 0.0001) and fibrinogen (7.2 ± 1.4 g/L vs 6.1 ± 1.4 g/L, p = 0.0001) significantly decreased in the DXM group, but did not in the no-DXM group. From day 4, UFH infusion rates became lower in the DXM group (Day 4: 435 ± 190 vs 360 ± 96 UI/kg/24 h p = 0.038) without any significant difference in plasma anti-Xa activity. CRP variations correlated with heparin dose variations between Day 0 and Day 3 (r = 0.39, p = 0.009). Finally, the incidence of venous thromboembolic events during in-ICU stay was significantly reduced in the DXM group (4 vs 43%, p < 0.0001).

Conclusion: In this before-after bi-centric cohort of critically ill COVID-19 patients, dexamethasone use was associated with a decrease in both pro-inflammatory and procoagulant profile.

Compliance with ethics regulations: Yes in clinical research.

FC-064 Pulmonary embolism in patients with COVID-19 versus non COVID-19 pneumonia

TOUJ Hager1, SAAD Soumaya1, SEDGHIANI Ines1, KDEYMI Henedi1, AOUAINI Khalil1, CHELBI Rym1, BORSALI FALFOUL Nebiha1

1hôpital Habib Thameur, Tunis, Tunisie
Correspondence: Hager TOUJ (hagertouj@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-064.

Rationale: We aim to compare epidemiological, clinical and prognostic characteristics of patients diagnosed with pulmonary embolism (PE) at the emergency department (ED), which we divided into two groups: patients with confirmed COVID-19 pneumonia versus those without it.

Patients and methods/Materials and methods: We conducted a single-centre, retrospective observational study in the period between April 2020 and February 2022. We included patients over 18 years admitted at the ED and diagnosed with PE following computed tomography pulmonary angiography (CTPA). SARS-CoV-2 pneumonia was confirmed by RT-PCR performed in all patients included in our study. Patients were divided into two groups: those affected with COVID-19 Pneumonia and those not affected by it. Patient’s demographics, comorbidities, clinical state and prognosis were collected in both.

Results: 144 patients were included. The mean age was 68 ± 15 years with a sex-ratio of 0.9. 79 patients (55%) were diagnosed with confirmed COVID-19 pneumonia. The mean length of stay at ED was 7 days. The clinical characteristics of both groups are presented in Table 1. The intra-hospital mortality rate was 30%.

Conclusion: The association of SARS-CoV-2 pneumonia and PE leads to a higher morbidity. Our findings therefore suggest that the phenotype of COVID-19 associated PE indeed differs from PE in patients without COVID-19.

Compliance with ethics regulations: Yes in clinical research.

figure bv

Table 1 Baseline characteristics in COVID-19 + group and COVID-19—group.

FC-065 Neutrophil phenotypes and microbicidal activity in SARS-CoV-2 associated ARDS patients

QUELVEN Quentin1, GRÉGOIRE Murielle2, COIRIER Valentin1, ROUSSEL Mikael2, TARTE Karin2, TADIÉ Jean-Marc1, LESOUHAITIER Mathieu1

1CHU Rennes, Pontchaillou, Rennes, France; 2Unitée MIcroenvironment, Cell differentiation, iMmunology And Cancer (MICMAC), UMR INSERM 1236, Rennes, France
Correspondence: Quentin QUELVEN (quentinquelven@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-065

Rationale: The SARS-CoV-2 infection can lead to a severe acute respiratory distress syndrome (ARDS) with prolonged mechanical ventilation and high mortality rate, sharing clinical and biological features with sepsis-induced immune dysfunction. Since neutrophils play a critical role in host defense against infections, the aim of our study was to investigate phenotypic and functional alterations of neutrophils in patients with SARS-CoV-2 associated ARDS.

Patients and methods/Materials and methods: SARS-CoV-2 associated ARDS patients admitted to the ICU, without known immunosuppression, were included. Neutrophil phenotypic maturation and functions (migration, adhesion, Neutrophil Extracellular Trap (NET) release, Reactive Oxygen Species (ROS) production, bacteria/aspergillus killing and phagocytosis) were evaluated within 24 h of ICU admission and at day 7. Furthermore, in a second set of experiments, we investigated the effects of bronchoalveolar lavage (BAL) fluids from SARS-CoV-2 associated ARDS patients on neutrophils.

Results: Forty-nine patients were included (Table 1). We found that SARS-CoV-2 associated ARDS induced a systemic inflammation with an increase of circulating mature neutrophils. However, we found a significant decrease in CD66b expression (a marker of granulocyte activation involved in adhesion to endothelial cells, degranulation, and reactive oxygen species (ROS) production). Neutrophil antifungal activity against Aspergillus fumigatus was not impaired in patients with SARS-CoV-2 associated ARDS.

Conclusion: Although neutrophils ROS production from patients with SARS-CoV-2 associated ARDS was significantly decreased, our results do not support that the increased risk of invasive aspergillosis is linked to neutrophil dysfunction.

Compliance with ethics regulations: Yes in clinical research.

figure bw

Table: Demographic data and outcomes of patients admitted to intensive care for SARS-CoV-2 associated ARDS.

FC-066 High plasma hyaluronate is associated with mortality in critically-ill patients with SARS-CoV-2 infections

BONNY Vincent1, URBINA Tomas1, ELABBADI Alexandre2, GABARRE Paul1, MISSRI Louaï1, EHRMINGER Sebastien1, DESNOS Cyrielle2, GUIDET Bertrand1, MAURY Eric1, VOIRIOT Guillaume2, CHANTRAN Yannick1, MARIO Nathalie1, JOFFRE Jérémie1, AIT-OUFELLA Hafid1

1Hôpital Saint-Antoine, Paris, France; 2Hôpital Tenon, Paris, France
Correspondence: Vincent BONNY (vincent.bonny@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-066

Rationale: SARS-CoV-2 infection could be responsible for life-threatening severe lung damage with inflammatory cell infiltration, increased vascular permeability and fluid leakage. Hyaluronic acid (HA) is an extracellular matrix polysaccharide, detected in large amounts in lung alveoli in lethal cases of COVID-19 patients. HA which is released by inflammatory cells may be involved in the pathophysiology of alveolar exudate formation through fluid retention. We aimed to evaluate the relationship between plasma HA levels and the outcome of critically ill COVID-19 patients.

Patients and methods/Materials and methods: We performed an observational, bi-center study including patients admitted to intensive care unit with a confirmed laboratory SARS-CoV-2 infection, for acute respiratory failure between April 2020 and December 2020. Plasma level of hyaluronan was measured by ELISA.

Results: Overall, 120 patients were included in this study, median age was 62 [53–70] years, 25 patients (21%) were female, median SOFA score was 3 [2–6] at ICU admission. 76 patients (63%) required invasive mechanical ventilation. At admission, median PaO2/FiO2 ratio was 157 [112–221] mm Hg, mortality at day 28 was 20%. Median HA level was 177 [68–356] ng/mL at admission. HA levels were twofold higher in non-survivors (379 [90–914] vs 150 [62–283] ng/mL), p = 0.01) whereas CRP and fibrinogen were not different according to the outcome. HA levels correlated with PaO2/FiO2 (R = − 0.22, p = 0.02, Pearson test) but did not correlate with CRP.

Conclusion: Plasma HA levels were associated with poor outcome in critically ill patients with SARS-CoV-2 infections.

Compliance with ethics regulations: Yes in clinical research.

FC-067 Serum complement C3 and C4 prediction of mortality in critically ill COVID19 patients

MESSAOUD Linda1, JAMOUSSI Amira1, AYED Samia1, RACHDI Emna1, JARRAYA Fatma1, YAALAOUI Sadok1, BESBES Mohamed1, BEN KHELIL Jalila1

1hôpital Abderrahmen Mami, Ariana, Tunisie
Correspondence: Linda MESSAOUD (lyndamessaoud1991@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-067

Rationale: The complement system has many protective effects against infectious agents following activation during innate immunity, through the alternative and lectin pathways, and acquired immunity, through the classical pathway. However, adverse events were observed in COVID-19 following activation of the complement system by the prolonged release of pro-inflammatory mediators. We aimed to investigate ability of serum complement C3, C4 to predict mortality in patients with critical COVID-19.

Patients and methods/Materials and methods: Prospective study carried in respiratory medical intensive care unit of Abderrahmen Mami teaching hospital. It included critically ill patients diagnosed with COVID-19 between September 2020 and December 2021. Complement C3 and C4 were measured during the first 24 h of hospitalization. C3 and C4 complement deficiency was defined respectively by a concentration below 0.9 g/L and 0.16 g/L respectively. Association with ICU mortality was then analyzed.

Results: During the study period, we enrolled 34 patients. Mean age was of 54 ± 13 years and gender ratio of 1.8. The most common comorbidities were diabetes (36%), obesity (35%) and hypertension (18%). Nineteen patients were transferred to general ward or discharged (survival group) and fifteen died in hospital (non-survival group). The condition of 9 of these patients (27%) degraded during hospitalization and needed invasive mechanical ventilation. The time from hospital admission to intubation varied from 1 to 8 days (median 1 day). During the first 24 h, median C3 was 1.72 g/L [0.6–2.61], and C4 was 0.38 g/L [0.06–0.73]. Six patients (19%) had a C3 deficit and 5 (16%) had a C4 deficit on admission. The overall mortality rate was 56% and the mean length of hospital stay was 10 days [6–17]. Patients who died had lower C3 concentrations in comparison to survivors (1.54 vs 1.85 g/L; p = 0.015). However, no significant difference was found in C4 concentrations (0.36 vs 0.40 g/L; p = 0.595). The level of complement C3 was also lower in patients who required invasive mechanical ventilation (1.42 vs 1.87 p = 0.016) compared to the non-invasive ventilation group.

Conclusion: Serum complement C3 and C4 deficiency can be observed in critical COVID-19 patients. C3 concentrations was significantly lower among non-survivors and invasively ventilated patients.

Compliance with ethics regulations: Yes in clinical research.

FC-068 Early decrease of CD4 and HLA-DR expression on monocytes predicts the severity of COVID-19 pneumonia

ALLARDET-SERVENT Jerome1, AIT BELKACEM Ines2,3, MILOUD Tewfik3, BENAROUS Lucas1, GALLAND Franck2, HALFON Philippe1, MEGE Jean-Louis4, BUSNEL Jean-Marc3, MALERGUE Fabrice3

1HOPITAL EUROPEEN MARSEILLE, Marseille, France; 2CENTRE D'IMMUNOLOGIE MARSEILLE-LUMINY, Marseille, France; 3BECKMAN COULTER IMMUNOTECH, Marseille, France; 4INSTITUT HOSPITALO-UNIVERSITAIRE DE MALADIES INFECTIEUSES, Marseille, France
Correspondence: Jerome ALLARDET-SERVENT (j.allardetservent@hopital-europeen.fr)

Annals of Intensive Care 2022, 12(1):FC-068

Rationale: Early prediction of COVID-19 pneumonia course remains challenging for physicians. Characterization of blood immune cell status may improve patient stratification1. This study investigates the value of a rapid one-step flow cytometry method in patients hospitalized for moderate to severe COVID-19 pneumonia.

Patients and methods/Materials and methods: Thirty patients with laboratory confirmed COVID-19 pneumonia were prospectively included and compared to 19 healthy controls. End-points of interest were the need for intensive care unit (ICU) admission and mechanical ventilation (MV) initiation. Whole-blood immunophenotyping was performed within the first 48 h of hospital admission using three antibody panels (Beckman Coulter, Brea, USA) focusing on leucocytes (DURAClone IM Phenotyping Basic panel), granulocytes (DURAClone IM Granulocytes panel), and myeloid activation markers (IOTest Myeloid Activation Antibody Cocktail: CD169, CD64, HLA-DR). Leucocyte staining and lysis were performed following the one-step method2. Comparisons were performed using Mann–Whitney U test. Receiver operating characteristic (ROC) analysis was used to determine the area under the curve (AUC) of factors associated with ICU admission and MV requirement. Continuous data are presented as median and interquartile.

Results: COVID-19 patients were mostly male (87%), aged 61 [50,71] years, and 12 (40%) were obese. Nine COVID-19 patients (30%) received standard oxygen therapy in the ward while 21 (70%) required ICU admission. Among ICU patients, 7 (23%) received high flow oxygen therapy and 14 (47%) required MV of whom 3 also received extracorporeal membrane oxygenation. Four patients (13%) deceased. We confirmed a COVID-19 signature including: 1) a reduction of HLA-DR expression; 2) decreased basophils, eosinophils, T-cells, NK cells, and non-classical monocyte count; and 3) an upregulation of CD169, CD64, the adhesion/migration markers (CD62L and CD11b), and the checkpoint inhibitor CD274. COVID-19 patients requiring MV presented significantly lower expression of HLA-DR and CD4 on monocytes, as well as reduced CD8+ T-cell count. These three parameters predicted MV requirement with respective AUC of 0.87, 0.87 and 0.79 but their combination increased the AUC up to 0.991 (Fig. 1). Similarly, ICU admission was best predicted by the combination of HLA-DR and CD4 on monocytes with CD4+ T-cell count, yielding an AUC of 0.947.

Discussion: This study further describes the immunophenotypic alterations associated with COVID-19, emphasizes the role of monocytes, and strengthens the clinical potential of a rapid, one-step, flow cytometry method.

Conclusion: HLA-DR and CD4 expression on monocytes, when combined to CD4+ and CD8+ T-cells count, may facilitate the early prediction of ICU admission and MV initiation in hospitalized patients with COVID-19 pneumonia.

Reference 1: Chevrier, S et al. A Distinct Innate Immune Signature Marks Progression from Mild to Severe COVID-19. Cell Rep Med 2021, 2 (1), 100166.

Reference 2: Ait Belkacem, I et al. One-Step White Blood Cell Extracellular Staining Method for Flow Cytometry. Bio-protocol 2021, 11 (16), e4135–e4135.

Compliance with ethics regulations: Yes in clinical research.

figure bx

Immune parameters at hospital admission in COVID-19 patients. A-D: Comparison of HLA-DR and CD4 expression on monocytes and CD4+ and CD8+ T cell count according to MV or ICU admission. B–D: Individual and combined ROC curves of the three best discriminant.

FC-069 Lymphocytic alveolitis in severe COVID-19 pneumonia

REYNAUD Faustine1, RODRIGUEZ Maeva1, ARRIVE François1, VEINSTEIN Anne1, CHATELLIER Delphine1, BOISSIER Florence1, FRAT Jean-Pierre1, COUDROY Rémi1, THILLE Arnaud W.1

1CHU de Poitiers, Poitiers, France
Correspondence: Faustine REYNAUD (faust.reynaud@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-069

Rationale: Neutrophil alveolitis has been reported in the early course of mechanically ventilated patients with COVID-191,2. Whereas lymphocytic alveolitis is described in organizing pneumonia, whether this pattern occurs during the course of COVID-19-related respiratory failure is unknown.

Patients and methods/Materials and methods: Retrospective observational cohort study performed in a single-center. All patients with COVID-19-related respiratory failure admitted to our ICU between September 2020 and June 2021 (second and third wave) and who had broncho-alveolar lavage (BAL) were included. BAL was performed for secondary worsening or lack of improvement after excluding ventilator-associated pneumonia or pulmonary embolism. Secondary worsening was defined as a one-point increase on the World Health Organization 7-point Clinical Progression Scale (WHO-CPS) occurring after steroid discontinuation and after a first step of improvement (at least one-point drop on the WHO-CPS). Lack of improvement was defined as no point-drop on WHO-CPS after ten days of steroids. The primary outcome was the prevalence of lymphocytic alveolitis defined by a lymphocyte count at least 20% of total cellular count.

Results: Among the 182 patients admitted for COVID-19-related respiratory failure over the study-period, BAL was performed in 20 patients with secondary worsening (n = 12) or lack of improvement (n = 8). As compared to the others, patients who underwent BAL were more likely to be intubated (18 of 20 patients, 90% vs. 76 of 162 patients, 47%; p < 0.001), and had longer duration mechanical ventilation (24 days in median [14–39] vs. 10 days [8–15]; p < 0.001). Among the 20 patients who underwent BAL, 10 (50%) had lymphocytic alveolitis including 50% of patients who had BAL for secondary worsening (6 out of 12 patients), and 50% of patients who had BAL for lack of improvement (4 out of 8 patients). All patients with lymphocytic alveolitis received a second course of steroid therapy after BAL. Mortality was 75% in patients with lack of improvement (3 of 4 patients) and 17% (1 of 6 patients) in those with secondary worsening.

Conclusion: Lymphocytic alveolitis was found in half of patients who underwent BAL for secondary worsening or lack of improvement and was associated with good outcomes when a second regimen of steroid was administered to patients with secondary worsening.

Reference 1: Baron A, Hachem M, Tran Van Nhieu J, Botterel F, Fourati S, Carteaux G, De Prost N, Maitre B, Mekontso-Dessap A, Schlemmer F. Bronchoalveolar lavage in patients with COVID-19 with invasive mechanical ventilation for acute respiratory distress syndrome. An.

Reference 2: Cornelissen C, Bergs I, Müller A, Daher A, Kersten A, Balfanz P, Lemmen S, Marx G, Marx N, Dreher M, Müller T. Broncho-alveolar lavage in patients with acute respiratory distress syndrome due to COVID-19. Internal Medicine Journal 51 (2021) 965–967.

Compliance with ethics regulations: N/A.

FC-070 Predictive factors of mortality in critically ill patients with SARS-CoV-2 pneumonia: a prospective study of 301 patients

MORATELLI Giulia1, REGAIEG Kais1, NAKAA Sabrine1, FRAJ Nesrine1, KALLEL Myriam1, AL HARACH Amir1, GAZAIGNE Laure1, GOLDGRAN-TOLEDANO Dany1

1Groupe Hospitalier Intercommunal Le Raincy Montfermeil, Montfermeil, France
Correspondence: Giulia MORATELLI (giulia.moratelli@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-070

Rationale: We want to describe the epidemiological, clinical and outcome of critically ill patients with SARS-CoV-2 pneumonia and to identify risk factors for in-hospital mortality in these patients.

Patients and methods/Materials and methods: We conducted a prospective cohort study of critically ill adults admitted into ICU from Mars 2020 to February 2022 for SARS-CoV-2 pneumonia.

Results: A total of 301 patients were admitted into our ICU for acute respiratory failure due to SARS CoV-2 pneumonia. Mean age was 62 years (25–86). Mean delay to ICU hospitalization was 8 (1–27) days and mean duration of ICU stay was 8 (1–149) days. Mean SAPS was 32 (12–75). Sex ratio (M/F) was 2. Mean body mass index was 30 (18–68). 169patients (56%) had hypertension, 100 (33%) were diabetics and 33 (11%) had chronic kidney diseases. Within the study period, 258 patients (86%) have needed non-invasive ventilation and 250 (83%) had high flow nasal oxygen as first line therapy.143 patients (48%) received mechanical ventilation for a mean duration of 12 days (1–47) and 67 (47%) of them were extubated. 129 patients (43%) needed catecholamine, 41 (14%) renal replacement therapy and 11 (7,7%) ECMO. Different immunomodulator’s therapies were used during study period: 124 patients (41%) received dexamethasone 6 mg/day for ten days, 113 (38%) received dexamethasone 0,1 mg/kg/days for ten days and 26 (8,6%) received bolus of methylprednisolone 250 mg/days for three days as rescue therapy. We have administrated tocilizumab in 22 patients (7,3%). In the univariate analysis, risk factors associated with mortality were age, hypertension, SAPS II, chronic renal diseases, AKI, use of catecholamine and mechanical ventilation. In the multivariate analysis, risk factors associated with mortality were mechanical ventilation and use of catecholamine.

Conclusion: Our experience during this pandemic period is similar to the results of most European studies. The use of mechanical ventilation and catecholamine were associated with a poor outcome. More studies are needed on this subject.

Compliance with ethics regulations: Yes in clinical research.

FC-071 Epidemiological and clinical characteristics of 600 COVID-19 patients

MERBOUH Manal1, EL AIDOUNI Ghizlane1, ALKOUH Rajae1, TAOUIHAR Salma1, ZAID Ikram1, EL MEZZIOUI Sanae1, BOUABDELLAOUI Amine1, AFTISS Fatima1, LAARIBI Ilias1, CHOUKRI Bahouh1, BENCHAIB Rajae1, MIMOUNI Hamza1, MAARAD Mohammed1, MEKKAOUI Ikram1, JEBAR Khaoula1, OUJIDI Younes1, BENSAID Amine1, DOUQCHI Badie1, CHETOUANI Badie1, HOUSSAM Bkiyar1, ABDA Naima1, HOUSNI Brahim1

1CHU Mohammed VI, Oujda, Maroc
Correspondence: Manal MERBOUH (manal.mrb@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-071

Rationale: COVID-19 is a global health crisis. The evolution of the disease is unpredictable with disastrous socio-economic consequences. The aim of the present work is to study the epidemiological, clinical, diagnostic, therapeutic and evolutionary aspects, as well as risk factors associated with SARS-CoV-2 infection in 600 patients, admitted to the intensive care unit of a university hospital during the first wave of the pandemic.

Patients and methods/Materials and Methods: This is a retrospective descriptive and analytical study conducted on patients with COVID-19 between 22 March and 31 December of 2020. Data were collected using computerized medical records on HOSIX and were analyzed by the SPSS software.

Results: Of 600 patients, the median age was 64 years (IQR 15–100), 403 patients were male (sex ratio = 2.05), 387 patients had a BMI above normal, 191 had a history of hypertension, 188 had a history of diabetes. Fever, cough, dyspnea were the predominant symptoms, 379 patients had more than 50% lung involvement on chest CT. The majority of patients had desaturation on admission. Respiratory distress, lymphopenia, thrombocytopenia, elevated CRP and hyperglycemia were significantly associated with an unfavorable outcome. The management was based on synthetic antimalarials associated with azithromycin, corticosteroids, ventilatory support as well as specific management of complications with a good evolution in 67.5% of cases, mean duration of hospitalization in the intensive care unit was 8.2 days varying from 2 to 49 days.

Conclusion: The results of our study are consistent with other series. COVID 19 remains a malignant disease if management is delayed and leads to the development of several complications. Barrier measures remain the best means of prevention against covid-19. Mass vaccination to acquire herd immunity is the way to control this infection.

Compliance with ethics regulations: Yes in clinical research.

FC-072 Prognosis of critically ill patients with acute respiratory failure due to the SARS-CoV-2 501Y.V2 variant: a multicenter retrospective matched cohort study

PUECH Bérénice1, LEGRAND Antoine1, SIMON Olivier1, COMBE Chloé1, JAFFAR-BANDJEE Marie-Christine1, CARON Margot1, VIDAL Charles 1, MAVINGUI Patrick1, BLONDE Renaud 1, BOUE Yvonnick1, BERGUIGUA Hamza1, ALLYN Jerome1, FERDYNUS Cyril1, ALLOU Nicolas1

1CHU Felix Guyon, Saint Denis, Reunion
Correspondence: Bérénice PUECH (berenice.puech@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-072.

Rationale: The aim of this study was to compare the prognosis of patients with acute respiratory failure (ARF) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variant 501Y.V2 to that of patients with ARF due original strain.

Patients and methods/Materials and methods: This retrospective matched cohort study included all consecutive patients who were hospitalized for ARF due to SARS-CoV-2 in our University Hospital between March 2020 and April 2021. Twenty-eight in hospital mortality was evaluated before and after matching.

Results: A total of 218 patients with ARF due to SARS-CoV-2 were enrolled in the study. Of these, 83 (38.1%) were infected with the 501Y.V2 variant. During intensive care stay, 104 (47.7%) patients received invasive mechanical ventilation and 20 (92%) patients were supported by venovenous extracorporeal membrane oxygenation. Patients infected with the 501Y.V2 varient were younger (58 [51–68] versus 67 [56–74] years old, p = 0.003), had less hypertension (54.2% vs 68.1%, p = 0.04), and had less chronic kidney disease (13.3% vs 31.9%, p = 0.002) than patients infected with the original strain. After controlling for confounding variables (62 matched patients in each group), 28-day mortality was higher in the group of patients infected with the 501Y.V2 variant (30.6%) than in the group of patients infected with the original strain (19.4%, p = 0.04).

Conclusion: In our department, where SARS-CoV-2 incidence remained low until February 2021 and the health care system was never saturated, mortality was higher in patients with ARF infected with the 501Y.V2 variant than in patients infected with the original strain.

Compliance with ethics regulations: Yes in clinical research.

FC-073 Characteristics and outcome of critically ill COVID-19 patients

HADDED Amina1, ALILA Ilef1, KHARRAT Sana1, TURKI Olfa1, BAHLOUL Mabrouk1, BOUAZIZ Mounir1

1hopital Habib Bourguiba Sfax, Sfax, Tunisie
Correspondence: Ilef ALILA (ilefalila1323@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-073

Rationale: The Covid-19 pandemic has hit our country as well as countries around the world since December 2019 with its beginning in Wuhan, China. This virus has threatened the life of human beings by attacking various organs, causing especially respiratory distress requiring hospitalization in intensive care unit and causing significant mortality. The aim of this study was to describe the clinical characteristics and outcome of patients with coronavirus disease-2019 (COVID-19) hospitalized in intensive care unit (ICU).

Patients and methods/Materials and methods: We conducted a retrospective study in a medical ICU over a period of 16 months [September 2020–December 2021] including patients with SARS-COV2 infection.

Results: During the study period, 586 patients were included with a mean age of 59.5 ± 14.7 years and a sex ratio of 1.6. The median SAPSII and SOFA score were respectively of 29 ± 14.8 and 4 ± 2.6. Most patients had comorbidities, including hypertension (36%), obesity (32.1%) and diabetes mellitus (36.2%). A total of 419 (71.5%) patients had severe acute respiratory distress syndrome (ARDS). Severe lung damage ranging between 50 and 75% of the lung parenchyma was estimated in 175 patients (30%). 117 (20%) had lung parenchyma damage ≥ 70%. Invasive mechanical ventilation was required in 264 patients (45.1%) for a median of 3 days. During the ICU stay, vasopressor therapy was required in 232 patients (39.6%). Thromboembolic complications were found in 32 (5.5%) patients. Pulmonary embolism was diagnosed in 22 patients (3.8%) and thrombophlebitis in 10 (1.7%). 239 patients (40.8%) developed renal failure during their hospitalization, and only 37 (6.3%) required hemodialysis. Median ICU length of stay was 6 [IQR 3–10] days and overall mortality was 49% (287 patients). Multivariate logistic analysis showed that an age older than 60 years, CRP value > 75 mg/l at admission, invasive mechanical ventilation, occurrence of infection or acute kidney injury were independent predictors of mortality in patients with severe COVID-19.

Conclusion: In this cohort of patients admitted to the intensive care unit, COVID-19 pneumonia was associated with high morbidity and mortality rates. The main clinical predictors were age, CRP value at admission, invasive mechanical ventilation, occurrence of infection or acute kidney injury.

Compliance with ethics regulations: Yes in clinical research.

FC-074 Epidemiology and demographic profile characteristics and outcome of covid-19 patients in intensive care unit at the medical emergency department

TABET AOUL Nabil1,2, ALACHAHER Djamel1,2, GOULMANE Mourad1,2, OUALI DADA Soufiane1,2, SIDI AISSA Nabil1,2, AZZA Mohammed1,2, BOUDADI Hajer2

1Faculty of Medicine of Oran, University Oran 1, Oran, Algerie; 2Medical Emergency Department, University Hospital Center of Oran, Oran, Algerie
Correspondence: Nabil TABET AOUL (tabetrea@yahoo.fr)

Annals of Intensive Care 2022, 12(1):FC-074

Rationale: The recent emergence of COVID-19 has confronted us with an unprecedented global health crisis with a saturation of hospitals, particularly in ICUs and consequently a rate of very high mortality. Our first priority is to improve the prognosis particularly with early management. The aim of this study was to evaluate the characteristics of COVID-19 patients admitted to ICUs and prognosis factors.

Patients and methods/Materials and methods: We conducted a retrospective analysis of COVID-19 patients’ mortality and predictive factors of mortality in ICU at the medical emergency department of UHC of Oran in Algeria between 01/01/2021 au 01/01/2022. Non-survivors were compared to survivors using multivariable analysis. We analyzed age, comorbidities, vaccination status, CT scan results, D-dimer rate at admission and invasive ventilation.

Results: During this period between January 2021, to January, 2022, 223 COVID-19 patients required ICU admission with a peak of 26,9% patients in July and august. In these patients with confirmed COVID-19, the sex ratio was 0.66, patients were older than 60 years in the majority of cases against only 4% under 40 years, and the majority of patients was Unvaccinated (those who have not received any dose of a COVID-19 vaccine). The presence of comorbidities (86%), the peribronchovascular distribution of lesions, the number of zones involved, and especially percentage greater than 50% in 55% cases and D-dimer greater than 1000 (62%) were associated with increased risk of ICU admission. The mortality of this group was higher (66%). Non-survivors were older and had more frequently various comorbid diseases (56% of patients were hypertensive and 43% were diabetic) than survivors. The use of invasive mechanical ventilation was independently associated with an increased mortality in ICU using the multivariable analysis.

Conclusion: In our cohort, patients with the higher mortality were older and had more frequently various comorbid diseases and received invasive mechanical ventilation despite adequate and early management. The initial chest CT scan can predict COVID-19 positivity, ICU admission, mortality, and disease severity.

Compliance with ethics regulations: N/A.

FC-075 Derivation and validation of the CERES score for the prediction of late intubation in Covid-19

GAUDET Alexandre1,2, GHOZLAN Benoit1, DUPONT Annabelle3,4, PARMENTIER—DECRUCQ Erika1,2, BAYON Constance1, TSICOPOULOS Anne2, SUSEN Sophie3,4, POISSY Julien1,5

1CHU Lille, Department of Intensive Care Medicine, Critical Care Center, Lille, France; 2Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d'Infection et d'Immunité de Lille, Lille, France; 3CHU Lille, Service D'hémostase et Transfusion, Centre de Biologie Pathologie, Lille, France; 4Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011 EGID, Lille, France; 5Univ. Lille, Inserm U1285, CHU Lille, CNRS, UMR 8576, UGSF, Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
Correspondence: Alexandre GAUDET (alexandre.gaudet@chu-lille.fr)

Annals of Intensive Care 2022, 12(1):FC-075

Rationale: Predictive scores assessing the risk of respiratory failure in Covid-19 mostly focused on the prediction of early intubation (1). A combined assessment of clinical parameters and biomarkers of endotheliopathy could allow to predict late worsening of acute respiratory failure (ARF) subsequently warranting intubation in Covid-19 (2).

Patients and methods/Materials and methods: Retrospective single-center derivation (N = 92 subjects) and validation cohorts (N = 59 subjects), including severe Covid-19 patients with non-invasive respiratory support for at least 48 h following ICU admission. We used stepwise regression to construct the Covid endothelial and respiratory failure (CERES) score in a derivation cohort, and secondly assessed its accuracy for the prediction of late ARF worsening requiring intubation within 15 days (D15) following ICU admission in an independent validation cohort.

Results: Platelets, fraction of inspired oxygen and endocan measured on ICU admission were identified as the top 3 predictive variables for late ARF worsening and subsequently included in the CERES score. The area under the ROC curve of the CERES score to predict late ARF worsening was respectively calculated in the derivation and validation cohorts at 0.834 and 0.780 (Fig. 1A). A CERES value ≥ 140 showed the best sensitivity to predict late ARF worsening on D15, observed respectively at 1 and 0.93 in the derivation and validation cohorts, while specificity was found at 0.48 and 0.44, respectively. Further, the best specificity for the prediction of late ARF worsening on D15 was observed for a CERES value ≥ 333, being then respectively found at 0.9 and 0.93 in the derivation and validation cohorts, while sensitivity was measured at 0.45 and 0.5 with this cut-off (Fig. 1B).

Discussion: Two distinct clinical applications may be derived from our results. First, we found that a CERES value ≥ 140 has a very high sensitivity for the detection of patients eventually requiring invasive respiratory support. Accordingly, the non-invasive strategy was successful in nearly all patients with a CERES score < 140. We could therefore propose to maintain non-invasive strategies in patients with a CERES score < 140. In the same view, a CERES score ≥ 333, which detected the further need for invasive support with a high specificity, could be used to propose earlier intubation in patients with the highest risk of failure of non-invasive strategies.

Conclusion: In patients with severe Covid-19 undergoing non-invasive respiratory support, CERES values < 140 and ≥ 333 appear as accurate predictors of late worsening of ARF requiring subsequent intubation.

Reference 1: Prakash J, Bhattacharya PK, Yadav AK, Kumar A, Tudu LC, Prasad K. ROX index as a good predictor of high flow nasal cannula failure in COVID-19 patients with acute hypoxemic respiratory failure: A systematic review and meta-analysis. J Crit Care. 2021 Dec;

Reference 2: Dupont A, Rauch A, Staessens S, Moussa M, Rosa M, Corseaux D, et al. Vascular Endothelial Damage in the Pathogenesis of Organ Injury in Severe COVID-19. Arterioscler Thromb Vasc Biol. 2021 May 5;41(5):1760–73.

Compliance with ethics regulations: Yes in clinical research.

figure by

Figure 1. ROC curves for the prediction of late ARF worsening at D15 in the derivation and validation cohorts. A) ROC curves were computerized in derivation and validation cohorts for the CERES score (black plain line), for the top 2 predictive variables.

FC-076 Early vs late intubation in COVID-19 acute respiratory distress syndrome

MESSAOUD Lynda1, JARRAYA Fatma1, RACHDI Emna 1, JEMMALI Rim1, JAMOUSSI Amira1, AYED Samia1, BEN KHELIL Jalila1

1Hôpital Abderrahmane Mami, Ariana, Tunisie
Correspondence: Fatma JARRAYA (fatma.jarraya8@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-076

Rationale: Although management of acute respiratory failure with coronavirus 2019 disease often involves the use of mechanical ventilation, the optimal time to initiate invasive mechanical ventilation (IMV) remains unknown. The aim of this study was to assess the impact of the timing from admission to intubation on mortality in patients with SARS-CoV-2 acute respiratory distress syndrome (ARDS).

Patients and methods/Materials and methods: This retrospective study was conducted in an intensive care unit (ICU) between March 2020 and September 2021. We included adult patients with ARDS secondary to SARS-CoV-2 who required IMV. We did not include patients who were intubated prior to admission. The median time from admission to intubation was 72 h. We defined “early” intubation as intubation within 72 h of ICU admission and “late” intubation as intubation occurring at any time after 72 h. Patients were divided into two groups: early intubation (G1) (≤ 72 h) or late intubation (G2) (> 72 h) for analysis.

Results: During the study period, 298 patients required IMV of which 175 were intubated early (58.7%) and 123 were intubated late (41.3%). The two groups were comparable in terms of age (61 ± 12 years vs 63 ± 11 years; p = 0.086, G1, G2 respectively) and gender ratio (1.69 vs 2.41, G1, G2 respectively). However, patients in G1 had higher SAPSII at admission (32.3 ± 11 vs 28 ± 7; p = 0,002). Patients in the G1 had a worse PaO2/FiO2 ratio (median, 100 mm Hg vs 130 mm Hg; p = 10–3), at the time of intubation in comparison with the G2. Lower static compliance (22 ml/cm H2O vs 28 ml/cm H2O; p = 0.562) and higher plateau pressure (29 cm H2O vs 22 cm H2O; p = 0.180) were noted in the G2, although these values were not statistically significant. The length of stay in the ICU was similar between both groups (8 days [4–15] vs 13 days [9–18]; p = 0.156). Even among survivors who were successfully weaned from mechanical ventilation (n = 25; 8.4%), length of stay was similar between both groups (30 days [12–45] vs 31 days [18–41]; G1, G2 respectively; p = 0.635). There was no significant difference in mortality between patients in G1 and G2 (57.5% versus 42.5% p = 0.159). The overall mortality rate was 91.6% and the average length of hospital stay was 11 days [6–17].

Conclusion: An early intubation strategy was not associated with decreased mortality and morbidity compared to late intubation in patients with ARDS due to SARS-CoV-2.

Compliance with ethics regulations: Yes in clinical research.

FC-077 Correlation between chest electrical impedance variation and tidal volume in mechanically ventilated patients

JOUSSELLIN Vincent1,2, JANIAK Vincent3,4, BONNY Vincent1,2, BUREAU Come1,2, MAYAUX Julien1, MORAWIEC Elise1, TALLEC Gwendoline4, SALEEM Umar4, PINNA Andrea3, DRES Martin1,2

1AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive – Réanimation (Département "R3S"), Paris, France; 2Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France; 3Sorbonne Université, CNRS, LIP6, Paris, France; 4Bioserenity, Paris, France.
Correspondence: Vincent JOUSSELLIN (vincent.joussellin@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-077

Rationale: Chest Electrical Impedance Tomography (EIT) is a non-invasive technique that produces continuous cross-sectional images of regional lung ventilation. Tidal impedance variation has been recently proposed to estimate the tidal volume of patients with acute respiratory failure by using a calibration factor given by the ratio of tidal volume divided by tidal impedance variation (1). Whether this calibration factor can be used in all patients is unknown. This study hypothesized that K-factor varies between patients.

Patients and methods/Materials and methods: We took the opportunity of a study evaluating chest electrical impedance tomography in mechanically ventilated patients. EIT was connected to the ventilator and a 5-min recording was performed while patients were still under pressure support. Median chest impedance variation and median tidal volume were calculated through 100 respiratory cycles over the 5-min period for each patient (or less if respiratory rate was below 20 per minute). K-factor was calculated by dividing median tidal volume by median chest impedance variation and was then expressed in mL/arbitrary units.

Results: Thirty-four patients were included, but only twenty-six had full EIT and ventilator data available. The median K-factor was 0.16 mL/UA (IQR 0.14–0.23 mL/UA) (Fig. 1). After applicating a Pearson correlation, factors associated with K-factor were height (r2 = 0.15, p = 0.04), weight (r2 = 0.50, p < 0.01), level of PEEP (r2 = 0.40, p < 0.01) and hematocrit (r2 = 0.30, p < 0.01).

Conclusion: K-factor largely varies among patients and a single value cannot accurately estimate the tidal volume. K-factor was correlated with other variables than chest impedance variation alone.

Reference 1: 1. Mauri T, Turrini C, Eronia N, et al. Physiologic Effects of High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med. 2017;195(9):1207–1215.

Compliance with ethics regulations: Yes in clinical research.

figure bz

Correlation between K-Factor and weight in 26 patients (K- factor median is represented with a red dash line).

FC-078 Effects of Almitrine administration as rescue therapy in spontaneously breathing patients with severe pneumonia related to SARS-COV-2 treated with high-flow nasal canula oxygen therapy

SACCHERI Clément1, MORAND Lucas1, DOYEN Denis1, HYVERNAT Hervé1, LOMBARDI Romain1, DEVANLAY Raphaël1, PANICUCCI Emilie1, DELLAMONICA Jean1, JOZWIAK Mathieu1

1CHU de Nice, Nice, France
Correspondence: Clément SACCHERI (clement.saccheri@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-078

Rationale: Hypoxemia in SARS-CoV-2 pneumonia results from abnormal ventilation/perfusion ratio related to blunted hypoxic vasoconstriction. Almitrine is a selective pulmonary vasoconstrictor that has been reported to improve the oxygenation in mechanically ventilated patients with acute respiratory distress syndrome related to SARS-CoV-2 pneumonia, but its effects in spontaneously breathing patients treated with high-flow nasal canula oxygen therapy (HFNO) as first-line ventilatory support remain to be determined.

Patients and methods/Materials and methods: In this single-center, observational and physiological study, a bolus of Almitrine was administered (0.5 mg/kg over 30 min) as rescue therapy in spontaneously breathing patients with severe pneumonia related to SARS-CoV-2 treated with HFNO and with persistent severe hypoxemia (PaO2/FiO2 ratio < 100 with FiO2 > 80%) after awake prone positioning failure. Arterial blood gases and transthoracic echocardiography were performed just before and after the Almitrine bolus. Almitrine responder was defined by an increase in PaO2/FiO2 ratio > 20%, that was analyzed in light of thoracic CT-Scan patterns (acute fibrinous and organizing pneumonia (AFOP); diffuse alveolar damage (DAD); bi-basal dependent areas of consolidation) obtained at hospital or ICU admission.

Results: Overall 62 patients were included (34% of female, 60 ± 11 years old). No patient experienced right ventricular dysfunction or acute core pulmonale after Almitrine administration. Almitrine increased the PaO2/FiO2 ratio from 68 (61–79) to 109 (85–156) (p < 0.001) and 46 (74%) patients were responders. Almitrine also decreased the PaCO2 (33 vs. 31 mm Hg, p < 0.001) while the respiratory rate remained unchanged (27 vs. 28 cycles/min, p = 0.45). The CT-Scan patterns distribution was: AFOP in 36 (58%) patients, DAD in 20 (32%) patients, and bi-basal dependent areas of consolidation in 6 (10%) patients. The proportion of Almitrine responders was similar across the different CT-Scan patterns (75% for AFOP, 70% for DAD and 83% for bi-basal dependent areas of consolidation, respectively). The responders had a lower intubation rate (33 vs. 88%, p < 0.001) and shorter ICU length of stay (5(3–9) vs. 10(6–17), p < 0.01) than non-responder patients.

Conclusion: Almitrine iv administration as a rescue therapy in severe COVID-19 pneumonia under HFNO improved oxygenation in responders with a decreased rate of intubation rate. Patterns of the thoracic CT-Scan performed on hospital or ICU admission did not help to predict the response to Almitrine in terms of oxygenation. Further clinical trials are needed to confirm these results.

Compliance with ethics regulations: Yes in clinical research.

FC-079 The use of inhaled nitric oxide (iNO) in Covid19 ARDS patients: a French retrospective registry

VIEILLARD BARON Antoine1, MEKONTSO DESSAP Armand2, PAPAZIAN Laurent3, MERCAT Alain4, HOUETO Patrick14, SCHALLER Manuella14, RAMIREZ Juan Fernando14, LECOURT Laurent13, MEGARBANE Bruno5, HAUDEBOURG Luc6, TIMSIT Jean-François7, TEBOUL Jean-Louis8, KUTEIFAN Khaldoun9, GAINNIER Marc10, SLAMA Michel11, NSEIR Saadalla12

1CH Ambroise Paré (AP-HP), Boulogne Billancourt, France; 2CHU de Créteil_Henri Mondor (AP-HP), Creteil, France; 3CHU MARSEILLE (APHM), Marseille, France; 4CHU d'ANGERS, Angers, France; 5CH LARIBOISIERE (AP-HP), Paris, France; 6CH Pitié Salpêtrière (AP-HP), Paris, France; 7CH BICHAT (AP-HP), Paris, France; 8CH BICETRE (AP-HP), Paris, France; 9CH de MULHOUSE, Mulhouse, France; 10Hôpital La Timone (APHM), Marseille, France; 11CHU Amiens, Amiens, France; 12CHU Lille, Lille, France; 13Air Liquide Healthcare, Gentilly, France; 14Air Liquide Healthcare, Les Loges Josas, France.
Correspondence: Laurent LECOURT (laurent.lecourt@airliquide.com)

Annals of Intensive Care 2022, 12(1):FC-079

Rationale: Inhaled Nitric Oxide (iNO) has been widely used all over the world during COVID19 pandemia1. Previous studies reported conflicting results on the effect of iNO on oxygenation improvement. The objective of this registry was to describe the use of iNO in a large cohort of Covid19 ARDS (CARDS) patients.

Patients and methods/Materials and methods: Multi-center, retrospective cohort registry conducted in 12 French hospitals during the first year of pandemia on CARDS patients treated with iNO. Patients’ characteristics, clinical respiratory support, nitric oxide therapy safety and efficacy parameters and patients’ clinical outcomes were collected. iNO response was defined as PaO2/FiO2 ratio improving by > = 20% after iNO initiation.

Results: From March to December 2020, 300 CARDS patients (22.3% female) were included in the registry. At ICU admission, their median (IQR) age, SAPS II, and SOFA scores were 66 (57–72) years, 37 (29–48), and 5 (3–8), respectively. Patients were still hypoxemic despite protective ventilation (in all patients) and prone positioning sessions (in 68%). At iNO initiation, 2%, 37%, and 61% patients had mild, moderate, and severe ARDS, respectively. Median (IQR) delay between iNO therapy initiation and ICU admission, ARDS diagnosis, and intubation were 7 (3–12), 6 (2–11) and 4 (1–10) days respectively. The median duration of iNO was 2.8 (1.1–5.5) days with a median dosage of 10 (7–13) ppm at initiation. Responders were analyzed at different stages: 45.7% of patients were responders within 6 h following iNO initiation, 56.9% based on the best PaO2/FiO2 ratio within 24 h after iNO initiation and 70.3% patients had at least one response during iNO administration. The severity of ARDS is the only predictive factor associated with iNO response considering the best PaO2/FiO2 ratio obtained within 24 h (Fig. 1). This arterial oxygenation improvement did not impact the patients’ outcomes (length of ICU/hospital stay, ventilation duration, mortality) in the global population. Regarding safety aspects, renal replacement therapy was initiated in 23.5% patients during iNO administration, and 60.5% patients presented a Kdigo score I, II and III within 24 h following iNO initiation, without a formal causal link with iNO.

Conclusion: This registry confirmed the benefits of iNO for arterial oxygenation improvement in severe ARDS patients still hypoxemic after optimization of ventilation and prone positioning.

Reference 1: Clinical characteristics and day-90 outcomes of 4244 critically ill adults with COVID-19: a prospective cohort study Intensive Care Med. 2020 Oct 29: 1–14. https://doi.org/10.1007/s00134-020-06294-x PMCID: PMC7674575 PMID: 33211135.

Compliance with ethics regulations: Yes in clinical research.

figure ca

Severity of ARDS at iNO initiation in iNo responders and non-responders. The distribution of ARDS severity between iNO responders and iNo non-responders was compared using Fisher's exact test.

FC-080 Predicting the outcome of patients with acute respiratory distress syndrome using a miniature transesophageal ultrasound probe

EDDERKAOUI Mehdi1, POULY Olivier1, GOUTAY Julien1, BOUREL Claire1, ONIMUS Thierry1, FAVORY Raphael1, DURAND Arthur1, PREAU Sébastien1

1CHRU LILLE, Lille, France
Correspondence: Mehdi EDDERKAOUI (mehdi-edderkaoui@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-080

Rationale: The objective of the study was to test whether sequential monitoring of the superior vena cava (SVC), by allowing measurement of the superior vena cava collapsibility index (SVCci), could be a prognostic marker in patients with acute respiratory distress syndrome (ARDS).

Patients and methods/Materials and methods: 50 patients admitted to 5 intensive care units (ICU) with moderate to severe ARDS and receiving invasive mechanical ventilation for less than 24 h were prospectively included. The minimum (inspiratory) and maximum (expiratory) telediastolic diameter of the SVC were monitored every 8 h using a miniature ClariTEETM transesophageal ultrasound probe (CLT0110-1, IMACOR, New York NY, USA) for up to 72 h after inclusion. The SVCci was calculated as follows: (maximum diameter − minimum diameter)/maximum diameter. The primary outcome was 90-day mortality.

Results: In-hospital mortality censored at 28 and 90 days was of 30% (n = 15) and 34% (n = 17), respectively. The median (interquartile range) length of stay in the intensive care unit (ICU) was 14 days (8–23). The number of days alive without mechanical ventilation at 28 days was 17 (0–23). The mean SVCci measured over the first 24 h after inclusion (SVCci-D1) was significantly higher in survivors compared to non-survivors at 90 days: 0.23 (0.16–0.31) versus 0.17 (0.14 0.21), p = 0.048. The mean SVCci measured over the first 72 h after inclusion (SVCci-D3) was significantly higher in survivors compared to non-survivors at 90 days: 0.22 (0.17–0.24) versus 0.17 (0.14–0.21), p = 0.028. A SVCci-D1 < 0.20 and a SVCci-D3 < 0.22 predicted 90-day mortality with areas under ROC curve (± standard error of the mean) of 0.692 (± 0.079) and 0.692 (± 0.078), sensitivities of 64% and 58%, and specificities of 71% and 88%, respectively.

Conclusion: The mean SVCci measured over the first days after ICU admission, appears to be a prognostic marker of 90-day mortality in patients with moderate to severe ARDS.

Compliance with ethics regulations: Yes in clinical research.

FC-081 Assessment of airway opening pressure with electrical impedance tomography in patients with acute respiratory distress syndrome

LOUIS Bruno2, COUR Martin1, ARGAUD Laurent1, GUÉRIN Claude1

1Hôpital Edouard Herriot Hospices Civils de Lyon, Lyon, France, France; 2Institut Mondor de Recherches Biomédicales, Créteil, France
Correspondence: Claude GUÉRIN (claude.guerin@chu-lyon.fr)

Annals of Intensive Care 2022, 12(1):FC-081

Rationale: Airway opening pressure (AOP) determined in patients with acute respiratory distress syndrome (ARDS) from the inspection of volume-pressure curve (1) should mean that lung ventilation increases once AOP is overcome. To address this issue, we compared AOP measured from both inspiratory volume-pressure curve and electrical impedance tomography (EIT) simultaneously recorded during low flow inflation of the respiratory system. If AOP reflects a critical opening pressure it should correlated with AOP measured with EIT (AOPEIT).

Patients and methods/Materials and methods: In this secondary analysis of a previous study (2) 10 ARDS patients were investigated at positive end-expiratory pressure of 5, 10 and 15 cm H2O in the semi-recumbent position under continuous sedation and paralysis. Airway pressure (Paw) and flow signals were measured at the proximal tip of the endotracheal tube and sent to MP 150 datalogger (Biopac Inc.). Pulmovista EIT device (Drager) was used to assess lung ventilation. The respiratory system was inflated at a 7 L/min constant flow inflation delivered by the ventilator (Evita XL) and airway pressure, flow and EIT signals recorded simultaneously. AOP was defined as the pressure where the volume delivered to the patient was 4 ml greater than the volume delivered to the occluded circuit (1). AOPEIT was estimated during low insufflation from Paw-EIT-derived Volume curves fitted by a sigmoidal equation. When the lower inflexion point was below PEEP, AOPEIT was considered equal to PEEP. The values of AOP and AOPEIT were analysed by using the rho Spearman correlation coefficient and the Bland and Altman representation over 30 pairs. P < 0.05 was set as the statistically significant threshold.

Results: AOP and AOPEIT were significantly correlated (Spearman rho = 0.73, P = 0.000005). The mean bias was 0.44 cm H2O. In 96% (29/30) of the cases the differences observed between the two methods were less than 2 cm H2O.

Conclusion: AOP and AOPEIT are significantly correlated.

Reference 1: (1) Chen et al. AJRCCM 2018.

Reference 2: (2) Guérin et al. J Appl Physiol 2020.

Compliance with ethics regulations: Yes in clinical research.

FC-082 Pattern of FRC variation following prone positioning in Covid-ARDS: evaluation by the nitrogen washin-washout method

LAHMAR Manel1, CHIHAOUI Abir1, BEN AHMED Hedia1, HAMMOUDA Zeineb1, SAADAOUI Oussema1, DACHRAOUI Fahmi1, ABROUG Fekri1, BESBES OUANNES Lamia1

1CHU Fattouma Bourguiba Monastir, Monastir, Tunisie
Correspondence: Manel LAHMAR (firassmal4@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-082

Rationale: Acute Respiratory Distress Syndrome (ARDS) is characterized by reduction of all lung volumes (in particular that of FRC), and a decrease in respiratory system compliance (Crs). Prone positioning which is recommended in severe ARDS allows a more uniform distribution of the ventilation/perfusion ratios with alteration in Crs properties resulting in lung recruitment, FRC increase, and improvement of oxygenation and survival. The alveolar recruitment process is time-dependent with uncertainty about the optimal daily prone duration. The aim of our study is to characterize the pattern of FRC increase (kinetic and magnitude) during the first 24 h following prone positioning in patients with Covid-19 related ARDS (C-ARDS).

Patients and methods/Materials and methods: a prospective observational study conducted between January and October 2021, including consecutive patients admitted to the ICU for severe C-ARDS (PaO2/FiO2 ≤ 150 mm Hg) and requiring tracheal intubation and mechanical ventilation. Patients were ventilated in supine position with a lung protective strategy (Vt ≤ 6 ml/kg of P BW, the highest PEEP level to obtain a plateau pressure ≤ 30 cm H2O). Patients were systematically turned prone and FRC was measured immediately after prone position and every 2 h during the first 24 h. The measurements were carried out using the Nitrogen Wash-in Wash-out technique available on the CARESCAPE R860 respirator (General Electrics, Wisconsin, USA). The usual oxygenation (SaO2/FiO2) and ventilatory mechanics (Csr, and strain) variables were also recorded.

Results: 20 patients (14 men, mean age: 65 ± 9 years, PaO2/FiO2: 105 ± 42, mean static compliance: 28.5 ± 5, mean PEEP: 14 ± 2) were included in the study.

Conclusion: Prone positioning evokes a rapid and progressive improvement in FRC and oxygenation. These effects are associated with improved strain on the lungs.

Compliance with ethics regulations: Yes in clinical research.

figure cb

the FRC variation during the first 24 h following prone positioning

FC-083 Regional airway closure and patients positioning in acute hypoxemic respiratory failure

PAVLOVSKY Bertrand1, LEPROVOST Pierre1, LESIMPLE Arnaud1, DESPREZ Christophe1, TAILLANTOU-CANDAU Mathilde1, RICHARD Jean-Christophe1, MERCAT Alain1, BELONCLE François1

1CHU Angers, Angers, France
Correspondence: Bertrand PAVLOVSKY (bertrand.pavlovsky@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-083

Rationale: Airway closure leading to an interruption of ventilation in the downstream alveoli may be associated with ventilation inhomogeneity and ventilation-induced lung injury. This phenomenon may be detected at the bedside by performing a low-flow insufflation pressure–volume or pressure–time curve. Airway opening may vary across the lung. We aimed to study the regional distribution of airway opening in semi-recumbent and strict supine position in a series of patients with acute hypoxemic respiratory failure (AHRF).

Patients and methods/Materials and methods: Twenty patients admitted to a Medical ICU and intubated for AHRF (PaO2/FiO2 ratio < 300 mm Hg) were enrolled within the 12 first hours after intubation. Patients were ventilated in volume-controlled ventilation (tidal volume 6 mL.kg−1 predicted body weight PBW) and a positive end-expiratory pressure of 5 cm H2O and positioned (1) in the semi-recumbent position (head of bed at 30°) and (2) in the strict supine position (0°). Measurements of end-expiratory lung volume (EELV) using the nitrogen wash-out wash-in technique and reported to PBW, respiratory mechanics, gas distribution using electrical impedance tomography and a low-flow insufflation to detect airway closure were performed after 30 min in each position. One global (obtained with the volume changes measured by the ventilator at the airway opening) and two regional (using regional impedance waveforms to estimate the non-dependent and dependent real-time volume changes) pressure–volume curves were constructed offline using a dedicated software.

Results: Age was 63 [52–71]. PaO2/FiO2 ratio was 240 [140–287] mm Hg, and respiratory system compliance (CRS) was 52 [46–59] mL.cm H2O−1. Twelve patients fulfilled acute respiratory distress syndrome (ARDS) criteria. An airway closure was detected on the airway pressure–volume curve in 3 patients (15%). A regional airway closure was observed in the dependent regions in 6 patients (30%). No difference in PaO2/FiO2 (240 [157–317] vs 227 [135–295], p > 0.999) nor CRS (51 [41–57] vs 53 [47–61] mL.cm H2O−1, p > 0.999) was observed between patients with or without regional airway closure. But EELV/PBW was lower in patients with regional airway closure (16 [15–17] vs 28 [23–34] mL.kg−1 PBW, p < 0.001). Supine position was associated with a decrease in EELV/PBW (25 [18–33] vs 21 [16–34] mL.kg−1, p = 0.009) and an increase (albeit non-significant) in regional airway closure prevalence (45% vs 30%, p = 0.515).

Conclusion: In patients with AHRF, airway closure seems frequent in dependent regions, in particular in strict supine position.

Compliance with ethics regulations: Yes in clinical research.

figure cc

Examples of airway closure patterns in three representative study patients. Left panel: partial airway closure; central panel: global airway closure, with differencial closure between the regions; right panel: absence of airway closure.

FC-084 Corticosteroid for acute exacerbations of COPD in ICU. A French cohort: OUTCOMEREA database

GALERNEAU Louis-Marie1,2, BAILLY Sébastien2, TERZI Nicolas1, RUCKLY Stéphane3, GARROUSTE-ORGEAS Maité4, COHEN Yves5, HONG TUAN HA Vivien6, GAINNIER Marc7, SIAMI Shidasp8, DUPUIS Claire9, DARMON Michael10, AZOULAY Elie10, FOREL Jean-Marie11, SIGAUD Florian1, ADRIE Christophe12, GOLDGRAN-TOLEDANO Dany13, BRUNEEL Fabrice14, DE MONTMOLLIN Etienne15, ARGAUD Laurent16, REIGNIER Jean17, PEPIN Jean-Louis1,2, TIMSIT Jean-François15

1CHU Grenoble Alpes, La Tronche, France; 2Université Grenoble Alpes, INSERM U1300 HP2,, Grenoble, France; 3Département de biostatistiques, Outcomerea, Paris, France; 4Hôpital Franco-Britannique, Levallois-Perret, France; 5AP-HP, Hôpital Avicenne, Paris, France; 6Grand Hôpital de l'Est Francilien, Meaux, France; 7Hôpital de ta Timone, Marseille, France; 8Centre Hospitalier Sud Essonne, Étampes, France; 9CHU Gabriel-Montpied,, Clermont-Ferrand, France; 10AP-HP, Hôpital Saint-Louis, Paris, France; 11Hôpital Universitaire Marseille Nord, Marseille, France; 12Hôpital Delafontaine Hôpital, Saint-Denis, France; 13Groupe Hospitalier Intercommunal Le Raincy Montfermeil, Montfermeil, France; 14Centre Hospitalier de Versailles, Le Chesnay, France; 15AP-HP, Hôpital Bichat, Paris, France; 16Hospices civils de Lyon, Hôpital Edouard Herriot, Lyon, France; 17CHU de Nantes, Nantes, France.
Correspondence: Louis-Marie GALERNEAU (lmgalerneau@chu-grenoble.fr)

Annals of Intensive Care 2022, 12(1):FC-084

Rationale: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a very frequent in intensive care unit (ICU). However, there are few data and conflicting results about corticosteroids therapy for critically ill patients with an AECOPD.

Patients and methods/Materials and methods: In this study, using data from the observational longitudinal cohort OutcomeRea™ database, with 32 french ICU centres participating, we assessed the impact of corticosteroid therapy for patients in ICU for an AECOPD. The prescription of corticosteroids therapy at admission was defined as a daily dose ≥ 0.5 mg/kg of prednisone during the first 24 h after admission in ICU. We assessed the effect of corticosteroids on a main composite criteria including death and invasive mechanical ventilation (IMV) at day 28 after admission in ICU using an inverse probability of treatment weight (IPTW) estimator. Secondary outcomes were: survival analyse at D-28 and D-90, NIV failure, length of stay in ICU and in hospital, duration of ventilation, consumption of antibiotics and adverse effects of corticosteroids.

Results: We included 1,247 patients of which 31,4% was treated by a corticosteroid therapy at admission. Corticosteroids administration at admission was significantly found as protector on the main composite outcome (RR = 0.693 [0.489; 0.98], p = 0.038). For the subgroup of patients with a very severe COPD, the protective effect of corticosteroid therapy on the primary composite outcome was not found (RR = 1,205 [0.577; 2.517], p = 0.6203). There was no significant impact of corticosteroids on failures of NIV, on lengths of stay in ICU and in hospital or on durations of ventilation. We did not observe statistical relation between the corticosteroid prescription at global prescription of antibiotics. However, corticosteroid therapy tended to be associated with longer duration of antibiotics treatment for patients in ICU at least 10 days (effect of corticosteroid therapy on antibiotic-free days at 10-day for the 395 patients with a length of stay in ICU ≥ 10 days: IRR = 0. 776 [0.597; 1.009], p = 0.059)). Nosocomial infectious had the same prevalence in the two groups of patients. But the maximum systolic blood pressure and the levels of urea was higher and the glycemic disorders more frequent when patient received corticosteroids.

Conclusion: A corticosteroids administration at admission in ICU to patients with AECOPD had a protective effect on death or invasive mechanical ventilation at Day 28. Studies on doses to use or the profile of patients to treat are needed.

Compliance with ethics regulations: Yes in clinical research.

FC-085 Use of high-flow oxygen nasal cannula oxygenation in adult patients with sickle cell disease admitted in ICU: a pilot study

PONS Bertrand1, BERTHOD Antoine1, CARLES Michel2, MARTINO Frédéric1

1CHU Guadeloupe, Les Abymes, Guadeloupe; 2CHU NICE, Nice, France
Correspondence: Bertrand PONS (pons.bertrand@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-085

Rationale: Sickle cell disease (SCD) is a life-threatening genetic disorder associated with many chronic and acute complications [1]. Oxygen therapy is one of the cornerstones of management of patients with SCD admitted to the hospital. Recently, high flow nasal cannula (HFNC) oxygenation has emerged, and clinical practice guidelines have been released for the use of HFNC in the overall population [2]. But at this very time, no evidence has been reported of the use of HFNC in patients with SCD. The objective of this pilot study was to evaluate the efficacy and tolerance of HFNC in comparison of conventional oxygen therapy via facial mask (FM) in adult patients with SCD admitted in ICU.

Patients and methods/Materials and methods: Consecutive adult patients with SCD (SS, SC, or SBeta thalassemia) admitted in ICU with clinical symptoms compatible with acute chest syndrome (ACS) were eligible. Early-stage ACS and management of all patients included was defined accordingly to the actual national French guidelines. Randomization defined the initial oxygen therapy during a 4-session course of 5-h oxygen therapy with, alternately, HFNC (FiO2 60%, flow rate 60 L/min) and FM (FiO2 60%, flow rate 15 L/min). Blood samples were analyzed at the beginning and end of each session. Comfort, dyspnea, and tolerance were assessed at multiple predefined times during the study. Accordingly, to the French law, written informed consent was obtained from all patients prior to enrollment.

Results: Seven patients were included and 24 sessions of oxygen therapy have been completed. There was no significant difference in clinical and biological variables between the beginning (H0) and the end (H5) of oxygen therapy session (Tab 1). Median PaO2 throughout the session was higher with HFNC (49 [23, 85] mm Hg) compared to FM (18 [− 26, 30] mm Hg, p = 0.04). Incidence of episodes of desaturation was greater in HFNC vs FM (4 episodes (33%) vs 1 (8%) respectively, p = 0.04) without any episode of severe desaturation (SpO2 < 90%). Comfort was statistically non different between the 2 techniques (9.4 [7–10] under FM vs 8.3 [4.7–9.4] under HFNC, p = 0.31).

Discussion: In our study, HFNC was associated with a greater benefit in term of oxygenation compared to conventional oxygen therapy. Despite the limitations of this study, our results suggest a potential benefit of HFNC use, in term of oxygenation, in SCD patients with acute respiratory failure.

Conclusion: In adult patients with SCD admitted in ICU for acute respiratory failure, HFNC could be of interest to improve oxygenation, compared to conventional oxygen therapy.

Reference 1: 1. Yawn BP, Buchanan GR, Afenyi-Annan AN, et al.: Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members [published correction appears in JAMA 2014; 312(18):1932] [published correction appears in JAMA 2015 Feb].

Reference 2: 4. Rochwerg B, Einav S, Chaudhuri D, et al.: The role for high flow nasal cannula as a respiratory support strategy in adults: A clinical practice guideline. Intensive Care Med 2020; 46(12):2226–2237.

Compliance with ethics regulations: Yes in clinical research.

figure cd

Clinical and biological during oxygen therapy

FC-086 Long-term exposure to ambient air pollution is associated with an increased incidence and mortality of acute respiratory distress syndrome in a large French region

GUTMAN Laetitia1,2, PAULY Vanessa2, ORLEANS Veronica2, PIGA Damien3, CHANNAC Yann3, ARMENGAUD Alexandre3, BOYER Laurent2, PAPAZIAN Laurent1,2

1Assistance publique des hôpitaux de Marseille - Hôpital nord, Marseille, France; 2Faculté de sciences médicales et paramédicales Aix Marseille, Marseille, France; 3ATMOSUD, Marseille, France
Correspondence: Laetitia GUTMAN (laetitiagutman@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-086

Rationale: Air pollution exposure is suspected to alter both the incidence and mortality in acute respiratory distress syndrome (ARDS). The impact of chronic air pollutant exposure on the incidence and mortality of ARDS from various etiologies in Europe remains unknown. The main objective of this study was to evaluate the incidence of ARDS in a large European region, 90-day mortality being the main secondary outcome.

Patients and methods/Materials and methods: The study was undertaken in the Provence-Alpes-Cote-d’Azur (PACA) region. Nitrogen dioxide (NO2), particulate matter (PM2.5 and PM10) and ozone (O3) were measured. The Programme de Médicalisation des Systèmes d’Information (PMSI), which captures all patient hospital stays in France, was used to identify adults coded as ARDS.

Results: From 2016 to 2018, 4,733 adults with ARDS treated in intensive care units were analysed. The incidence rate ratios for 1-year average exposure to PM2.5 and PM10 were 1.207 ([95% confidence interval (95% CI), 1.145–1.390]; P < 0.01) and 1.168 (95% CI, 1.083–1.259; P < 0.001), respectively. The same trend was observed for both 2- and 3-year exposures, while only chronic 1- and 2-year exposure NO2 exposures were related to a higher incidence of ARDS. Increased PM2.5 exposure was associated with a higher 90-day mortality for both 1- and 3-year exposures (OR 1.096 (95% CI, 1.001–1.201) and 1.078 (95% CI, 1.009–1.152), respectively). O3 was not associated with either of incidence or mortality.

Conclusion: Increased exposures to NO2, PM2.5 and PM10 were associated with an increased incidence of ARDS. Increased exposure to PM2.5 was also associated with increased 90-day ARDS mortality.

Compliance with ethics regulations: Yes in clinical research.

FC-087 Clinical practice survey: assessment and ventilatory management of sickle cell patients in intensive care

HAGRY Julien1, MEKONTSO DESSAP Armand2, MONNET Xavier1, RAZAZI Keyvan2, CHANTALAT Christelle1, DE PROST Nicolas2, PHAM Tài1

1CHU Bicêtre, Le Kremlin-Bicêtre, France; 2CHU Henri Mondor, Créteil, France
Correspondence: Julien HAGRY (hagryjulien@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-087

Rationale: Sickle cell disease, a common genetic disease in France, is a haemoglobinopathy characterised by a β-globin abnormality and the production of haemoglobin S. Hyperalgesic vaso-occlusive crisis (VOC) and acute chest syndrome (ACS) are the main complications leading to intensive care units (ICU) admissions. Despite frequent hospitalizations in ICUs, there is heterogeneity in treatment and global management due to a lack of ICU-specific guidelines. We aimed at gathering the medical practices of ICUs nationwide.

Patients and methods/Materials and methods: We carried out an online survey that was sent to medical teams of all ICUs of French hospitals identified as expert centers in the Orphanet database (https://www.orpha.net). Physicians from the same unit sent consensus answers to capture the usual care in their ICU, providing one survey answer per unit. The survey included sections related to: demography; usual pain management, and three clinical situations (hyperalgesic VOC, VOC with chest pain, and ACS with chest pain, dyspnea and fever).

Results: Of 55 centers contacted, 29 (53%) answered the survey, including 18 (62%) university-hospitals, 10 (34.5%) general hospital centers and 1 (3.5%) private hospital. The median [IQR] number of ICU beds was 23 [18–28]. We grouped centers according to the annual number of admissions: 16 (55%) centers admitted less than 10 patients with sickle cell disease per year. Pain management: nitrogen monoxide-oxygen mixture was used in 72% of centers. Nonsteroidal anti-inflammatory drugs were more likely used by centers admitting more than 10 patients per year, though not achieving statistically difference (61.5% vs 25%, p = 0.108). Oxygenation and physiotherapy: conventional oxygen therapy was decided regardless of the oxygen saturation in 52% for VOC and 55% in VOC associated with chest pain or ACS). Physiotherapy and incentive spirometry was systematically prescribed in 69% of the centers during a VOC, 82% in case of VOC with chest pain and 62% during ACS. Ventilatory support: according to physicians, non-invasive ventilation main benefit during ACS was the effect on alveolar recruitment and hypercapnia (90%), but patients’ tolerance seems to be its main limitation for 69%. High-flow nasal oxygen (HFNO) was considered easy to use (86%) and well-tolerated by patients (83%), but to 76% of the responders, its efficacy during ACS needs to be proven by large studies.

Conclusion: Pain and respiratory management of patients with sickle cell disease acute complications seems to be heterogeneous amongst expert centers. Incentive spirometry to treat or prevent ACS needs to be generalized. Further studies evaluating the benefits of HFNO are needed.

Compliance with ethics regulations: Yes in clinical research.

figure ce

Table 1: main management and respiratory devices effects according to the number of patients with sickle cell disease admitted per year.

FC-088 Acute exacerbations in chronic obstructive pulmonary diseases: eosinophil-guided corticosteroid therapy versus standard care

BEN ABA Feriel1, GHARBI Rim2, HAMMOUDA Zeineb1, LAHMAR Manel1, SIKALI Habiba2, FEKIH HASSEN Mohamed2, BESBES Lamia1, ELATROUS Souheil2, ABROUG Fekri1

1Service de réanimation polyvalente CHU Fattouma Bourguiba, Monastir, Tunisie; 2Service de réanimation médicale CHU Tahar Sfar, Mahdia, Tunisie
Correspondence: Feriel BEN ABA (benaba.feriel@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-088

Rationale: Administration of systemic corticosteroid (SC) in acute exacerbations of chronic obstructive pulmonary diseases (AECOPD) patients requiring mechanical ventilation (VM) is controversial. There are biomarkers such as plasmatic eosinophilia (PE) that could predict a beneficial response to SC. The aim of our study was to assess whether a strategy of CS administration based on PE level was not inferior to the standard strategy consisting in systematic administration of CS regardless of the severity.

Patients and methods/Materials and methods: In a bi-centric, prospective, randomized, controlled, and single-blind trial conducted between December 2018 and December 2020, eligible patients over 18 years of age, hospitalized for an AECOPD and requiring ventilatory support (n = 43) were included and randomized to usual care (n = 25) or eosinophil-guided strategy (n = 18). The prescription of SC in the eosinophil-guided group was based on PE (1 mg/kg of prednisone if PE > 2%; no SC if PE ≤ 2%). The primary end- point was whether patients still needed MV in the sixth day or not.

Results: There was no between-group difference for demographics, COPD and acute episode characteristics. Regarding the primary end-point, there was no difference for the type of ventilation modality in the sixth day following the inclusion (Still on MV: 32% versus 39% in the standard group and the eosinophilic group, respectively). A difference of 7% that is less than the 10% which confirm the non-inferiority hypothesis. The relative risk to be still on MV by the 6th day was 1.2 (IC 95%: 0.54–2.7) p = 0.640, reaching the prior fixed non difference margin. Both study groups showed similar secondary outcomes: Treatment failure (p = 0.712), MV duration (p = 0.620), length of stay (p = 0.429) and mortality (p = 0.701). Hyperglycemic episodes due to SC occurred more frequently in the control group (6 cases versus 2) but no statistical significance was found (p = 0.434).

Conclusion: This preliminary study confirms the similarity between a CS sparing strategy based on PE count and the standard systematic administration of CS.

Compliance with ethics regulations: Yes in clinical research.

FC-089 Effect of beta-blockers prescription on the outcome of severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) requiring ICU admission

HAMMOUDA Zeineb1, BOUATTIA Maroua1, BEDHIAFI Emir1, MAATOUK Iyed1, HOURI Fadoua1, LAHMAR Manel1, DACHRAOUI Fahmi1, ABROUG Fekri1, BESBES OUANES Lamia1

1CHU Fattouma Bourguiba MONASTIR, Monastir, Tunisie
Correspondence: Zeineb HAMMOUDA (zanoubia83@hotmail.com)

Annals of Intensive Care 2022, 12(1):FC-089

Rationale: Cardiovascular diseases are frequent comorbidities in patients with COPD and are conditions with large use of beta-blockers (BB). We aimed to evaluate the influence of BB prescription on AECOPD outcome.

Patients and methods/Materials and methods: This is a single-centre retrospective study conducted in a 16-bed ICU of Fattouma-Bourguiba University-hospital. From January 2016 to June 2019, all consecutive patients admitted for an AECOPD and aged ≥ 18 years were included. Exclusion criteria were: AECOPD requiring specific treatment and unavailable long-term follow-up. Patients were divided on 2 groups: (BB+) previously receiving Beta-blockers or requiring Beta-blockers agents upon their admission and (BB-) who did not receive beta-blockers neither previously nor during ICU stay. Data were collected on socio-demographic characteristics, past history and COPD GOLD stage, clinical presentation and labs findings. Severity was assessed using SAPS II and ABG’s parameters. We also recorded details of ICU course. Follow-up data included mortality at 6 months of ICU discharge and life quality assessment using the Clinical COPD Questionnaire (CCQ).

Results: 220 patients were included. Median age was 68 (IQR: 61–75), 88.2% were male with a BMI at 26.12 (23.6–30.1). Main comorbidities were hypertension 83 (37.7%), chronic heart disease 60 (27.3%) and diabetes 40 (18.2%). Median SAPS II was 45 (40–53). Main exacerbation causes were acute left heart failure in 99 (45%) followed by tracheobrochitis 75 (34.1%). NIV was the first-line ventilatory treatment in 88.2% with a failure rate at 26.8%. Median LOS was 16 (IQR 10–27) days with a survival rate at 80.5%. 62 (28.2%) were assigned to BB+ group versus 158 (71.8%) to BB-. Bisoprolol was the most used molecule (96.8%) with a median posology of 2.5(2.5–5) mg. 15 (24.2%) patients were previously receiving BB, indications for BB upon admission were hypertension 39 (62.5%) followed by left heart failure and tachycardia. Comparing the two groups, no major differences in severity assessment, ventilatory management or NIV failure were found. BB+ were older [73 (65–78) versus 67 (60–73.5), p = 0.001] with higher BMI [27.7 (24.7–31.2) versus 24.9 (22–30), p = 0.02] without difference in GOLD staging or long-term NIV requirement (p = 0.4). BB− had lower LOS 15(9.7–23) versus 20.5(12.7–30.2) p = 0.004 with similar rates of ICU complications and mortality. Thus, 6 months mortality was significantly higher in BB- (34.2 versus 17.7%, p = 0.016) [Fig. 1], and recurrence of AECOPD at one-year was lower in BB+ (43.5% versus 58.2%; p = 0.04). No significant difference in CCQ assessment was found (p = 0.2).

Conclusion: Despite similarities in ICU evolution, patients under beta-blockers appears to have better log-term outcome after AECOPD. Further studies might be needed to confirm this result.

Compliance with ethics regulations: Yes in clinical research.

figure cf

Figure 1: Kaplan–Meier survival curves (6 month mortality) according to beta-blockers use status

FC-090 Impact of intubation on the evolution of fractions of inspired oxygen in patients treated with high flow oxygen therapy for COVID-19 associated pneumonia

LAFAY Valentin1, WINISZEWSKI Hadrien1, GUILLIEN Alicia2, CAPELLIER Gilles1

1CHU de BESANCON, service de Réanimation Médicale, Besançon, France; 2Institut pour l’avancée des biosciences, Equipe d’épidémiologie environnementale appliquée au développement et à la santé respiratoire, Grenoble, France
Correspondence: Valentin LAFAY (valentin.lafay@sfr.fr)

Annals of Intensive Care 2022, 12(1):FC-090

Rationale: Since second wave, High Flow Oxygen Therapy (HFOT) is a first line treatment for COVID-19 associated respiratory failure. However, patients treated with HFOT may be exposed for a long time to high Fractions of Inspired Oxygen (FiO2), potentially leading to hyperoxic alveolar injuries. We aimed to determine whether intubating patients after HFOT failure was associated with a decrease in high FiO2 exposure within the 24 first hours following intubation.

Patients and methods/Materials and methods: Among 218 patients admitted for COVID-19 associated pneumonia in Medical Intensive Care Unit (ICU) at Besançon teaching hospital between October 2020 and October 2021, 27 treated with HFOT for more than 24 h before intubation were retrospectively included. The number of hours exposed to FiO2 > 60% and > 90% during the 24 h preceding intubation and the 24 h following intubation were calculated and compared.

Results: Most of the 27 patients were men, with a median age of 71 years-old. Twenty-one patients performed awake prone positioning (PP) under HFOT. The median PaO2/FiO2 was 79 mm Hg before intubation, and 193 mm Hg 24 h after protective ventilation using a median Positive End-Expiratory Pressure (PEEP) of 12 cm H2O. The median dynamic compliance of the respiratory system was 40 mL/cm H2O. All ventilated patients benefited from neuromuscular blockade and PP. Seven (26%) died in ICU. The median number of hours with FiO2 > 60% decreased from 22,5 (Interquartile range—IQR—[20,0; 24,0]) within the 24 h under HFOT preceding intubation to 6,0 [4,0; 9,8] within the 24 h following intubation, corresponding to a median difference of − 15,0 [− 18,0; − 8,8], statistically significant (p < 0,001). The median number of hours with FiO2 > 90% decreased from 3,0 [1,3; 15,5] to 2,0 [1,3; 3,0], corresponding to a median difference of − 2,0 [− 10,0; 0], statistically significant (p = 0,005).

Discussion: Intubation itself likely doesn’t explain the decrease in FiO2. High PEEP, neuromuscular blockade, and prone positioning are confounding factors. FiO2 is also dependent from the target of oxygenation set as a goal. To the best of our knowledge, this study is nevertheless the first caring about this pragmatic issue. Its main limitations are a retrospective and monocentric design, and a small sample size.

Conclusion: In COVID-19 patients treated with high flow oxygen therapy > 24 h, intubation is associated with a statistically significant decrease in high FiO2 exposure. Whether intubation could decrease hyperoxic alveolar injury need to be investigated.

Compliance with ethics regulations: Yes in clinical research.

figure cg

Evolution of the number of hours exposed to FiO 2  > 60% during the 24 h preceding and the 24 h following intubation for each patient

FC-091 Importance of antithrombotic treatment monitoring in ventricular assisted patients

HANAFIA Omar1, PRIEUR-GARROUSTE Julie1, BERTAULT-PERES Pierre1, HONORE Stéphane1, MICHEL Fabrice1

1Hopitaux Universitaires de Marseille, Marseille, France
Correspondence: Omar HANAFIA (omarhanafia@yahoo.fr)

Annals of Intensive Care 2022, 12(1):FC-091

Rationale: We looked at a long-term external ventricular assist device (VAD), it’s a mechanical, pulsatile heart support system. It is indicated for patients with severe heart failure waiting for transplantation or recovery of their ventricular function. VAD imposes a stable and effective antithrombotic strategy. In pediatric resuscitation patients, inter- and intra-individual pharmacokinetic variability makes the use of these treatments with hemorrhagic and ischemic risks difficult. We conducted an evaluation of the professional practices of this strategy within the hospital’s pediatric resuscitation unit.

Patients and methods/Materials and methods: Our monocentric, retrospective study included a population of VAD-implanted patients from December 2017 to January 2020. Clinical data was collected from the computerized patient record. The prescriptions for anticoagulants and antithrombotics were followed on the shipboard prescription. The results of the aggregation tests and the anti-Xa assays were recorded on the laboratory software.

Results: Of the 36 months of the study: 5 middle-aged patients 12 months (sd = 7.9) were implanted with a left mono VAD. 4 patients had dilated cardiomyopathy and one had cardiogenic shock. We had 14 serious vascular incidents of which 4 were hemorrhagic and 10 ischemic. The frequency of tests does not exclude accidents and 67% of them had clinical repercussions. Anti-Xa measurements were 53% (n = 352) in the targets, the arachidonic acid test was effective in 58% (n = 44) of cases and ineffective in 15%, the adenosine diphosphate test was effective in 22% (n = 17) and ineffective in 58%. Dosage re-evaluations were proposed by the pharmacy when targets were not met. These results highlight the difficulty in obtaining and maintaining target rates. Our study did not establish a correlation between the duration under VAD and the number of accidents. By studying the 7 days before each accident, we found that even for patients previously anticoagulated and antiaggregated effectively, 71% of accidents are explained by a punctual but frank exit from the objective.

Conclusion: The number of accidents is not proportional to the frequency of tests, nor to the duration of implantation and it is essential to be constantly in the targets. A study described a decrease in accidents through the appointment of a referral physician to analyze the results on a daily basis and increased awareness of the care team. This allowed us to establish a sustainable strategy throughout the management of the patient, the pharmaceutical team already participates in and that could be improved.

Compliance with ethics regulations: Yes in clinical research.

FC-092 Levosimendan use in pediatric resuscitation: clinical impact and proper use of the medication

HANAFIA Omar1, LESLUYES Bruno1, HONORE Stéphane1, BERTAULT-PERES Pierre1, MICHEL Fabrice1

1Hopitaux Universitaires de Marseille, Marseille, France
Correspondence: Omar HANAFIA (omarhanafia@yahoo.fr)

Annals of Intensive Care 2022, 12(1):FC-092

Rationale: Levosimendan is used as a last resort in severe or decompensated chronic heart failure. For pharmacoeconomic reasons its delivery in our center is subject to a prior agreement, which is why the problem of positioning of this molecule in the therapeutic arsenal of our establishment arises. We carried out a study within the pediatric cardiac resuscitation unit, the objective of which was to analyse the habits of the department and the prescription conditions as well as the profile and the outcome of patients who received a levosimendan cure.

Patients and methods/Materials and methods: This is a retrospective, monocentric study from January 2017 to June 2019. We analysed the service’s paper prescriptions thanks to the prescriptions and the computerized patient record, we recorded the cures, the prescription modalities, the length of hospitalization. We also sought to determine the clinical impact of the first cure via the serum level of nt-proBNP at D-1, D1 and D9 as well as the fate of patients at D30 and D60.

Results: 18 patients were included, the average age was 12.8 months, and the H/F ratio was 0.63. On the first cure: only 6 cures respected the good practices, 7 patients had dobutamine prescribed before the first cure. 11 patients received several cures (2.9 total cures on average). The average length of hospitalization was 72 days. The rate of nt-proBNP decreased by an average of 49% between D-1 and D1 in 10 patients, and increased by 203% in the remaining 8 patients. Between D1 and D9, this rate decreased by an average of 52% in 8 patients and increased by 178% in the remaining 9 patients. At D30 of the first treatment, 1 patient had returned home, 10 were hospitalized, 3 were hospitalized under circulatory assistance and 4 had died. At D60 of the first treatment, 4 patients were at home, 6 were hospitalized, 3 were hospitalized under circulatory assistance, 5 died. The efficacy of levosimendan is evaluated by the improvement of the ventricular ejection fraction, unfortunately this ultrasound parameter does not appear in the PDI for each patient and therefore could not be analyzed in our study.

Conclusion: Levosimendan brings a proven benefit in certain physio-pathological terrains thanks to its singular mechanism of action. However, according to the literature, it is no more effective than dobutamine. Given its cost, it would be fair to continue this multidisciplinary work to redefine the place of this treatment in the therapeutic arsenal of our institution.

Compliance with ethics regulations: Yes in clinical research.

FC-093 Risk factors associated with prolonged ECMO in children: a referral center cohort study

BERGEZ Léa1, LEVY Yael1, LEGER Pierre Louis1, RAMBAUD Jerome1.

1Armand-Trousseau, Paris, France
Correspondence: Jerome RAMBAUD (jerome.rambaud@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-093

Rationale: This study aimed to investigate the characteristics and clinical outcomes of children supported with prolonged ECMO (≥ 28 days) for severe acute respiratory failure or cardiac failure.

Patients and methods/Materials and methods: We conducted a retrospective study in our referral center for ECMO between 2009 and 2020. All pediatric patients age from 28 days to 18 years-old supported with ECMO for ≥ 28 days were included. All neonatal indications for ECMO were excluded. We looked for pre-ECMO treatment such as mechanical ventilation settings, the use of prone positioning, nitric oxide, exogenous surfactant, neuromuscular blockers. We also gathered the ventilation settings at day 1, 3, 7, 14 and 21, outcome criteria as the median duration of ECMO, the length of invasive mechanical ventilation, the length of intensive care stays and the survival rate following intensive care discharge and 6 months after ICU discharge.

Results: On the 223 patients treated by ECMO during the study period, 14 (7%) patients underwent an ECMO run longer than 28 days. Median ECMO run duration was 44 days (28–122). Patients requiring a long ECMO run were younger (574 vs 1079 days), had a significantly lower PaO2/FiO2 ratio (51 vs 62, p < 0.001) and higher mean airways pressure (22 vs 18, p: 0.03). A lower tidal volume at day 7 of ECMO was significantly associated with long run (2.3 vs 4.6, p: 0.02). Higher FiO2 requirement on oxygenator and mechanical ventilator were significantly associated with long-run ECMO at day 7 and 14. Patients having a long run were suffering from more bleeding and infectious complications. Half of the deaths for long run patients were related to palliative care. Survival rate was lower for patients having a long run.

Conclusion: Long run ECMO represent a minority of all case of ECMO. Ventilator parameters at day 7 of ECMO may help to identified theses runs. Early identification of early patients at risk of a long run could be useful to prevent bleeding complication and to prepare potential bridge to transplantation.

Compliance with ethics regulations: Yes in clinical research.

FC-094 Cefepime population pharmacokinetics and dosing regimens optimization in pediatric intensive care unit

DE CACQUERAY Noémie1, HIRT Deborah2, ZHENG Yi2, BILLE Emmanuelle1, LEGER Pierre Louis3, RAMBAUD Jerome3, TOUBIANA Julie1, CHOSIDOW Anais3, VIMONT Sophie3, CHOUCHANA Laurent1, BÉRANGER Agathe1, TRELUYER Jean-Marc1,2, BENABOUD Sihem2, OUALHA Mehdi1

1Necker, Paris, France; 2Cochin, Paris, France; 3Trousseau, Paris, France
Correspondence: Noémie DE CACQUERAY (n_a_cacqueray@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-094

Rationale: Cefepime is commonly used in pediatric intensive care units (PICU) while patients are subject to unpredictable variability in pharmacokinetic (PK) parameters leading to drug concentrations modification. This study aimed to build a population PK model for cefepime in critically ill children, to optimize and individualize initial dosing regimens.

Patients and methods/Materials and methods: Children (age > 1 month and < 18 years, weight > 3 kg) receiving cefepime were included. Cefepime total plasma concentrations were measured using high performance liquid chromatography. Data were modelled using Monolix software and Monte Carlo simulations were performed using a PK target of 100% fT > MIC.

Results: Fifty-nine patients with median (range) age of 13.5 months (1.1 month-17.6 years) and 129 cefepime concentrations were included in the analysis. Cefepime data were best fitted by a one-compartment model and the selected covariates were body weight (BW) through allometric scaling and estimated glomerular filtration rate (eGFR) on clearance (CL). Mean population values for CL and volume (V) were 1.2 L.h−1 and 5.01 L, respectively. According to the simulations, 150 mg.kg−1.day−1 q6h over 3 h or in continuous infusions better achieved the PK target in case of normal or augmented renal clearance.

Conclusion: Extended and more frequent or continuous cefepime infusions are needed in critically ill children with normal or augmented renal clearance. Cefepime displays narrow therapeutic index and require therapeutic drug monitoring.

Compliance with ethics regulations: Yes in clinical research.

FC-095 Meropenem and piperacillin population pharmacokinetics and dosing regimen optimization in critically ill children receiving continuous renal replacement therapy

THY Michael1,3, URIEN Saik3,4, FOISSAC Frantz3,4, BOUAZZA Naim3,4, BILLE Emmanuelle5, BÉRANGER Agathe2,3, RAPP Mélanie2,3, LUI Gabrielle3,6, LESAGE Fabrice2, RENOLLEAU Sylvain2, TRÉLUYER Jean-Marc3,4,6, OUALHA Mehdi2,3

1Assistance Publique-Hôpitaux de Paris, Infectious and tropical diseases department, Bichat University Hospital, Université de Paris, Paris, France, Paris, France; 2Assistance Publique-Hôpitaux de Paris, Paediatric Intensive Care Unit, Necker-Enfants Malades University Hospital, Université de Paris, Paris, France, Paris, France; 3EA 7323 - Pharmacology and Therapeutic Evaluation in Children and Pregnant Women, Université de Paris, France, Paris, France; 4Unité de recherche Clinique-Centre d’Investigation Clinique, Hôpital Cochin-Necker, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015 Paris, France, Paris, France; 5Laboratoire de microbiologie, Hôpital Necker Enfants- Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015 Paris, France, Paris, France; 6Service de pharmacologie clinique, Hôpital Cochin, Université Paris Descartes, Sorbonne-Paris Cité, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France, Paris, France.
Correspondence: Michael THY (michael245thy@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-095

Rationale: High variability in critically ill children receiving Continuous Renal Replacement Therapy (CRRT) increases the risk of inadequate concentrations. We aimed to develop a meropenem (MRP) and piperacillin (PIP) population pharmacokinetic (PK) model in this population and simulate dosing regimens to optimize patient exposure.

Patients and methods/Materials and methods: MRP and PIP plasma concentration was quantified by high-performance liquid chromatography. PK was investigated using a non-linear mixed-effect modeling approach. Monte Carlo simulations were performed to determine the most appropriate therapeutic dosing regimens.

Results: Respectively, for MRP and PIP, 27 patients with an age of 4 [0–11] years old, weight of 16 [7–35] and 32 children with a median (IQR) postnatal age of 2 years (0–11), body weight (BW) of 15 kg (6–38), receiving continuous replacement renal therapy (CRRT) were included. For both MRP and PIP, concentration–time courses were best described by one-compartment model with first-order elimination with body weight (BW) and CRRT flow (Qd) for MRP and residual diuresis (Qu) for PIP as covariates explaining the lower between-subject variabilities on volume of distribution (V) and clearance (CL). For a 70-kg subject patient i, the final equations were: -For MRP: CLi = (CLpop × (BWi/70)0.75) × (Qd/1200)0.4), where CLpop and Vpop are 6 L/h and 35 L respectively. -For PIP: Vi = Vpop × (BW/70)1 and clearance (CL): CLi = (CLpop × (BWi/70)0.75) × (Qu/0.06)0.12), where CLpop and Vpop are 7 L/h and 53 L respectively. After Monte-Carlo simulations for MRP and PIP, we suggested dosing regimens for a target of 100% fT > 4xMIC in Fig. 1.

Conclusion: Optimal antibiotic exposure in critically ill children under CRRT needs an adaptation of the doses to CRRT flow rate for MRP and to residual diuresis for PIP.

Compliance with ethics regulations: Yes in clinical research.

figure ch

Fig. 1 Dosing regimens suggestions for a target of 100% fT > 4xMIC.

FC-096 Septic shock in severe trauma patients in pediatric intensive care

KALOUCH Samira1, FAKHR Kawtar1, AISSAOUI Wissal1, CHLILEK Abdelaziz1

1CHU Ibn Rochd, Casablanca, Maroc
Correspondence: Samira KALOUCH (dr.kalouch@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-096

Rationale: Sepsis is the result of complex interactions between infectious microorganisms and the host's immune, inflammatory, and coagulant responses. The signs of sepsis constitute a continuum of increasing severity, ranging from the trivial association of tachycardia, tachypnea and fever with hyper leukocytosis or leukopenia to the occurrence of circulatory abnormalities, then organ dysfunction, and finally a state of shock that responds more or less easily to vascular filling and vasopressors.

Patients and methods/Materials and methods: This is a descriptive and analytical retrospective study spread over 5 years (January 1, 2015–December 31, 2020) in the pediatric intensive care unit including 47 cases. Statistical analysis is done using SPSS software.

Results: In this study, we report 47 cases of septic shock in severe trauma patients collected in the pediatric intensive care unit of the children's hospital of CHU Ibn Rochd in Casablanca during the years 2015–2020. The study was carried out according to an operating sheet including demographic, clinical, biological, radiological and therapeutic data, followed by statistical analysis using SPSS software 20. The average age is 75 months with a male predominance. The sites of infection were, in descending order, respiratory infection, bacteremia, urinary tract and skin. The germs mainly isolated were Acinetobacter baumanii, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella spp. The evolution was fatal in 59.5% of cases. The prognostic factors retained were the delay of transfer to the intensive care unit > 4 h (p = 0.003), the presence of more than 2 failing organs (p = 0.004), the need for filling > 60 ml/kg (p = 0.02), the use of more than one active substance (p = 0.006), the use of adrenaline (p = 0.01) and the delay of antibiotic therapy > 1 h (p = 0.0006).

Conclusion: Identification of the deficiencies in the management of septic shock and the application of the recommendations of the survivor sepsis campaign would improve the prognosis.

Compliance with ethics regulations: Yes in clinical research.

FC-097 First nosocomial infections in children supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO)

COUSIN Vladimir1, RODRIGUEZ-VIGOUROUS Robert1, KARAM Oliver2, RIMENSBERGER Peter1, POSFAY-BARBE Klara1

1Hôpitaux Universitaires de Genève, Genève, Suisse; 2Children’s Hospital of Richmond at VCU, Richmond, Va, Etats-Unis
Correspondence: Vladimir COUSIN (vladimir.cousin@hcuge.ch)

Annals of Intensive Care 2022, 12(1):FC-097

Rationale: Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) is a standard rescue procedure for patient with refractory shock in Pediatric Intensive Care Unit (PICU). They are at high risk of nosocomial infection with potential severe consequences. Aim of study was to determine the frequency, timing and microbiological specificity of VA-ECMO-related infection.

Patients and methods/Materials and methods: Study period spanned from 01/2008 to 12/2014 with a retrospective charts review; inclusion criteriawere patients with a VA-ECMO support for > 6 h. It was approved by local Ethics Committee (CE 14–231), who waived the need for informed consent. We recorded the first PICU infection during VA-ECMO support. Infection was defined as a positive microbiological sample with clinical signs of infection or clinical signs of severe infection without positive sample. Time to infection, length of VA-ECMO support, PICU stay and risk factors for infection were evaluated.

Results: During study period 41 patients were included, with a mortality of 53%. Mean time with VA-ECMO was 5,6 d (SD 4,7), mean time in PICU was 17.3 d (SD 14,3) (Fig. 1, stratified by infection status). Overall, 34% patients developed an infection, with an incidence of 60/1000 VA-ECMO days. Mean time to first infection was 3.8 d (SD 1.7), with Pseudomonas spp. as the most commonly detected microorganism (42%). Infected sites were ventilator-associated pneumonia (9/14), sternotomy infection (2/14), bloodstream (2/14) and urinary tract infections (1/14). Only length of VA-ECMO support and length of PICU stay were associated with infection: longer VA-ECMO support (> 5 d) (OR 5.9 (CI 95% 1.4–24.6; p = 0.01) or longer PICU stay (> 14 d) (OR 12 (95% CI 2.2–65.5; p = 0.004).

Discussion: In this monocentric study, we described the outcome and infectious complications in 41 patients with pediatric VA-ECMO. Our results underline the high proportion of infections in this population, its occurrence early during the VA-ECMO support period. We highlighted the association of the time with VA-ECMO support and PICU length of stay with the occurrence of infection. However, such findings may be surrogate markers for sicker patients, who are intrinsically more at risk for nosocomial infections rather than a direct impact of duration of VA-ECMO support.

Conclusion: Pediatric patient with refractory shock supported by VA_ECMO are at high risk of nosocomial infection. Strategies aimed at preventing these infections may improve the outcome of these critically ill children.

Compliance with ethics regulations: Yes in clinical research.

figure ci

Kaplan–Meier cumulative probability of survival during PICU stay for patient with veno-arterial exatracorporeal membrane oxygenation (VA-ECMO), depending on infection status. Comparison of curve using log-rank test found significant difference.

FC-098 Non-invasive evaluation of the response to vascular filling in the first three hours of sepsis and septic shock by comparison of two diagnostic strategies

YALAOUI Ilia1,2, BENMATI Abdellatif1,2, BOUHROUM Abdelhafid1, TEBOUL Jean Louis3

1University 3 of Constantine, Faculty of Medicine, Constantine, Algerie; 2Preventive Medicine of Chronic Diseases Laboratory (Med Prev AC), Constantine, Algerie; 3The Kremlin-Bicêtre, Paris XI University, France, Paris, France
Correspondence: Ilia YALAOUI (yalabox@live.fr)

Annals of Intensive Care 2022, 12(1):FC-098

Rationale: Evaluating preload to predict response to vascular filling (RVF) prompts the clinician to have criteria that predict the effectiveness of vascular filling (VF). Changes in the time velocity integral (TVI) of aortic or subaortic blood flow and cardiac output (CO) measured by echocardiography, as well as the passive leg raise (PLR) test, are excellent methods for predicting preload reserve. The objective of this work is to decrease hospital mortality (HM) and to improve survival, quality of RVF prediction and occurrence of incidents related to VF in patients with sepsis or septic shock and in spontaneous ventilation.

Patients and methods/Materials and methods: Through a prospective randomized prognostic trial, comparing two methods of evaluating the prediction of RVF, clinical and echocardiographic, of two groups of adult patients with sepsis or septic shock, in spontaneous ventilation and not previously infused. The clinical hemodynamic measurements collected before and after a 30 ml/kg of crystalloid filling test are: mean arterial pressure (MAP) and urine output (UO) in the control group (CG), as well as the TVI of the flow subaortic (TVIsa) and CO in the preload dependency group (PDG). In the PDG, TVIsa and CO measurements are also taken before and after PLR and VF.

Results: HM in responder patients is zero in sepsis and higher in septic shock and CG more than PDG (83,3% vs 72,7%). Survival is better in patients with PDG, in sepsis and in septic shock. RVF is significantly elevated in PDG compared to CG (92% vs 61,5%), and better in septic shock (77,3%) compared to sepsis (71,4%). There are more incidents in the GC compared to the GPD (19,2% vs 8%). The incidents are absent in sepsis and weak in septic shock (23,8% GC versus 8,7% GPD).

Discussion: Our study provided evidence in the acute phase of sepsis and septic shock in spontaneously ventilated patients, in predicting RVF and managing VF non-invasively and effectively by echocardiography, as well as in improving HM in septic shock, survival and the occurrence of VF-induced incidents.

Conclusion: The non-invasive prediction of RVF, by TVIsa measured by echocardiography, makes it possible to identify responders and non-responders in VF in real time, to test the hemodynamic efficiency of VF, to limit incidents related to overload during VF, to decrease mortality and to improve survival.

Reference 1: Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017; 43(3):304–77.

Reference 2: Jozwiak M, Monnet X, Teboul JL. Implementing sepsis bundles. Ann Transl Med. 2016; 4(17):332.40.

Compliance with ethics regulations: Yes in clinical research.

figure cj

Contribution of echocardiography in the evaluation of the response to vascular filling.

FC-099 Ultrasound-guided subclavian vein catheterization: infraclavicular versus supraclavicular approach

DAFFEF Saoussen1, TRABELSI Becem1, BEN TALEB Ibtissem1, KTATA Hiba1, BEN ALI Mechaal1

1Mohamed Taher Maamouri Teaching Hospital, Anesthesiology and intensive care unit, Nabeul, Tunisie
Correspondence: Saoussen DAFFEF (sawssendaffef91@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-099

Rationale: The subclavian vein (SCV) is the preferred site for central venous catheterization (CVC) in intensive care unit due to its ability to stay patent in hypovolemic situations and lower risk of infections. Difficulty in its ultrasonic visualisation with the infraclavicular (IC) approach is the reason why this approach has fallen out of favour. The ultrasound (US) guided supraclavicular (SC) approach seems to be a good alternative. The aim of this study was to compare the IC and the SC approaches in US-guided SCV catheterization.

Patients and methods/Materials and methods: This was a prospective randomized study (NCT04637347). We included adult patients requiring a CVC in the superior vena cava area. Patients with infection at puncture site, coagulopathy, contralateral pneumothorax, trauma of clavicle and distorted anatomy of the neck were excluded from the study. Patients were randomly divided into two groups: US-guided SCV catheterization using either SC approach (SCGr) or IC approach (ICGr). We used long-axis scanning in combination with in-plane technique for all catheterizations. The primary outcome was the first attempt success rate. Overall success rate, venous scanning time, number of punctures, number of redirections, puncture time, guidewire insertion time, overall catheterization time, incidence of difficulties in catheterization and mechanical complications were secondary outcomes.

Results: We included 110 patients in this study: 55 in the SCGr and 55 in the ICGr. First attempt success rate was significantly higher in SCGr compared to ICGr (81.8% versus 63.6%; p < 10–3). The overall success rate was significantly higher in SCGr compared to ICGr (96.4% versus 85.5%; p < 10–3). Venous scanning time was significantly longer in the ICGr compared to the SCGr (21.7 ± 15.6 s versus 15.35 ± 8.9 s; p < 10–3). The number of punctures was significantly lesser in the SCGr compared to the ICGr (1.2 ± 0.5 versus 46 ± 0.7; p < 10–3). Regarding the number of redirections, the puncture time and the guidewire insertion time, no significant difference was observed between the two groups. The overall catheterization time was significantly shorter in SCGr compared to ICGr (63.13 ± 31.7 s versus 76.34 ± 33.6 s; p < 10–3). The rate of mechanical complications were higher in the ICGr without significant difference (14% versus 5%; p = 0.065). No cases of pneumothorax or malposition were observed in the SCGr however we observed three cases of pneumothorax and two cases of malposition in the ICGr. The incidence of arterial punctures and hematoma formation were comparable between the two groups.

Conclusion: US-guided in-plane catheterization of SCV using SC approach is safe and seems to be a good alternative to the classic IC approach.

Compliance with ethics regulations: Yes in clinical research.

FC-100 Transcranial doppler: easy or difficult technique?

SADAT Souhila1, ZEGHDOUD Dalila 1, BOUGDAL Dalila1.

1EHS Salim Zemirli, Alger, Algeria
Correspondence: Souhila SADAT (sadatsouhila@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-100

Rationale: Transcranial Doppler (DTC) is a specific monitoring of cerebral hemodynamics in the brain-damaged, allowing the evaluation of cerebral blood flow. Purpose of the study: Evaluate the DTC learning curve, because the acquisition of a medical technical gesture is part of a quality approach in the training of junior doctors.

Patients and methods/Materials and methods: The study included ten residents, it took place in three phases, -The first phase: The participating doctors benefited from a theoretical presentation on DTP followed by a practical demonstration lasting three hours. -A second phase: Over a period of three weeks consisted for the junior doctors, a phase in which between 25 to 35 DTCs were carried out. The evaluation by the referent was carried out at each DTC in order to detect any anomalies. -The third phase: Follows the previous phase, it consists of performing ten DTCs by each candidate in order to complete their learning curve. The data for each exam was collected by the candidate. The candidate also provides the results of his DTC as well as that carried out by the referent. This examination concerns the search for the right and left middle cerebral artery with the values of the systolic (Vs), average (Vm) and diastolic (Vd) velocities, the value of the pulsatility index (IP) and the duration of each examination.

Results: The failure rate of completing the DTC was higher in the first and second attempts by our ten learners, which ranged from 60 to 80%, the success and failure rates were similar in the third and fourth trials. From the fifth attempts the success rates are higher than those of failures which vary from 20 to 30%. The comparison of the mean values of Vs, Vm, Vd and IP of the candidates compared to those of the referent made it possible to conclude that there is no significant difference between the results obtained. The comparison of the time taken to perform the DTC by the candidates compared to the referring doctor revealed the presence of a significant difference in the results obtained (P < 0.001).

Conclusion: The DTC is an easy technique, quick to learn, but an evaluation of the sustainability of the acquisition of this technique by the learners is essential.

Compliance with ethics regulations: N/A.

FC-101 Teaching intensive care nurses to recognize the misplacement of endotracheal and nasogastric tubes on chest radiographs

KAMEL Toufik1, SAUVAGE Brice1, LAKHAL Karim2, OTTAVY Gregoire3, JANSSEN-LANGENSTEIN Ralf4, JACQUIER Marine5, LARRAT Charlotte6, JACQ Gwenaëlle 7, E. DAUVERGNE Jérôme 2, MAUGARS Diane3, LABRUYERE Marie5, SIMEON Véronique 6, CUGNART Cécile 8, GIRAULT Christophe9, BOULAIN Thierry1

1Service de Médecine Intensive Réanimation, Centre hospitalier régional d'Orléans,, Orleans, France; 2Service d'Anesthésie-Réanimation, hôpital Laënnec, Centre Hospitalier Universitaire,, Nantes, France; 3Service de médicine intensive-réanimation, CHU de Nantes, France, Nantes, France; 4Service de Médecine Intensive et Réanimation – Hautepierre, CHU de Strasbourg,, Strasbourg, France; 5Service de Médecine Intensive et Réanimation, CHU de Dijon,, Dijon, France; 6Service de Médecine Intensive et Réanimation CHRU de Tours,, Tours, France; 7Service de Réanimation médico-chirurgicale, centre hospitalier de Versailles, Versailles, France; 8Rouen University Hospital, Medical Intensive Care Unit,, Rouen, France; 9Normandie Univ, UNIROUEN, EA 3830, Rouen University Hospital, Medical Intensive Care Unit, Rouen, France
Correspondence: Toufik KAMEL (toufik.kamel@chr-orleans.fr)

Annals of Intensive Care 2022, 12(1):FC-101

Rationale: To assess the effectiveness of a single standardized training on the ability of intensive care registered nurses (RN) to recognize the misplacement of endotracheal and nasogastric tubes on bedside chest radiographs of intensive care unit (ICU) patients.

Patients and methods/Materials and methods: In 8 French ICUs, RNs received a 110-min standardized teaching on the position of endotracheal and nasogastric tubes on chest radiographs. Their knowledge was evaluated within the subsequent weeks. On 20 chest radiographs, each with an endotracheal and a nasogastric tube, they had to indicate whether each tube was in proper or incorrect position. A lower bound of the 95% confidence interval (95%CI) of the mean correct response rate (CRR) was chosen to indicate the training success when > 90%. Residents of the participating ICUs were subjected to the same evaluation (without prior specific training).

Results: One hundred eighty-one RNs were trained and evaluated, and 110 residents evaluated. The mean CRR in RNs was 84.6% (95%CI: 83.3–85.9), significantly higher than in residents (81.4% [95%CI: 79.7–83.2]) (P = 0.003 by t test). Linear mixed modelling handling the centers as random effect variable confirmed the significant difference (P < 0.0001) in CRR between RNs and residents as shown in Fig. 1. For misplaced nasogastric tubes, the mean CCR in RNs was 95.9% (95% CI: 93.9–98.0). Age, sex, seniority, delay between training and evaluation (for RNs) and period of evaluation within the semester of internship (for residents) did not significantly impact (all P > 0.05) on the mean CRR, either in the whole set of participants or in RNs and residents taken separately.

Conclusion: The ability of trained RNs to detect tube misplacement was higher than that observed among residents and was considered satisfactory for detecting misplaced nasogastric tubes. This is encouraging but insufficient to ensure patients safety. Transferring responsibility for reading radiographs to detect the misplacement of endotracheal tubes to intensive care RNs will need a more advanced or more in-depth teaching method than that used in this study.

Compliance with ethics regulations: N/A.

figure ck

Titre: Mean percentage of correct responses by type of tube and by position (correct or incorrect)

FC-102 Involvement of healthcare teams in the evaluation and selection of smart-pumps in intensive care

BRUAIRE Léo-Paul1, BECK Nathalie1, PIERRE DE LA BRIÈRE Jean-Charles1, LEVEAUFRE Guillaume1, ROUSSEL Damien1, LECOUTOUR François1, JORET Aurélie1, GOYER Isabelle1, BROSSIER David1

1CHU de Caen, Caen, France
Correspondence: David BROSSIER (david_brossier@yahoo.fr)

Annals of Intensive Care 2022, 12(1):FC-102

Rationale: Medication errors are a major public health issue. As part of the project of dematerialization of the patient record in our intensive care units, the computerization of the medical prescription and the securing of the administration of the drug were among our objectives. In order to secure the drug circuit and reduce the drug errors, many scientific societies recommend the use of injectable drug delivery devices connected to the computerized medical record, called “smart-pumps”. The main objective of the study was to compare 2 ranges of smart-pumps available in France. The secondary objective was the involvement of the paramedical teams in the choice of their future work tools.

Patients and methods/Materials and methods: We carried out a prospective monocentric, comparative, interventional study, without human involvement of the ranges proposed by B.Braun and a second company between September the 23rd and October, the 15th of 2019, in adult, pediatric and neonatal intensive care units of the Caen university hospital. This assessment was coupled with a satisfaction survey. All staff nurses received a training in the use of the equipment. Subsequently, the nurses trained on the 2 ranges proceeded to the successive evaluation of these throughout two scenarios of application of medical prescriptions. The order in which each nurse evaluated the 2 ranges was randomized. The main criterion of judgement was the overall satisfaction of nursing staff with the use of the devices. The secondary criteria concerned the handling of materials and consumables as well as navigation in drug libraries and the duration of each scenario, timed by a project member.

Results: 77 agents (25% of the nurses concerned) were trained, 54 of whom evaluated the two ranges. The fulfilment of the medical prescription and the installation of the tubing in the pump was considered longer with the range proposed by B.Braun. No other significant difference was observed. However, 56% of nurses advised the range proposed by B.Braun which appeared safer, more ergonomic and less bulky.

Conclusion: To our knowledge, no such study has ever been published. Without observing major differences in use between the two companies, this comparison process allowed us to determine the equipment that seemed to best meet the expectations of the paramedical teams. Moreover, by involving and following the teams in the choice of their work equipment we hope to have strengthened the adherence of the teams to the change of practice induced by the use of smart pumps.

Compliance with ethics regulations: Yes in clinical research.

FC-103 Influence of clinical pharmacist presence on acceptance and delivery of pharmaceutical interventions in a pediatric resuscitation unit

HANAFIA Omar1, HACHE Guillaume1, BERTAULT-PERES Pierre1, HONORE Stéphane1, MICHEL Fabrice1

1Hopitaux Universitaires de Marseille, Marseille, France
Correspondence: Omar HANAFIA (omarhanafia@yahoo.fr)

Annals of Intensive Care 2022, 12(1):FC-103

Rationale: Studies have shown that medication errors are common in intensive care units. The drug management of pediatric and neonatal populations is particularly at risk of iatrogenia due to the pathophysiological characteristics of these populations, the lack of suitable pharmaceutical forms and based on weak agreements. In addition, the clinical situations of these patients are serious and often require complex therapeutic strategies. Securing drug prescriptions is critical in these situations. The objective of this study was to measure the influence of the presence of the clinical pharmacist in the clinical department on the safety of drug prescriptions.

Patients and methods/Materials and methods: We conducted an observational study, before/after a pharmacist was involved in a 30-bed critical care unit. The analysis and daily pharmaceutical validation of prescriptions were performed from the pharmacy on the first part of the study (before). The issuance of Pharmaceutical Interventions (PI) was conducted by telephone and plotted on the printed prescription. For the second part (after), the pharmaceutical validation of the prescriptions was carried out in the service and the PI transmitted orally to the prescribers in person and plotted in the same way. The main criterion for evaluating the securing of prescriptions was the number of PI issued. We also characterized the nature of the PI, the consensus achieved orally, and the achievement of the prescription change suggested by the PI.

Results: We have 351 PI out of 126 days before, these PI mainly concerned overdoses (52%), route and/or inappropriate administration (17%) and non-conformities to the repository (10.8%). 179 children were affected by these IP. We found 1120 IP over 287 days, these IP mainly concerned monitoring (27.8%), overdoses (21.8%) and under dosing (10.1%). 300 children were affected by these IP.

We observed an increase in the number of IP performed per day (2.8 vs 3.9), the average number of IP per patient (2 vs 3.7). An increase in the number of IP accepted (267 vs 756; p = 0.036) and the number of implementations (183 vs 629; p < 0.001) was highlighted.

Conclusion: The presence of the pharmacist in the clinical department increased the number and relevance of PI performed. The nature of PI has evolved with a more patient-centred orientation. Acceptance and achievement rates are better, the percentage of PI achieved is higher, and these results show that PI are both better monitored and better monitored. Risk reduction is best with pharmaceutical expertise through the presence of a clinical pharmacist in the care unit.

Compliance with ethics regulations: Yes in clinical research.

FC-104 A prospective pharmacist review of drug-related problems after ICU discharge: preliminary data

ANDRÉ Sébastien1, ROUSSEAU Anne-Françoise2,3, COLSON Camille2,3, MISSET Benoît2,3, GILLET Manon1

1Hospital Pharmacy Department, University Hospital of Liège, Liège, Belgique; 2Intensive Care Department, University Hospital of Liège, Liège, Belgique; 3University of Liège, Liège, Belgique
Correspondence: Sébastien ANDRÉ (sebastien.andre@chuliege.be)

Annals of Intensive Care 2022, 12(1):FC-104

Rationale: A stay in an intensive care unit (ICU) and the transitions of care are known to be at risk of drug-related problems (DRPs). These problems may contribute to readmissions and development of post-intensive care syndrome. The objective of this monocenter prospective study was to describe the prevalence of specific DRPs in patient’s post-ICU drug treatments.

Patients and methods/Materials and methods: Adults with an ICU stay ≥ 7 days between 16th November 2021 and 25th January 2022 were included if they were enrolled in our post-ICU follow-up program. A pharmacist conducted a full medication review including medication reconciliation. This review was planned in general ward, during the week following ICU discharge. The pharmacist identified potential DRPs that were classified using the Pharmaceutical Care Network Europe Classification for Drug-Related Problems. Tailored interventions were also delivered to general wards clinicians based on identified DRPs.

Results: We included 29 patients (72.4% men, age 59 [33–76] years, ICU stay 19 [7–95] days). Drug treatments were reviewed 5 [2–9] days after ICU discharge. A total of 148 DRPs were identified: 27/29 patients (93.1%) experienced at least 1 DRP and a median of 5 [0–12] DRPs were observed per patient. Most DRPs referred to (potential) adverse drug events (86/148, 58.1%), (potential) non-optimal effect of drug treatment (26/148, 17.6%) and unnecessary drug-treatment (26/148, 17.6%). The main cause of DRPs was related to drug selection (80/160, 50.0%) comprising absence of indication, inappropriate drug according to guidelines and inappropriate combination of drugs. Other causes of DRPs included prolonged duration of treatment (36/160, 22.5%), inappropriate dose or dosage regimen (23/160, 14.4%) and medication reconciliation problem (7/160, 4.4%). Drugs involved in DRPs belonged mainly to the nervous system group, the alimentary tract and metabolism group, and the cardiovascular system group. The most common drugs implied were tramadol and pantoprazole. Based on identified DRPs, 147 pharmacist interventions were discussed with the clinicians. Withdrawal of a drug was the predominant intervention (75/147, 51.0%) followed by provision of information about the DRP, dosage regimen modification, dose change, initiation or resumption of a drug and drug switch. 74.2% of all interventions were accepted by the clinicians.

Conclusion: DRPs were common after ICU discharge. Drugs of the nervous system group and proton pump inhibitors probably require sustained attention. Future research should evaluate the impact of pharmaceutical interventions on mid-term outcomes of ICU survivors.

Compliance with ethics regulations: Yes in clinical research.

FC-105 Evaluation of a negative pressure aerosol protection box to prevent airborne transmission of SARS-COV-2 to healthcare providers in pediatric intensive care

CECÍLIA Rotava Buratti1,2, JOUVET Philippe1, BRIDIER Armelle1, VEILLETTE Marc3, DUCHAINE Caroline3

1Sainte Justine Research Center, University of Montreal, Montreal, Canada; 2Postgraduate program in child and adolescent health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Bresil; 3Research Center of the institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Canada.
Correspondence: Rotava Buratti CECÍLIA (ceciliaburatti@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-105

Rationale: High contagiousness of SARS-COV-2 is caused by bioaerosols’ emission1. The risk of healthcare providers (HCPs) developing infectious diseases through contact with patients is well recognized, and clinical situations involving tissue manipulation with high viral load called “aerosol-generating procedures” (AGP) may increase this risk2. The aim of this study was to investigate the impact of the aerosol protection box, the Splash-Guard Caregivers (SGGC), on the presence of viral particles after an AGP.

Patients and methods/Materials and methods: Prospective observational study conducted between April and June 2020, including the HCPs in charge of children admitted to a Pediatric Intensive Care Unit who tested positive for COVID-19. SGCG (https://rsr-qc.ca/Splashguard-cg/) was not used systematically and room patients analyzed were divided in: SGCG+ and SGCP−. Virus detection was performed in the single room patient’s environment using two methods (air pumps and swabs) on several sites: 1) on the air one meter from the patient’s head (wearable pumps), 2) inside the SGGC from the patient’s air (if used), also 3) on the air near each HCPs (wearable pumps), and 4) at each HCPs forehead (swab) after an AGP. Samples were analyzed for SARS-COV-2 RNA by qPCR.

Results: Eight batches of samples were performed in the single room of SARS-COV-2 + child (SGCG+ n = 3 and SGCG− n = 5). Five samples (11.4%) were qPCR positive for SARS-COV-2 among the 44 analyses. Three of these (14.3%) among the 21 analyses from the group SGCG−: in the air before the AGP (n = 1), in the air near HCP’s head after the AGP (n = 1), and in the HCP forehead swab after the AGP (n = 1). In the group SGCG+, 2 positive samples (8.7%) were observed among the 23 analyses in the HCP forehead swab (n = 1) and in the air near HCP’s head (n = 1), both after an AGP (see Supplementary Table). None of the HCPs studied were infected by SARS-COV2.

Conclusion: Our results document the presence of SARS-COV2 in infected children environment. The protection effect of SGCG needs additional research.

Reference 1: van Doremalen N et al.: Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020.

Reference 2: Nguyen LH et al.: Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Heal 2020.

Compliance with ethics regulations: Yes in clinical research.

figure cl

Supplementary Table: Sample characterization

FC-106 Acute kidney injury in patients with necrotizing soft tissue infection in intensive care unit: a comparative retrospective study

ROZENBLAT David1, URBINA Tomas4, HUA Camille5, RAZAZI Keyvan1,2,3, MEKONTSO-DESSAP Armand1,2,3, DE PROST Nicolas1,2,3, ARRESTIER Romain1,2,3

1Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, CEDEX, Créteil, 94010 Paris, France, Créteil, France; 2Groupe de Recherche Clinique CARMAS, Faculté de Santé de Créteil, Université Paris Est Créteil, CEDEX, Créteil, 94010 Paris, France, Créteil, France; 3INSERM, IMRB, Université Paris Est Créteil, CEDEX, Créteil, 94010 Paris, France, Créteil, France; 4Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France, Paris, France; 5Service de Dermatologie, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, CEDEX, Créteil, 94010 Paris, France, Créteil, France.
Correspondence: Romain ARRESTIER (romain.arrestier@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-106

Rationale: Necrotizing soft tissue infections (NSTI) are life-threatening bacterial infections and often requires admission to intensive care unit (ICU). Severity and specificities of this pathology, such as micro-organisms involved, rhabdomyolysis and nephrotoxic drugs used, could lead to a higher incidence of acute kidney injury (AKI) than in other sepsis conditions. Our objectives were to describe the clinical and biological characteristics of NSTI related AKI and to compare its frequency to a cohort of non-NSTI septic shock.

Patients and methods/Materials and methods: We conducted a single-center retrospective comparative study of patients with NSTI admitted in ICU between 2006 and 2021. Patients < 18 years old, patients with end-stage renal disease requiring dialysis and patients with nosocomial NSTI acquired after 7 days of hospitalization were excluded. Clinical, biological characteristics and outcomes of NSTI patients with AKI were compared to NSTI patients without AKI. A matching analysis of NSTI patients to a historical cohort of patients with septic shock non related to NSTI and admitted in ICU between 2010 and 2013 was performed.

Results: Overall, 77 patients with NSTI were included. Clinical and biological characteristics are described in Table 1. 65 patients (84,4%) developed AKI and 29 (44,6%) displayed stage 3 KDIGO with fourteen patients (21,5%) needed renal replacement therapy (RRT). Time from ICU admission to AKI onset was 1 (0–2) days. Shock at ICU admission was independently associated with AKI (OR = 6.2 [1.3–44.0], p = 0.045). Initiation of antibiotic therapy before ICU admission (OR = 0.05 [0.0–0.6], p = 0.045) and Enterobacteriaceae infections (OR = 0.17 [0.0–0.7], p = 0.02) were associated with a lower risk of AKI. Rhabdomyolysis was not associated with AKI. Total ICU length of stay and mortality were slightly higher for patient with AKI but not statistically different. 45 patients with septic shock non related to NSTI were matched to 45 NSTI patients. The rate of AKI (95,6% vs 84,4%, p = 0,16) and the need for RRT (31,1% vs 26,7%, p = 0,64) were not statistically different between the two groups.

Conclusion: AKI is common in patients with NSTI but is not significantly associated with outcome. Risk factors for AKI in patients with NSTI are shock at ICU admission and late initiation of antibiotherapy, however NSTI is not a risk factor of AKI compared to other etiology of septic shock.

Compliance with ethics regulations: Yes in clinical research.

figure cm

Characteristics and outcome of NSTI patients with and without AKI

FC-107 Cardiorenal syndrome in piglets: development and characterization of a preclinical model

ORIEUX Arthur1,2, PIERONI Laurence2,4, DROUIN Sarah2,4, SAMSON Chloé2, DANG VAN Simon3, MIGEON Tiffany2, HADCHOUEL Juliette2, GUIHAIRE Julien3, MERCIER Olaf3, GALICHON Pierre2,4

1Service de Médecine Intensive Réanimation - CHU de Bordeaux, Bordeaux, France; 2INSERM UMR_S1155, CoRaKiD - Sorbonne Université, Hôpital Tenon, Paris, France; 3INSERM UMR_S999, Hôpital Marie Lannelongue, GHPSJ, Université Paris Saclay, Le Plessis-Robinson, France; 4AP-HP, Paris, France.
Correspondence: Arthur ORIEUX (arthur.orieux@chu-bordeaux.fr)

Annals of Intensive Care 2022, 12(1):FC-107

Rationale: Cardio-renal syndromes (CRS) type 1 and 2 are complex disorders in which cardiac dysfunction leads to kidney dysfunction. However, the mechanisms remain incompletely explained, in particular in right heart failure (RHF). Our objective was to develop an original preclinical model of CRS secondary to RHF associated with post embolic pulmonary hypertension (PH) in piglets.

Patients and methods/Materials and methods: Twelve 2-month-old large white piglets were randomized: group with induction of PH by ligation of the left pulmonary artery followed by weekly iterative embolization (soft tissue adhesive) of the right lower pulmonary artery, or SHAM control group (sham interventions) (Fig. 1). The sacrifice is made after 5 embolizations. We performed hemodynamic evaluation (right cardiac catheterization), echocardiography, laboratory blood, and urine tests. Histological evaluation and immunostaining of renal damage and repair were fulfilled. Measured glomerular filtration rate (GFR) procedures by injection of an exogenous tracer were repeated weekly.

Results: At sacrifice, mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and central venous pressure (CVP) were significantly higher in the PH group: 32 ± 10 vs 13 ± 2 mmHg (p = 0.001); 9.3 ± 4.7 vs 2.5 ± 0.4 mmHg (p = 0.004) and 10 ± 4 vs 6 ± 2 mmHg (p = 0.04) while the cardiac index (CI) was not different. Piglets with PH had right ventricular dysfunction and higher troponin I (302 [53–3054] vs 33 [17–47] ng/mL; p = 0.03). PH piglets showed increased histological marker of kidney injury (acute tubular necrosis-ATN-) and repair (proliferation assessed by Ki67). Albuminuria was increased (4.4 ± 0.6 vs. 2.9 ± 0.4 mg/L; p < 0.001) while serum creatinine (SCr) and uremia were not significantly different between the two groups. Unlike the estimated GFR, the measured GFR decreases from the 3rd week of the protocol. We reported a correlation between PH parameters and kidney function: mPAP (R2 = 0.4, p = 0.03), PVR (R2 = 0.50, p = 0.01) and CVP (R2 = 0.37; p = 0.04), but not with CI.

Conclusion: We reported the first porcine model of SCR on RHF secondary to PH. Renal dysfunction was characterized by ATN, increased albuminuria, and low measured GFR. The GFR estimated from SCr did not informed on renal dysfunction in these young piglets, unlike the measured GFR.

Compliance with ethics regulations: Yes in animal testing.

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Figure 1. Study protocol of pulmonary hypertension induction. D: day; E: embolization; mGFR: measured glomerular filtration rate; LPA: left pulmonary artery; PH: pulmonary hypertension; RHC: right heart catheterization; TTE: transthoracic echocardiography.

FC-108 Impact of positive fluid balance on outcomes in COVID-19 critically ill patients with ARDS

BOUGUEZZI Nabil1, TOUMI Radhouane1,2, MAATOUK Iyed1, BEDHIAFI Amir1, ZOUARI Hajer1, MAATOUK Khalil1, MEDDEB Khaoula1,2, BEN SAIDA Imene1,2, BOUSSARSAR Mohamed1,2

1Medical Intensive Care Unit, Farhat Hached University Hospital, Sousse, Tunisie; 2Research Laboratory N° LR12SP09. Heart Failure. Farhat Hached University Hospital, University of Sousse, Sousse, Tunisie.
Correspondence: Nabil BOUGUEZZI (dr_nabil@live.fr)

Annals of Intensive Care 2022, 12(1):FC-108

Rationale: COVID-19 pandemic represents a major public concern worldwide. Acute respiratory distress syndrome (ARDS) and lung failure are the main lung diseases found in COVID-19 patients. In ARDS patients, positive fluid balance can be associated with prolonged mechanical ventilation, more intensive care unit (ICU) complications, and higher mortality. Objective: The aim of this study was to evaluate the effect of fluid balance on morbidity and mortality in COVID-19 patients admitted to the ICU.

Patients and methods/Materials and methods: We conducted a retrospective observational study from March 2020 to October 2021 in a Medical ICU. Data concerning daily fluid balance, cumulative fluid balance at day 7, PaO2/FiO2 (P/F) ratio and outcomes of Critically Ill COVID-19 patients were obtained from medical records. The acute kidney injury (AKI) severity was classified according to the Kidney Disease Improving Global Outcomes guidelines. The study sample was divided into 2 groups according to fluid balance. Different outcomes (length of stay, invasive mechanical ventilation, acute kidney injury and death) were compared between the 2 groups.

Results: During the study period, 442 critically ill COVID-19 patients were admitted to our ICU. Positive fluid balance was found in 46% of patients (n = 207), and negative fluid balance was found in 53% of cases (n = 235), with a mean of 2271 ± 2285 ml and -2144 ± 2369 ml respectively. The mean cumulative fluid intake at day 7 was − 76 ± 3206 ml. Patients with positive fluid balance had a higher incidence of AKI (58.9%, n = 122) versus (37%, n = 87) (p < 0.001), of capillary leak (39%, n = 80) versus (27.8%, n = 63) (p = 0.013) and a higher mortality (54.4%, n = 112) versus (43.8%, n = 102) (p = 0.027). Mean length of stay was the same for the 2 groups (10.16 ± 6.15 days versus 9.99 ± 6.68 days, p = 0.79). The majority (50.6%, n = 118) required invasive mechanical ventilation (p = 0.11). P/F improved from 132 ± 77 on day 1 to 197 ± 90 on day 7 in negative fluid balance group (p < 10–3). Mean P/F was stable from day 1 and day 7 in positive fluid balance group (123 ± 55 and 129 ± 51 respectively, p = 0.36). Mean fluid balance at day 7 was significantly less for survivors than non survivors (− 505 ± 3364 ml and 413 ± 2961 ml respectively, p = 0.002).

Conclusion: Our study showed that patients with excessive fluid balance had more ICU complications and higher hospital mortality. Therefore, restrictive fluid strategies should be used to improve oxygenation and reduce mortality among COVID-19 patients.

Compliance with ethics regulations: Yes in clinical research.

FC-109 Acute Kidney Injury (AKI) in the intensive care unit (About 151 cases)

KHALEK Khalid1, OULAHIANE Malika1, BOUHOURI Aziz1, AL HARRAR Rachid1

1Service de réanimation chirurgicale des urgences (P.33), CHU Ibn Rochd, Casablanca, Casablanca, Maroc
Correspondence: Oulahiane MALIKA (oulahiane2238@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-109

Rationale: Acute kidney injury (AKI) is a frequent complication in intensive care units (ICU). The mortality remains high due to the aging of the affected population, the multiplicity of causes generating it, the association with other visceral failures and the frequent evolution in a septic context. The aim of this study is to study the different epidemiological and therapeutic aspects of AKI and try to determine the predictive factors of mortality in our population.

Patients and methods/Materials and methods: a descriptive and analytical cross-sectional study, which focused on 151 records of patients admitted to the ICU, who presented an AKI on admission or developed it during hospitalization. This study is spread over a period of 24 months, from 01/2019 to 12/2020.

Results: The incidence of AKI in our series was 17.32%. The average age of the patients was 49 ± 18 years with a male predominance (sex ratio M/F 2.14). The most common risk factors were: injection of contrast (77.9%), mechanical ventilation (67.8%), use of vasopressors (64.2%), nephrotoxic drugs (58%), diabetes (23.3%) and arterial hypertension (19.2%). The time of appearance of AKI was 2 ± 3 days. KDIGO stage 3 was predominant in our patients with a percentage of 53.6% followed by stage 1 (23.8%), and lastly stage 2 with a percentage of 22.5%. Dialysis was used in 18% of the patients. The mortality rate in our series was 62.33% and the factors found to have a significant relationship with death were: age, mechanical ventilation, use of vasopressors, multivisceral failure and septic shock.

Conclusion: A better knowledge of the risk and prognostic factors of AKI could be a major asset for a more effective management.

Reference 1: John R. Prowle, Christopher J. Kirwan and Rinaldo Bellomo. Fluid management for the prevention and attenuation of acute kidney injury. Nat. Rev. Nephrol. 10, 37–47 (2014):11. https://doi.org/10.1038/nrneph.2013.232.

Reference 2: Gaudry S, Ricard J-D, Leclaire C, Rafat C, Messika J, Bedet A, et al. Acute kidney injury in critical care: Experience of a conservative strategy. J Crit Care. déc 2014;29(6):1022–7.

Compliance with ethics regulations: Yes in clinical research.

FC-110 Association of nitrogen balance trajectories with clinical outcomes in critical ill COVID-19 patients: a retrospective single center cohort study

DUPUIS Claire1, BRET Alexandre1, JANER Alexandra1, GUIDO Olivia1, BOUZGARROU Radhia1, DOPEUX Loïc1, HERNANDEZ Gilles1, MASCLE Olivier1, CALVET Laure1, THOUY François1, GRAPIN Kévin1, ADDA Mireille1, BOIRIE Yves1, SOUWEINE Bertrand1

1CHU Gabriel Montpied, CHU Clermont Ferrand, Clermont Ferrand, France
Correspondence: Claire DUPUIS (cdupuis1@chu-clermontferrand.fr)

Annals of Intensive Care 2022, 12(1):FC-110.

Rationale: The intensity and duration of the catabolic phase in COVID-19 patients might differ between survivors and no survivors. The purpose of the study was to assess the association between nitrogen balance (NBAL) trajectories and outcome in critical ill COVID-19 patients.

Patients and methods/Materials and methods: This retrospective study was conducted in intensive care at Clermont Ferrand University Hospital, France. From January 2020 to May 2021. The present study was approved by the Ethics Committee of Clermont Ferrand. Patients over 18 years old with a severe COVID-19 disease were eligible. Patients were excluded if they were referred from another ICU, if their ICU length of stay was < 72 h, and if they were treated by renal replacement therapy during the first seven days after ICU admission. The primary objective was to compare the profile of NBAL during the first two weeks after ICU admission between the patients with ICU death and the other patients. All data were prospectively collected and comprised details on ICU admission and during ICU stay. Vital status was collected at day 60. NBAL was estimated as proposed by Dickerson et all (Ref 1). Statistical analysis Comparisons between the evolution of NBAL depending on outcome was achieved using 2 level ANOVA. At day 3, 5 and 7, to represent the relationship between NBAL and protein intake, linear and non nonlinear models were achieved and the protein intakes necessary to reach a zero NBAL were determined. Sub-group analyses were achieved according to BMI, age, gender.

Results: 99 patients were included in the study. Their characteristics are reported in Table 1. On day 3, a negative similar NBAL was observed in survivors and non survivors: -16.4 g/d [− 26.5; − 3.3] and − 17.3 g/d [− 22.2; − 3.8] (p = 0.54). Then, the trajectories of NBAL over time differ between survivors and non survivors (p = 0.01). In survivors, NBAL increased over time (Patients with a net protein catabolism: 73.9% at day 3 versus 45.5% at day 14) whereas in non survivors, NBAL decreased from day 2 to day 6, and thereafter increased slowly up to day 14 (Patients with a net protein catabolism: 73.3% at day 3 vs 78.9% at day 14). Administrating higher protein amounts were associated with higher NBALs.

Conclusion: We reported a prolonged catabolic state in COVID patients which seemed more pronounced in non survivors than in survivors. Our study underlined the need for monitoring urinary nitrogen excretion to guide protein intakes in COVID-19 patients.

Reference 1: Dickerson, Nutrition, 2005.

Compliance with ethics regulations: Yes in clinical research.

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Characteristic and comparisons of ICU COVID-19 patients between survivors and no survivors

FC-111 Management of renal replacement therapy in adults French intensive care units: a survey practices at the bedside (READIAL)

JOLLY Florian1, JACQUIER Marine1,5, PECQUEUR Delphine2,3, LABRUYÈRE Marie1,2, VINSONNEAU Christophe4, FOURNEL Isabelle2, QUENOT Jean-Pierre1,2,5

1CHU Dijon, Dijon, France; 2INSERM, CIC 1432, Module Epidémiologie Clinique, Dijon, France; 3CHU Dijon-Bourgogne, Centre d’Investigation Clinique, Module Epidémiologie Clinique/Essais Cliniques, Chu Dijon-Bourgogne, Centre D’Investigation Clinique, Module Epidémiologie Clinique/essais Cliniques, France; 4Centre Hospitalier de Bethune, Service de Médecine Intensive Réanimation-Unité de Sevrage Ventilatoire et Réhabilitation, Bethune, France; 5Equipe Lipness, centre de recherche INSERM UMR1231 et LabEx LipSTIC, université de Bourgogne-Franche Comté, Dijon, France.
Correspondence: Jean-Pierre QUENOT (jean-pierre.quenot@chu-dijon.fr)

Annals of Intensive Care 2022, 12(1):FC-111

Rationale: In France, recommendations for renal replacement therapy (RRT) in the intensive care unit (ICU) were published in 2015 and their uptake was recently assessed in a nationwide self-report online survey1. We performed an evaluation of real-life practices in the field in terms of RRT in a representative sample of ICUs across France.

Patients and methods/Materials and methods: The READIAL study was performed from 1 July to 5 October 2021. It was an evaluation of professional practices, and each centre was required to prospectively include 5 consecutive patients. Patients who required initiation of a first RRT using a hemodialysis catheter were eligible for inclusion. Patients with chronic renal failure requiring RRT through a tunneled catheter or an arterio-venous fistula were excluded.

Results: A total of 67 centres (83% of those contacted) agreed to participate, and included a total of 295 analysable patients (8 patients were erroneously included and therefore excluded from analysis). We found divergences between previously declared practices1 and actual practice observed in this study. The main indications for initiation of RRT are detailed in Fig. 1 (left panel), and the main sites of insertion of the first hemodialysis catheter are shown in Fig. 1 (right panel). The vast majority of centres used citrate, unfractionated heparin or NaCl as a catheter lock solution (47%, 24% and 21% respectively).

Conclusion: In this evaluation of professional practices that collected data at the bedside, the modalities of initiation of RRT in the ICU in patients with acute kidney failure were found to be globally in line with guidelines and literature data. The results should be interpreted in light of the limitations inherent to this type of study.

Reference 1: Quenot JP, Amrouche I, Lefrant JY, et al. Blood Purification 2021;4:1–10.

Compliance with ethics regulations: Yes in clinical research.

figure cp

Figure.

FC-112 Scleroderma cardiac crisis: a-life-threatening but reversible complication of systemic sclerosis

VIGNERON Clara1, PÈNE Frédéric1, CHARPENTIER Julien1, MOUTHON Luc1, CHAIGNE Benjamin1

1Hôpital Cochin, Paris, France
Correspondence: Clara VIGNERON (claravigneron@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-112

Rationale: Systemic sclerosis (SSc) heart involvement account for 30% of SSc patient’s deaths.

Patients and methods/Materials and methods: We retrospectively studied patients with previous diagnosis of SSc admitted to the ICU for acute cardiac dysfunction between 2012 and mid-2021.

Results: Nine female patients were included, mainly with diffuse SSc (n = 7, 78%). Six (67%) had digital ulcers. All but one patient complained about physical cardiac symptoms (n = 8, 89%), 5 (56%) had electrocardiogram modifications. Biological exams revealed elevated troponin (705 µg/l [421–1582]) and Nt-pro-BNP (16,062 ng/l [10419–40738]). Patients exhibited severe left ventricular ejection fraction (LVEF) impairment (20% [10–20] vs 58% [53–60] before ICU admission (p = 0.0002)) requiring vasopressors and/or inotropes for 7 patients (78%) and mechanical ventilation or renal replacement therapy for 4 patients (44%). LVEF spontaneously improved during ICU stay (LVEF 40% [30–40] vs 20% [10–20], p = 0.0007) and returned to baseline within 6 months following ICU discharge (LVEF 53% [40–63] vs 58% [53–60]) (Fig. 1). Seven (78%) patients survived the ICU-stay and 4 (44%) were alive at 6 months.

Conclusion: We report an uncommon and specific severe acute life-threatening cardiac dysfunction in SSc patients, which can be reversible but remains associated with a poor long-term prognosis.

Compliance with ethics regulations: N/A.

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Figure 1. Evolution of left ventricular ejection fraction (%): at baseline, at ICU admission and discharge and within 6 months post-ICU discharge in ICU-survivors. *p < 0.05.

FC-113 A simplified algorithm to predict left ventricular systolic function in septic shock patients

BRAULT Clément1, ZERBIB Yoann1, MAIZEL Julien1, SLAMA Michel1

1CHU Amiens-Picardie, Amiens, France
Correspondence: Clément BRAULT (brault.clement@chu-amiens.fr)

Annals of Intensive Care 2022, 12(1):FC-113

Rationale: Septic cardiomyopathy (SCM) is characterized by a transient biventricular dysfunction with reduced contractility. Left ventricular (LV) ejection fraction (LVEF) is the conventional method to determine LV systolic function in septic shock, but is unhelpful to predict mortality. In contrast, the longitudinal strain (LVLS) might aid in early diagnosis of SCM, and was strongly associated with mortality. In this study, we developed an echocardiographic algorithm, using simple bedside parameters, to predict LVEF and LVLS in patients with septic shock.

Patients and methods/Materials and methods: We included all consecutive patients admitted with septic shock (defined in accordance with the Sepsis-2 criteria) or developing a septic shock during the ICU stay. We measured septal and lateral mitral annular plane systolic excursion (MAPSE), septal and lateral mitral S-wave velocity, and the left ventricular longitudinal wall fractional shortening (LV-LWFS). We used a conditional inference tree method to build a stratification algorithm; recursive partitioning was used to stratify the population of interest into subgroups. The best predictor and the corresponding optimal cutoff value were calculated. Bonferroni correction for multiple testing was applied to univariate p values. The tree-building process continued as long as a predictor led to significantly different child nodes.

Results: We included 71 patients (males: 59%; mean ± SD age: 61 ± 15 years). We found that 31% and 73% had an impaired LV systolic function assessed by LVEF and LVLS, respectively. The septal MAPSE, with a threshold of 1.2 cm, was the best parameter to predict the LV systolic function (Fig. 1). Other parameter (such as the S-wave or LV-LWFS) did not allow improving the algorithm’s performance. Septal MAPSE ≥ 1.2 cm predicted normal LVEF with near certainty. Conversely, septal MAPSE < 1.2 cm almost always predicted impaired LVLS, while almost half patients remained with preserved LVEF.

Discussion: Septal MAPSE, used as the main parameter to predict LV systolic function, has several advantages. First, it only requires a simple M-mode measurement, available in all ultrasound devices including handheld machines. Second, MAPSE is easily recorded even in patients with poor acoustic window (including obese patients) because of the high echogenicity of the atrioventricular plane. Third, its reproducibility is excellent even in inexperienced users, and require only minimal training.

Conclusion: Septal MAPSE, easily measurable at bedside and with good reproducibility, might be useful to support clinicians in early detection of SCM, especially when strain is not available or feasible.

Compliance with ethics regulations: Yes in clinical research.

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Proposed algorithm for predicting LV systolic function

FC-114 An impaired global longitudinal strain at speckle tracking is associated with poorer haemodynamic condition irrespectively of the left ventricular ejection fraction during septic cardiomyopathy

GOBÉ Thibaut1, CARELLI Simone1, ROGER Guillaume1, LAI Christopher1, PHAM Tài1, TEBOUL Jean-Louis1, MONNET Xavier1

1Hôpital de Bicêtre, Le Kremlin Bicetre, France
Correspondence: Thibaut GOBÉ (thibautgobe@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-114

Rationale: Global Longitudinal Strain (GLS) is more sensitive than left ventricular ejection fraction (LVEF) to detect impaired contractility during septic cardiomyopathy. However, its evolution over time has been poorly described. Moreover, the clinical importance of an impaired GLS is unclear. In particular, the haemodynamic consequences of an impaired GLS per se have never been reported.

Patients and methods/Materials and methods: In 61 adult patients with septic shock, we performed transthoracic echocardiography to measure LVEF and GLS with speckle tracking within the first 24 h (day-0), at day-1, day-3 and on the day when vasopressors were stopped. Simultaneously, central venous oxygen saturation (ScvO2), blood lactate and cardiac index (PiCCO2 device) were assessed.

Results: Eleven patients were excluded for poor echogenicity or prone positioning at the time of inclusion. The prevalence of a low LVEF (< 45%) was 36% at day-0, 39% at day-1, 38% at day-3 and 14% on the day of vasopressors weaning. At these time points, systolic arterial pressure was 118 [109; 127], 121 [116; 133], 123 [114; 132] and 130 [120; 134] mmHg, respectively. The prevalence of an impaired GLS (> − 16%) was 70% at day-0, 72% at day-1, 75% at day-3 and 58% at vasopressors weaning. Pooling all time points, GLS was correlated with blood lactate (rho = 0.369, 95% confidence interval: [0.213;0.506], p < 0.0001), and ScvO2 (rho = − 0.293 [− 0.457; − 0.110], p < 0.0021). At each measurement time, we classified the cardiac status into three groups: normal LVEF and normal GLS (LVEFn-GLSn, n = 40), normal LVEF and impaired GLS (LVEFn-GLSimpaired n = 52) and low LVEF and impaired GLS (LVEFlow-GLSimpaired, n = 36). Compared to the LVEFn-GLSn group, the LVEFn-GLSimpaired group exhibited a lower cardiac index (2.6 [2.3;3.1] vs. 3.1 [2.6;3.9] L/min/m2, p = 0.03), a higher lactate level (1.7 [1.3;2.3] vs. 1.4 [1.0;2.1] mmol/L, p = 0.04) and lower ScvO2 (67 [63;74] vs. 72 [67;78]%, p = 0.02). In the LVEFlow-GLSimpaired group, cardiac index was lower (2.4 [2.2;2.8] vs. 2.6 [2.3;3.1] L/min/m2, p = 0.03), lactate higher (2.8 [2.0;3.8] vs. 1.7 [1.3;2.3] mmol/L, p = 0.01) than in the LVEFn-GLSimpaired group and ScvO2 was not significantly different (69 [57;74] vs. 67 [63;74]%, p = 0.76) (Fig. 1).

Conclusion: During septic cardiomyopathy, GLS remains impaired in a large proportion of patients when vasopressors are stopped. An impaired GLS is associated with lower cardiac index and poorer tissue oxygenation irrespectively of the value of LVEF. This suggests that an impaired GLS has clinical meaning per se. The study is ongoing.

Compliance with ethics regulations: Yes in clinical research.

figure cs

Comparison of markers of tissue oxygenation between cardiac status subgroups

FC-115 Decrease in lactate level and norepinephrine dosage in the first 24 h of resuscitation is strongly associated with survival in 502 patients with refractory shock

HUGEROT Antonin1, CLERE-JEHL Raphaël1, SUBLON Cédric1, STEIN Julien1, GARIJO Carlos1, GUILLOT Max1, HERBRECHT Jean-Etienne1, JANSSEN-LANGENSTEIN Ralf1, LEROUX Justine1, PEREZ Yonatan1, SCHENCK-DHIF Maleka1, SCHNEIDER Francis1, CASTELAIN Vincent1

1Hôpitaux Universitaires de Strasbourg, Strasbourg, France
Correspondence: Antonin HUGEROT (antonin.hugerot@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-115

Rationale: To determine the prognostic impact of maximum norepinephrine dosage received in the first 24 h following admission to the intensive care unit, regardless of indication, and to determine factors associated with in-ICU and in-hospital mortality.

Patients and methods/Materials and methods: All patients receiving norepinephrine in the first 24 h after admission to our University Hospital intensive care unit between January 1, 2015 and January 1, 2020 were included, retrospectively. We collected for each patient the maximum dosage of norepinephrine and all diagnostic, clinical and biological parameters of interest. Univariate and multivariate inferential statistical analysis was performed.

Results: We included 2009 patients, mean age 66 years, 40% of whom were women, and presenting with septic shock in 53% (n = 1073). Mean SAPS II reached 59 ± 19 points. Mechanical ventilation and renal replacement therapy were required in 77% and 23%, respectively. Intra-ICU and intra-hospital mortality were 32% and 39%, respectively. The median maximum norepinephrine dosage received during the first 24 h was 0.4 µg/kg/min (IQR 0.2–0.85). A significant increase in mortality was observed in uni- and multivariate analysis in patients who received more than 0.85 µg/kg/min of norepinephrine corresponding to the 3rd quartile distribution of maximum norepinephrine dosage, (in-ICU mortality 62%, p < 0.001). Among patients who received more than 0.85 µg/kg/min norepinephrine, defined as refractory shock, decreasing kinetics of lactate and norepinephrine dosage at 24 h were found to be highly significantly and independently associated with patient survival (in-ICU mortality 43%). On the other hand, the need for extrarenal purification or the use of adrenaline were independently associated with excess mortality in this group.

Conclusion: In our study, the threshold of 0.85 µg/kg/min is an independent marker of mortality in patients admitted to the ICU and could be considered to define refractory shock, regardless of diagnosis. However, when dosages higher than this threshold are used, lactate level and norepinephrine doses rapid decrease are strongly associated with a better prognosis. These findings need to be confirmed by further work in other patient populations before being used in clinical practice.

Compliance with ethics regulations: Yes in clinical research.

figure ct

Survival in patients with refractory shock according to kinetics of lactate level and norepinephrine dosage at 24 h

FC-116 Prehospital norepinephrine administration reduces 30-day mortality among septic shock patients

HAJJAR Adèle1, JOUFFROY Romain1,8, GILBERT Basile2, TOURTIER Jean Pierre3, BLOCH-LAINE Emmanuel4, ECOLLAN Patrick5, BOULARAN Josiane6, BOUNES Vincent6, VIVIEN Benoit8, GUEYE Papa7.

1APHP - CHRU Ambroise Paré, Boulogne-Billancourt, France; 2Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France; 3Paris Fire Brigade, Paris, France; 4Emergency Department, Cochin Hospital, Paris, France & Emergency Department, SMUR, Hôtel Dieu Hospital - Assistance Publique - Hôpitaux Paris, Paris, France; 5Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital - Assistance Publique - Hôpitaux Paris, Paris, France; 6SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France; 7SAMU 972 University Hospital of Martinique,, Fort-De-France Martinique, France; 8Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France
Correspondence: Romain JOUFFROY (romain.jouffroy@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-116

Rationale: Despite differences in time of sepsis recognition, recent studies support that early initiation of norepinephrine in patients with septic shock (SS) improves outcome without adverse effects increase. This study aims to investigate the relationship between 30-day mortality in patients with SS and prehospital norepinephrine infusion in order to reach a mean blood pressure (MAP) at 65 mmHg at the end of the prehospital stage.

Patients and methods/Materials and methods: From April 06th, 2016 to December 31st, 2020, patients with SS requiring prehospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To consider cofounders, propensity score method was used to assess the relationship between prehospital norepinephrine administration in order to reach a MAP at 65 mmHg at the end of the prehospital stage and 30-day mortality.

Results: Four hundred seventy-eight patients were retrospectively analysed, among which 309 patients (65%) were male. The mean age was 69 ± 15 years. Pulmonary, digestive, and urinary infections were suspected among 44%, 24% and 17% patients, respectively. One third of patients (n = 143) received prehospital norepinephrine administration with a median dose of 1.0 [0.5–2.0] mg.h−1, among which 84 (69%) were alive and 38 (31%) deceased on day 30 after hospital-admission. 30-day overall mortality was 30%. Cox regression analysis after propensity score showed a significant association between prehospital norepinephrine administration and 30-day mortality: adjusted hazard ratio of 0.42 [0.25–0.70], p < 10−3. Multivariate logistic regression of IPTW retrieved a significant decrease of 30-day mortality among prehospital norepinephrine group: ORa = 0.75 [0.70–0.79], p < 10−3.

Conclusion: In this study, we report that prehospital norepinephrine infusion in order to reach a MAP at 65 mmHg at the end of the prehospital stage is associated with a decrease in 30-day mortality in patients with SS cared for by a MICU in the prehospital setting. Further prospective studies are needed to confirm that very early norepinephrine infusion allows to decrease septic shock mortality.

Compliance with ethics regulations: Yes in clinical research.

figure cu

Kaplan Meier curves for 30-days survival between patients with prehospital norepinephrine administration and those without prehospital norepinephrine administration

FC-117 Time for restauration of radial arterial pressure after a transient arm vascular occlusion correlates with outcome in critically ill patients: preliminary results of an observational study

LAI Christopher1, SHI Rui1, TEBOUL Jean-Louis1, MORETTO Francesca1, GUÉRIN Laurent1, XAVIER Monnet1

1AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU 4 CORREVE, Inserm UMR S_999, FHU SEPSIS, CARMAS, Université Paris-Saclay, Le Kremlin-Bicêtre, France
Correspondence: Christopher LAI (christopher.lai@aphp.fr)

Annals of Intensive Care 2022, 12(1):FC-117

Rationale: Impairment of vascular reactivity is one of the characteristics of septic shock and is associated with a poor outcome in critically ill patients. It can be assessed by the resaturation slope of the muscular tissue oxygen saturation after a transient vascular occlusion (TVO). Another means for assessing vascular reactivity might be to observe the time of the increase in radial arterial pressure after a TVO at the arm level.

Patients and methods/Materials and methods: Mechanically ventilated patients hospitalized in intensive care unit and equipped with a radial artery catheter were prospectively included. A brachial cuff was rapidly inflated to induce a transient arterial stop-flow. Arterial pressure thus decreased down to the level of mean systemic pressure (Pmsarm). After 60 s of TVO, the cuff was abruptly deflated and time to return from Pmsarm to baseline systolic arterial pressure was measured (Trevasc).

Results: We included 41 patients, among whom 19 (46%) where in shock, including 13 (32%) septic shock, 10 (24%) had acute respiratory distress syndrome and 9 (22%) were intubated for neurological impairment. Norepinephrine was infused in 25 (61%) patients (0.3 [0.17–1.10] μg/kg/min). Measurements were obtained 3 (2–6) days after onset of mechanical ventilation or vasopressors infusion. Mean arterial pressure was 84 ± 12 mmHg, Pmsarm was 29 ± 9 mmHg, central venous pressure was 12 ± 4 mmHg and the (Pmsarm-CVP) gradient was 16 ± 8 mmHg, with no difference between patients with or without shock. In the whole population, Trevasc was 26 (20–33) sec. It was significantly increased in patients with shock compared to those without shock (33 ± 18 vs. 23 ± 10 s., respectively, p = 0.028). Among patients with shock, Trevasc was longer in patients with septic shock than in the other ones (33 (28–44) vs. 16 (9–30) sec., respectively, p = 0.048). Trevasc was significantly increased in the 21 (51%) patients who died (11 patients with shock) compared to survivors (33 ± 19 vs. 23 ± 10 s., respectively, p = 0.037).

Conclusion: In critically ill patients under mechanical ventilation, Trevasc was increased in patients with shock compared to patients without shock, especially in septic shock patients. Trevasc was also higher in non-survivors. This new variable might indicate vasoreactivity at bedside and, as such, be associated with severity and mortality. More data are needed to confirm these preliminary results and inclusions are ongoing.

Compliance with ethics regulations: Yes in clinical research.

FC-118 Vitamin C improves microvascular reactivity and peripheral tissue perfusion in septic shock patients

LAVILLEGRAND Jean-Rémi1, RAIA Lisa1, URBINA Tomas1, HARIRI Geoffroy1, GABARRE Paul1, BONNY Vincent1, BIGÉ Naike1, BAUDEL Jean Luc1, BRUNEEL Arnaud2, DUPRE Thierry1, GUIDET Bertrand1, MAURY Eric1, AIT OUFELLA Hafid1

1APHP-CHU Saint Antoine, Paris, France; 2APHP-CHU Bichat, Paris, France
Correspondence: Jean-Rémi LAVILLEGRAND (jrlavillegrand@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-118

Rationale: Vitamin C has potential protective effects through antioxidant and anti-inflammatory properties. However, the effect of vitamin C supplementation on microvascular function and peripheral tissue perfusion in human sepsis remains unknown. We aimed to determine vitamin C effect on microvascular endothelial dysfunction and peripheral tissue perfusion in septic shock patients.

Patients and methods/Materials and methods: Patients with septic shock were prospectively included after initial resuscitation. Bedside peripheral tissue perfusion and skin microvascular reactivity in response to acetylcholine iontophoresis in the forearm area were measured before and 1 h after intravenous vitamin C supplementation (40 mg/kg). Norepinephrine dose was not modified during the studied period.

Results: We included 30 patients with septic shock. SOFA score was 11 [8–14], SAPS II was 66 [54–79], and in-hospital mortality was 33%. Half of these patients had vitamin C deficiency at inclusion. Vitamin C supplementation strongly improved microvascular reactivity (AUC 2263 [430–4246] vs 5362 [1744–10585] UI, p = 0.0004). In addition, vitamin C supplementation improved mottling score (p = 0.06), finger-tip (p = 0.0003) and knee capillary refill time (3.7 [2.6–5.5] vs 2.9 [1.9–4.7] s, p < 0.0001), as well as and central-to-periphery temperature gradient (6.1 [4.9–7.4] vs 4.6 [3.4–7.0] °C, p < 0.0001). The beneficial effects of vitamin C were observed both in patients with or without vitamin C deficiency.

Conclusion: In septic shock patients being resuscitated, vitamin C supplementation improved peripheral tissue perfusion and microvascular reactivity whatever plasma levels of vitamin C.

Compliance with ethics regulations: Yes in clinical research.

FC-119 Noradrenaline dose change-related effects on mean arterial pressure: preliminary results from the NoVaMAP study

MORETTO Francesca1, SHI Rui1, TEBOUL Jean-Louis 1, PAVOT Arthur1, LAI Christopher1, FAGE Nicolas1, PHAM Tài1, MONNET Xavier1

1Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Le Kremlin-Bicêtre, France
Correspondence: Francesca MORETTO (francescamoretto90@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-119

Rationale: Responsiveness to norepinephrine (NE) dose change in terms of mean arterial pressure (MAP) change is highly variable among patients with acute circulatory failure. This preliminary study aimed to investigate the factors influencing the pharmacodynamic effect of NE on MAP in critically ill patients.

Patients and methods/Materials and methods: This monocentric, observational, prospective study was conducted in patients with acute circulatory failure requiring NE and invasive arterial pressure monitoring. To characterize the responsiveness of MAP to NE change, the maximal amplitude of MAP change over the amplitude of change in the NE (deltaMAPmax/deltaNE) was calculated.

Results: From January to July 2021, 29 patients presenting 86 occurrences of change in the NE dose, including 55 dose-increases and 31 dose-decreases, were included. The most common origin of shock was sepsis in 59 (69%) cases, followed by hypovolemic/hemorrhagic shock in 16 (18%) cases and non-septic vasoplegia in 11 (13%) cases. Septic shock was characterized by significantly lower baseline values of MAP (66 [58–86] vs. 82 [71–103] mmHg) and of diastolic arterial pressure (50 [44–64] vs. 64 [55–78] mmHg) and by a larger amplitude of the change in NE dose (0.08 [0.05–0.12] vs. 0.04 [0.03–0.06] µg/kg/min). DeltaMAPmax/deltaNE was significantly lower in septic shock than in hypovolemic/hemorrhagic shock or non-septic vasoplegia (315 [161–590] vs. 575 [401–776] vs. 446 [336–1119] mmHg/µg/kg/min, respectively, p = 0.03). At multiple linear regression analysis, preexisting hypertension, body temperature at the study time and shock etiology were associated with deltaMAPmax/deltaNE (p = 0.002). In septic shock patients, body temperature and C-reactive protein levels independently influenced deltaMAPmax/deltaNE (p = 0.003).

Conclusion: Septic shock is characterized by lower vascular reactivity compared to other shock etiologies and MAP responsiveness to NE change is not identical to other types of distributive shocks. The results of this ongoing study will be entered in a model of artificial intelligence with the aim of adapting the dose of NE required to reach an individualized target level of MAP.

Compliance with ethics regulations: Yes in clinical research.

FC-120 Is precariousness a risk factor for COVID-19 mortality in intensive care units?

GILLIBERT Adrien1, LAINE Laurent1

1Delafontaine, Paris, France
Correspondence: Adrien GILLIBERT (gillibertadrien@gmail.com)

Annals of Intensive Care 2022, 12(1):FC-120

Rationale: During the SARS-CoV-2 pandemic, the first wave overwhelmed hospitals in Paris area (Ile-de-France) with a variable impact depending on the territory. Several studies highlighted variable ICU mortality rates during COVID-19 surges across territories (10 to 60%) with higher rates in those most affected by poverty1,2. We assessed the impact of precariousness, as an independent risk factor, on mortality linked to Covid-19 between ICUs at Delafontaine hospital, Saint-Denis, and Ambroise Paré hospital, Boulogne-Billancourt, two Paris suburbs.

Patients and methods/Materials and methods: We carry out a retrospective observational cohort study of consecutive ICU patients aged ≥ 18 years admitted at Delafontaine and Ambroise Paré hospitals during the first wave of the Covid-19 outbreak in order to compare mortality rates according to predefined risk factors (age, diabetes, arterial hypertension, BMI, active solid or haematological cancer, IGS2, poverty rate at the threshold of 60% (%) according to the island grouped for statistical information (IRIS)37 of the patient, invasive ventilation or not) that include precariousness.

Results: We found a difference for mortality in the two groups (p = 0,033) and with the univariate analysis the poverty rate was a risk factor for mortality at 90 days (p = 0,04). But we could not find a statistical relation between deprivation and mortality at 90 days in Covid-19 in intensive care in multivariate analysis.

Conclusion: Despite lake of significative statistical relationship between precariousness and covid-19 mortality in intensive care, it seems we could find correlation between importance of precariousness and mortality. We should realise a prospective study with more important population to find a relationship between deprivation and mortality at Covid-19 in intensive care.

Reference 1: 1. Quenot, Jean-Pierre et al. “Influence of deprivation on initial severity and prognosis of patients admitted to the ICU: the prospective, multicentre, observational IVOIRE cohort study.” Annals of intensive care vol. 10,1 20. 11 Feb. 2020, doi:10.1186/s.

Reference 2: 2. Rahi, Mayda et al. “Sociodemographic characteristics and transmission risk factors in patients hospitalized for COVID-19 before and during the lockdown in France.” BMC infectious diseases vol. 21,1 812. 13 Aug. 2021, https://doi.org/10.1186/s12879-021-06419-7

Compliance with ethics regulations: Yes in clinical research.

figure cv

Forrest plot for relationship between mortality at 90 days et risk factors in multivariate analysis

FC-121 Management of a massive inflow of patients in a very large cluster of covid-19 cases

POINTURIER Valentin1, POIDEVIN Antoine1, DEGOUL Samuel1, VIROT Edouard1, MOOTIEN Yoganaden1, PINTO Luis1, MATHIEN Cyrille1, LABRO Guylaine1, RABOUEL Yannick1, ETIENNE Arnaud1, KUTEIFAN Khaldoun1

1Hôpital Emile Muller, Mulhouse, France
Correspondence: Valentin POINTURIER (valentin.pointurier@ghrmsa.fr)

Annals of Intensive Care 2022, 12(1):FC-121

Rationale: Our general tertiary hospital had to face an unprecedented wave of respiratory distress in early 2020 that quickly overwhelmed its 40 ICU beds. The aim of this study was to report on ICU admission process and in-flow management at time of Covid-19 outbreak.

Patients and methods/Materials and methods: We conducted a retrospective analysis of every consecutive patient requiring the advice of the intensivist team between March 2 and May 1, 2020 from a call register filled prospectively on daily basis.

Results: Local ICU capacities have more than doubled (92 beds) thanks to the deprogramming of the scheduled surgical activity and the deployment of a military mobile hospital. Medical ICU physician on duty centralized all calls for Covid-19 admission. Priority was given to patient requiring immediate intubation. The others were placed on a waiting list according to their severity and expected prognosis based on their comorbidities, their frailty and their age until a ventilator was available. At the peak, 46 patients required the advice of the intensivist daily. A total of 591 patients were proposed for ICU admission. 75% had acute respiratory distress due to severe Covid-19, other were medical (14%) and surgical (11%) non covid related situations. ICU admission was decided for 370 patients. Mean age was 62 years (± 12), 69% were male. The most serious patients and those with contraindications to transfer were kept in local ICU (154 patients). 244 patients were transferred to France, Germany, Switzerland, and Luxembourg representing more than one third of all French transfers of the Covid-19 first wave. The patients managed in standard ward were older (mean age: 69 years (± 12)) and had more significant cardiovascular diseases (12,7% vs 5%), malignant tumors (10,5% vs 3,1%) and hematological diseases (8,2% vs 4,7%).

Conclusion: In situation of high tension on ICU capacities, priority must be given to increasing resources and optimizing means. The establishment of triage rules respecting the ethical principles of equality, beneficence, and transparency guarantees equitable access to intensive care and maximization of the number of lives saved.

Compliance with ethics regulations: Yes in clinical research.

FC-122 Evaluation of communication training in paediatric intensive care

DUCERT Floriane1, OHNOUNA Rachel1, VANEL Noémie1, GRIMALDI Céline1, RONCIN Cesar1, MICHEL Fabrice1

1Hopital Timone 2, Marseille, France
Correspondence: Fabrice MICHEL (fabrice.michel@ap-hm.fr)

Annals of Intensive Care 2022, 12(1):FC-122

Rationale: Communication with patients requires interpersonal skills and is a challenge for physicians, especially in paediatric critical care units. The need for good communication contrasts with the lack of training in communication skills in medical studies, and there is little experience in the literature of evaluating communication with families training in paediatric critical care. The main objective of this study was to heteroevaluate the impact of communication training for residents in a paediatric intensive care unit.

Patients and methods/Materials and methods: 14 residents were evaluated on their performance in communicating with families through video recordings of simulated breaking bad news to parents, before and after a 2-day training in communication with families including theoretical teaching and situational practice in relational simulation. The skills were also evaluated 3 month after the training to measure maintenance of acquisition over time. Residents were confronted to 3 standardized situations in a predetermined order, different for each of them. The ‘’modified Breaking Bad News Assessment Scale’’ (mBAS) was used as the evaluation tool scored by resident an not involved in the training, and analyzing the videos in a totally random order. The duration of interviews, speaking and silence times were recorded. Self-assessment was also performed using the ‘’Breaking Bad News’’ and ‘’Cungi and Rey’’ scales scored after each session.

Results: Both self-assessment scores showed important and significant improvement of the participants after the training, and maintenance of acquisitions over time. The global mBAS score decrease (corresponding to skills improvement) non-significantly, immediately after training (55.8 ± 8.1 vs. 49.0 ± 8.0; p = 0.071), but there was a significant improvement in two of the five score domains (A: setting the scene, C: eliciting concerns). Stress of residents after interviews decreased non significantly between the 3 measures (5,0 ± 1,7;4,4 ± 2,1;3,7 ± 1; p = 0,214). Duration of interviews and silence did not vary significantly.

Conclusion: Our study showed that training in communication with parents in the paediatric intensive care unit resulted in an improvement in the resident’s autoevaluation. This effect was less pronounced during heteroevaluation, which should encourage teachers to evaluate their training by objective methods.

Compliance with ethics regulations: Yes in clinical research.

FC-123 Mental health problems among Tunisian healthcare workers in the second year of Covid-19 pandemic

ZGHIDI Marwa1, BEN SAIDA Imen1,2, HAMDI Dhouha1, BOUBTANE Rihab1, BOUSSARSAR Mohamed1,2

1Farhat Hached University Hospital, Medical Intensive Care Unit, Sousse, TUNISIA, Sousse, Tunisie; 2Research Laboratory N° LR12SP09. Heart Failure. Farhat Hached University Hospital, Sousse, Tunisia, Sousse, Tunisie
Correspondence: Marwa ZGHIDI (marwa_zghidi@outlook.fr)

Annals of Intensive Care 2022, 12(1):FC-123

Rationale: The fear to contaminate and being contaminated, the quality of preparedness, the availability of personal protection equipment (EPI), diagnostic and therapeutic blur of an emergent disease and patients’ severity leading to high workload have added a burden of acute emotional stress in healthcare workers. The aim was to evaluate the impact of Covid-19 pandemic on healthcare workers mental health and identify factors associated with adverse mental outcomes.

Patients and methods/Materials and methods: It is a cross-sectional study conducted in critical care and emergency departments of 3 hospitals (Hached; Sahloul and Military hospital of Instruction of Tunis) from January 18, 2021, to March 13, 2021.Mental health outcomes: depression, anxiety, stress, post-traumatic stress disorder and burnout were assessed by depression anxiety stress scales (DASS), Impact of event scale revised(IES-r) and Maslach Burn out Inventory (MBI), respectively. Multivariate logistic regression analysis was performed to identify factors associated with those adverse mental health outcomes.

Results: One hundred and ten healthcare workers filled the questionnaire with a response rate at 86.6%. Respondents characteristics’ were: median age, 32 [28–37] years; female 68(61.8%); nurses 57(51.8%); 63(57.3%) worked in emergency departments. Fifty-two respondents (47.3%) had been contaminated by the SARS COV2. 88.2% of the respondents reported a feeling of fear of personal and family physical safety,74.5% felt an increased work overload and 72.7% confirmed a poor working condition. 43 respondents (43.6%) were considering quitting their profession because of severe psychological distress. 48.2%, 42.7% and 48.98% of respondents had respectively severe stress, severe anxiety and severe burnout. 49.1% of participants had probable PTSD according to IES-r score. On the multivariate regression, female sex (OR, 9.7; CI [2.5–36.7]; p < 0.001), age (OR, 0.083; IC [0.013–0.537]; p = 0.009), work overload (OR, 5.6; IC [1.3–23.7]; p = 0.018), were factors associated with stress. Age (OR, 0.6; IC [0.5–0.87]; p = 0.000), work overload (OR, 29; IC [3–63]; p = 0.002); change of work location (OR, 11.3; IC [1.4–88.7]; p = 0.021); poor work conditions (OR,20.7; IC [12–66]; p < 0.001) were associated with anxiety. Lack of psychological support (OR, 5.8; IC [2–16]; p < 0.001) was the only risk factor associated with depression. Age (OR, 0.6; IC [0.4–0.73]; p < 0.001); fear of personal and family safety (OR,7.2; IC [1.1–15]; p < 0.001); working with suspected or confirmed patients with COVID-19 (OR, 29; IC [2–69]; p = 0.009) were factors independently associated with PTSD. Female sex (OR, 1.1; IC [1.04–1.2]; p = 0.003), poor work conditions (OR,3.5; IC [1.7–4.6]; p = 0.047) were predictors of burnout.

Conclusion: The current study highlights that health care workers are at high risk of psychological distress during the covid-19 outbreak. Early psychological interventions may be beneficial.

Compliance with ethics regulations: Yes in clinical research.

FC-124 Prevalence of post-traumatic stress disorder in intensive care workers

DELTOUR Victoire1,3, LAURENT Alexandra1,2, POUJOL Anne-Laure3,4

1Université de Bourgogne Franche-Comté, Psy-DREPI EA 7458, Dijon, France; 2Service de réanimation chirurgicale, CHU Dijon, Dijon, France; 3Ecole de Psychologues Praticiens, Paris, France; 4Service de réanimation chirurgicale polyvalente, La pitié Salpêtrière, Paris, France
Correspondence: Victoire DELTOUR (victoire.deltour@hotmail.fr)

Annals of Intensive Care 2022, 12(1):FC-124

Rationale: Working in intensive care unit confronts professionals with extreme and unpredictable situations that have a traumatic dimension and constitute a risk of post-traumatic stress disorder (PTSD). Since 2019 this extreme context has been accentuated by unprecedented epidemic waves. We will present a systematic review to better identify the traumatic impact of ICU on healthcare and associated factors before and during the health crisis.

Patients and methods/Materials and methods: We used Pubmed; Science direct and Ovid (APA) databases to identify all quantitative, qualitative and mixed studies examining PTSD in Intensive care workers between 2009 and 2022.

Results: Of the 704 articles identified, only 8 met our inclusion criteria. 4 studies that were conducted before the COVID period showed that 3.3% to 18.2% of the surveyed intensive care workers had PTSD symptoms. The associated risk factors were life-threatening emergencies; exposure to death; management of organ and body donations; and situations experienced by caregivers as therapeutic overkill. Individual factors such as personality also appear to play a role in the development of traumatic symptomatology (Cho and Kang 2017). Four studies conducted during the COVID period showe